Value of Inpatient Neuromodulation: A National Analysis of Paddle Spinal Cord Stimulation Outcomes

Spinal cord stimulation (SCS) effectively manages chronic pain and degenerative spine conditions. Paddle SCS often necessitates inpatient care because of surgical complexity, yet the impact of procedural setting on outcomes, costs, and disparities remains unclear. This study evaluates total costs, 90-day readmission and complication rates, and socioeconomic disparities in paddle SCS delivery.

Using Merative MarketScan data (2007-2023), we retrospectively identified adults undergoing initial paddle lead SCS implantation. Outcomes were total costs, 90-day readmission, and complication rates. Multivariable regression adjusted for age, sex, insurance, geographic region, surgery year, and Elixhauser comorbidity index. Propensity score matching minimized confounding, and longitudinal analyses assessed temporal outcome trends.

Of 13 704 patients, 89.4% underwent outpatient procedures. Inpatients had higher comorbidities (Elixhauser comorbidity index: 1.47 vs 0.55, P < .001). After propensity score matching, complication (4.76% vs 3.51%, P = .093) and readmission rates (16.54% vs 16.88%, P = .804) were similar between groups, but inpatient procedures incurred significantly higher costs (difference = $5341.15, P = .001). Over 17 years, readmissions declined from 18% to 5% (-0.76% annually, P < .001), complications decreased from 4% to 0% (-0.33% annually, P < .001), yet costs rose annually by $912 (P < .001). Cost disparities were influenced by age (-$347/year, inpatient), insurance type ($10 940 higher for outpatient high-deductible plans), and region (North Central vs Northeast: -$13 505, inpatient). Readmissions varied by sex (female odds ratio [OR] = 1.206, outpatient), age (OR = 0.982/year, inpatient), and region (North Central OR = 0.506 vs Northeast). Southern inpatient patients had higher complication risks (OR = 3.878).

Outpatient paddle SCS demonstrates equivalent short-term safety at substantially lower cost for appropriately selected patients. Inpatient implantation remains appropriate for select higher-risk patients at the surgical team's discretion, and payer policies should consider preserving coverage across both settings when clinically indicated to ensure access and equity.