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HANOVER, N.H., Sept. 11 -- For patients with a herniated disc, surgery proved a cost-effective alternative to nonsurgical treatment over the course of two years, an observational study found.

But, its estimated economic value varied considerably according to the method used for assigning surgical costs, Anna N.A. Tosteson, Sc.D., of Dartmouth Medical School here, and colleagues reported in the Sept. 1 issue of Spine.

The findings came from an analysis of treatment outcomes and costs for patients in the Spine Patient Outcomes Research Trial, which compared spinal surgery versus nonsurgical treatments for back pain related to a herniated vertebral disc.

Patients were followed from baseline at six weeks up to 24 months at 13 spine clinics in 11 states. Quality adjusted life years (QALYs), a standard measure for assessing medical treatments, were used to measure differences in the two treatments.

Among 775 patients who underwent surgery and 416 treated nonoperatively, both surgery and nonsurgical treatment improved health and quality of life.

Spinal fusion was uncommon as a first surgical course, but occurred in eight patients. Among all patients, 53 (6.8%) had repeat surgeries.

After two years the results were somewhat better for the surgery patients, with a mean difference in quality adjusted life years (QALY) of 0.21 (95% CI 0.16 to 0.25) in favor of surgery.

Surgery was more costly than nonsurgical treatment.

The average cost of the surgery itself was $12,754 for patients without complications and about $19,000 for the 3% who experienced complications.

Overall treatment costs, including factors such as the increase in diagnostic tests and pain medications for surgery patients were $27,273 (95% CI $26,009 to $28,644) for surgery versus $13,135 (95% CI $11,244 to 14,902) for nonsurgical patients.

Surgery patients also had higher immediate indirect costs, including more missed work days and reduced productivity.

When treatment costs were estimated using Medicare rates, particularly appropriate as those 65 and older make up a growing percentage of patients using disc surgery, the cost per additional QALY gained with surgery was $34,355 (95% CI $20,419 to $52,512).

This compared very favorably with the economic value of widely accepted medical and surgical treatments, such as medications to lower blood pressure, the researchers said.

However, surgery appeared less cost-effective when the researchers measured cost for the general adult population. In this estimate the cost per QALY gained for surgery relative to nonoperative care was twice as high as the Medicare rate: $69,403 (95% CI $49,523 to $94,999).

Although surgery was more expensive than nonoperative treatment, health outcomes over two years were better for those treated surgically, the researchers pointed out. Mean indirect costs for non-surgery patients tended to be higher over time than for surgical patients.

To the extent that differences in the values for health status are maintained beyond two years, the incremental value of surgery may be greater, the researchers wrote. They noted that continued follow-up should permit an economic evaluation over a longer time horizon.

A key strength of this study is the inclusion of data on indirect costs, such as missed work time and reduced job productivity, the researchers said. On the other hand, they noted, the findings for the Medicare-based analysis illustrate the importance of the method used to assess the costs of surgery.

Study limitations included the use of self-reports of resource use and productivity losses. To minimize recall issues, the recall window was limited to six weeks at early visits and one month at annual visits for nonhospital care.

As noted, Medicare payment schedules may not reflects true costs for most use of medical resources, and finally, the evaluation was based on an observational rather than a randomized measure of outcomes.

Changing trends in spine surgery in the U.S. and the continued escalation in healthcare expenditures highlight the importance of understanding the economic value of a common surgical intervention, the researchers wrote.

To date, the economic value of surgery for disc herniation has received relatively little attention, they said. This comprehensive analysis suggests that surgical treatment of a herniated disc represents a reasonably cost-effective healthcare intervention when compared with the economic value of other common health-care treatments, they concluded.

This study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and by the Office of Research on Women's Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, and the Centers for Disease Control and Prevention. No financial conflicts were reported.

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