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The cost-effectiveness of physical therapy versus laminectomy for lumbar spinal stenosis: a Markov decision analysis
Prashant V Rajan1, Joshua Eisenberg2, Stephen Selverian3
1Division of Spine Surgery, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, USA; University Hospitals Spine Institute, Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Background Context:
Physical therapy is often utilized as a nonoperative modality for the treatment of lumbar stenosis, oftentimes a prerequisite for insurance approval for surgery.
Purpose:
The goal of our study was to evaluate the relative cost-effectiveness of physical therapy as compared to a hospital-based or inpatient single-level lumbar laminectomy from the outset for lumbar stenosis.
Study Design/Setting:
Cost-effectiveness analysis, Markov model simulation.
Patient Sample:
We developed a Markov model to analyze the baseline case: a 55-year-old patient with symptomatic lumbar stenosis undergoing physical therapy versus lumbar laminectomy from outset.
Outcome Measures:
Model outcome measures were total quality-adjusted life years (QALYs) and costs, organized into incremental cost-effectiveness ratios (ICERs). ICERs were evaluated against willingness-to-pay thresholds (WTP) of $50,000 and $100,000.
Methods:
Transition probabilities were derived from the literature. Univariate and bivariate sensitivity analyses were performed as well as a probabilistic analysis varying several sensitive variables over distributions through 10,000 different simulations. Both healthcare payer and societal perspectives were included.
Results:
From healthcare payer perspective, laminectomy from outset produced higher QALYs (12.11 vs 11.87) at lower total cost ($15,735 vs $16,877) and was thus the dominant treatment. From societal perspective, physical therapy generated lower costs ($32,007) compared to laminectomy ($32,368). With an ICER of $1,485 per QALY for laminectomy which was below the WTP thresholds. The results were not sensitive to the procedural costs of laminectomy and physical therapy. In probabilistic sensitivity analysis, virtually all iterations found laminectomy from outset to be cost-effective over physical therapy across all WTP thresholds.
Conclusions:
Our cost-effectiveness analysis showed laminectomy to be the preferred treatment strategy from the outset for symptomatic lumbar stenosis from both healthcare payer and societal perspectives. These findings highlight the need for further study into the effectiveness and cost-efficiency of physical therapy to validate these model-based findings and explore ways to optimize the management of lumbar stenosis.
