Anterior cervical decompression and fusion (ACDF) is a major component of cervical procedures for various spinal cord conditions because of its durable and consistently favorable outcomes. There has been substantial growth in the various types of constructs and grafting options, though, and none is superior to another.
Because of this variation, hospital costs associated with ACDF are highly heterogeneous, and they continue to rise, partially due to increasingly complex patient populations. Andrew K. Simpson, MD, MBA, MHS, director of Minimally Invasive Spine Surgery in the Department of Orthopaedic Surgery at Brigham and Women’s Hospital, and colleagues conducted the first rigorous analysis of the relative drivers of ACDF costs. In Clinical Spine Surgery, they report an approximately seven-fold variation in the cost of ACDF constructs, ranging from $967 to $7,370, with the most important drivers being instrumentation type and implant materials.
The researchers reviewed data on 264 patients who underwent a single-level primary ACDF procedure at any level from C3 through C7 between January 2016 and December 2020 in the Mass General Brigham system. 53% of the patients were female, the mean age was 53, and most were ASA class II (59%) and privately insured (50%). All costs were adjusted to 2020 U.S. dollars.
Costs in all categories ranged widely:
- Total material cost: $967–$7,370 (mean, $2,317)
- Spacers and cages: $700–$3,847 (mean, $959)
- Screws: $4–$670 (mean, $163)
- Plates: $431–$3,722 (mean, $572)
Fusion adjuncts were used in 67% of patients at a mean cost of $301 (range, $147–$2,283). The most common type of cage material (allograft) was used in 26% of patients at a mean cost of $741 (range, $700–$1,510).
Contributors to Cost
Anterior instrumentation (plate/screws) was nearly twice as expensive as a stand-alone device with integrated fixation (mean total cost $2,686 vs. $1,466; P<0.001). The cost of the cage itself did not differ by type of instrumentation.
When comparing stand-alone and anterior plate constructs, the interbody spacer did not significantly change the cost, suggesting the plate construct was the driving factor in the difference.
The type of interbody material was another important driver of cost variance. Carbon fiber and titanium cages were significantly less costly than allograft, and polyether ether ketone cages were significantly more expensive.
After adjustment for demographic factors, clinical factors, and type of cage material, there were largely no differences among individual surgeons for material and implant costs.
Substantial Opportunity to Realize Savings
The heterogeneity of procedural costs demonstrated here reflects a misalignment of surgeon and healthcare system incentives. Surgeons are the decision-makers about construct components, but in most delivery models, they are shielded from procedural cost data and the fiscal consequences of higher costs and procedural waste.
As risk-based and capitation payment models are adopted, healthcare systems and surgeons will become increasingly accountable for procedural expenses. Systems that fail to address cost heterogeneity and inefficiency may find themselves fiscally disadvantaged.
It’s also worth noting that direct costs to the healthcare system are passed on to patients and consumers via increased charges to insurance programs. These can ultimately result in higher insurance premiums and restrictions on services.