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Defining the value of elective lumbar fusion: a systematic review of existing methodologies and framework for the
Advith Sarikonda1,2, Anthony Y Chen3, Theo S Biddle3
1Section of Spine Surgery, Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA - advith.sarikonda@gmail.com.
Background:
Despite wide variation in the outcomes and costs of lumbar fusion, few studies have integrated these domains together within a single metric to assess "value" (outcomes achieved per dollar spent). In this review, we sought to 1) characterize existing metrics of cost-effectiveness for lumbar fusion, 2) evaluate all applications of time-driven activity-based costing (TDABC) in spine surgery, and 3) outline the conceptual foundation for a standardized Operative Value Index (OVI).
Methods:
Two PRISMA-concordant systematic reviews were performed on PubMed and Scopus databases. The first review examined all studies which reported a cost-effectiveness metric for lumbar fusion. The second review examined all applications of TDBAC in spine surgery.
Results:
Among 366 screened studies, 40 (21 for cost-effectiveness in lumbar fusion, 19 for TDABC in spine surgery) fulfilled inclusion criteria. The incremental cost-effectiveness ratio (ICER) was the most common metric, followed by OVI. Costs were frequently defined as reimbursement or charges; few studies assessed actual costs or TDABC. TDABC studies consistently demonstrated that costs were driven primarily by surgeon-level and procedure-specific factors, not patient characteristics. OVI studies uniformly used TDABC costs combined with disease-specific outcomes, but were limited to short-term follow-up and primarily intraoperative costs.
Conclusions:
Current value assessments in lumbar fusion are limited by heterogeneous outcomes and imprecise costing. A standardized framework integrating pathology-specific outcomes with episode-level costing (not charges or reimbursement) may enable more generalizable and accurate comparisons of operative value.
