Less opioid at no extra cost: charge-code decomposition of an ERAS pathway for adolescent scoliosis surgery

Enhanced recovery after surgery (ERAS) pathways using dexamethasone and liposomal bupivacaine (Dex/LB) have been shown to reduce opioid use after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), but their economic impact is unknown. This study examined whether the Dex/LB pathway increases hospital cost, analyzing charge lines rather than encounter-level totals.

Retrospective sequential implementation study at a single pediatric center. Of 140 consecutive AIS patients undergoing PSF (2019-2025), a transitional cohort (n = 20) was excluded, leaving 120 for primary analysis: traditional (n = 87) versus Dex/LB (n = 33). Charge lines were classified a priori as protocol-sensitive (medication, hospital stay, anesthesia/recovery) or protocol-independent (implant cost, imaging, laboratory studies, etc.).

The Dex/LB group had lower inpatient opioid use (median 30.0 vs. 150.0 MME; adjusted - 133.7, 95% CI - 177.1 to - 90.3, P < 0.001) and shorter length of hospital stay (LOS) (2.1 vs. 2.8 days, P < 0.001; adjusted P = 0.46). Total Direct Cost was higher in the DEX/LB cohort ($57,288 vs. $50,780, P = 0.006), but protocol-sensitive Direct Cost did not differ ($5873 vs. $6324; adjusted +$326, 95% CI - $679 to $1330, P = 0.52), with decrease LOS offsetting increased LB cost. The total cost increase traced to implant charges (+ $7034, P < 0.001) from concurrent billing changes. When implants were excluded, total Direct Cost did not differ (- $880, P = 0.58). Cost equivalence was sensitive to payer composition (Medicaid exclusion: +$596, P = 0.035).

Protocol-sensitive Direct Cost did not differ significantly between the Dex/LB and traditional pathways. The apparent total cost increase was attributable to concurrent changes in implant charge capture unrelated to the analgesic protocol.