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Vlerick Health Care conferenceLeveraging the understanding of costs: a case aboutSpine
L. Moke, MD, PhDUniversity Hospitals Leuven, Division of Orthopaedics
Clinical costs of the Adult Spinal Deformity pathway
Acknowledgements of co-authors
Jacobs Karel, Dewilde Thibault, Boeckxstaens Anton, Himpe Nicolas, Jaspers Maïté, Vansteenkiste Nancy, Vandoren Cindy, Tambeur Wim, Roodhooft Filip, Cardoen Brecht, Scheys Lennart, Moke Lieven, Kesteloot Katrien
Table of Contents
A. Introduction1. Background: Adult Spinal deformity2. Poor understanding of costs in ASD care
B. Materials / Methods1. Process mapping of care pathway2. Clinical data3. Clinical cost data
C. Results1. ASD Care pathway: key activities2. Clinical data3. Clinical cost data
D. ConclusionE. Take Home Message
A. Introduction – Adult Spinal Deformity (ASD)
1. Introduction – ASD’s different faces
SF-36-scorein patients with Diabetes, Chronic lung disease, Congestive heart failure and Arthritis as assessed in the IQOLA project1
versusAdult Spinal Deformity.
1. Pellisé et al. Impact on health-related quality of life of adult spinal deformity (ASD) compared with other chronic conditions.Eur Spine J. (2015) 24:3-11.
1. Introduction – ASD’s Burden on society
GOAL: Improve HRQOL in symptomatic ASD patients
Non-surgical ASD care:
1. Analgetics2. Core Stability Training3. Interventional Pain Therapy4. Bracing5. ….
is marked by…
1. a lack in evidence based approach1
2. an unpredictable outcome2
3. a significant cost without significant impact on longtermoutcome3
1. Liu et al. The benefit of nonoperative treatment for adult spinal deformity: identifying predictors for reaching a minimal clinically importantdifference. Spine J. 2016;16:210-8.
2. Passias et al. Patient profiling can identify adult spinal deformity patients at risk for conversion from non-operative to surgical treatment:initial steps to reduce ineffective ASD management. Spine J. 2017.
3. Paulus et al. Cost and value of spinal deformity surgery. Spine 2014;39:388-93.
1. Introduction – non-surgical ASD care
GOAL: Improve HRQOL in symptomatic ASD patients
Surgical ASD care
1. Decompression of neurological structures
2. Improvement of spino-pelvic alignment
3. Reduced use of compensatory mechanisms
is marked by…
1. a high complication rate (17-39%)1,2
2. an unpredictable outcome2
3. a lack of insights in dynamic functional level3
1. Mario et al. Predictive factors for Proximal Junctional Kyphosis in Long Fusions to the Sacrum in Adult Spinal Deformity. Spine 2013; 38(23):E1469-E1476.
2. Charosky et al. Complications and Risk Factors of Primary Adult Scoliosis Surgery. Spine 2012:37(8):693-700.3. Glassman et al. Sagittal balance is more than just alignment: why PJK remains an unresolved problem. Scoliosis Spinal Discord 2016;11:1
1. Introduction – surgical ASD care
1. Introduction – Outcome in ASD care
PREOPERATIVE
02468
PREOP 6 MonthsPOSTOP 12 Months
POSTOP
COMI-BACK
VAS-pain score
12 m Post-OPERATIVE
1. Introduction – Outcome in ASD care: ill-defined
2. Introduction – Poor understanding of costs in ASD care
• At present, care givers have little insight in drivers and total cost of ASD care, with abscence of research based, appropriate state of the art cost analysis of spinal deformity
• Reported literature all structured their cost analysis around the way treatment is reimbursed and/or charged to the patient…
• However…the relevant cost is the total cost of all resources – clinical and administrative personnel, drugs and other supplies, devices, space, and equipment – used during the spinal deformitypatient’s full cycle of care, including treatment of associated complications and comorbidities
• This study will focus on the relevant direct clinical care cost of ASD patients
2. Introduction – Value spiral in ASD care is out of control
2. Introduction – Michael Porter Value-Based health care system
1. Organizeinto
integratedpractice units
(IPUS)
2. Measureoutcomes
and costs forevery patient
3. Move tobundled
payments forcare cycles
4. Integratecare delivery
acrossseperatefacilities
5. Expandexcellent services across
geography
2. Introduction – Research questions
What are the key activities in the care pathway for ASD patients in UZL?
Which activities of the care pathway contribute most to the direct clinical care costs?
Is there variability in costs between patients & activities?
Do patient and intervention characteristics explain the variability in direct clinicalcare costs?
Question 1
Question 2
Question 3
Question 4
2. Measureoutcomes
and costs forevery patient
B. Materials and methods
ACCP
OutcomeProcess
Patient
B. Materials and methods
1. Process mapping of ASD care pathway2. Clinical data3. Clinical cost data
ACCP
OutcomeProcess
Patient
All surgical interventionswith ASD surgery codes
Inclusion criteria
• Adult Spinal Deformity
• ≥ 18 years old
• Index (= initial) ASD surgery between
• 30/11/’14 and 01/01/’18 in division of
Orthopaedics, University Hospitals Leuven
• At least 1 year post-surgical follow-up
Classification of intervention• initial surgery• planned re-operation• unscheduled revision
Retrospective study at UZ Leuven registered with S number 61657
B. Materials and methods
1. Process mapping of ASD Care pathway
• Mapping the highlevel flowchart of key activities in theclinical ASD pathway
• Through expert interviews, observations andretrospective study of Electronic Patient Record analyses
• Optimized via different rounds of feedback in focus groups
2. Clinical data
Demographics Comorbidities
Surgical Invasiveness Complications
ASD patient
• Demographics• Gender, Age, BMI• Smoking-status• Mobility status
• Walking without device, with device or weelchairbound
• Functional Status• Living independently, partially dependent (eg.
serviceflat) or dependent (eg. care centre)
2. Clinical data Demographics
2. Clinical data
• Comorbidities• Relevant medical comorbidities in different organ systems
• American Society of Anesthesiologists (ASA)-score
• Modified-Frailty Index (m-FI)*• Quantifies the physiological reserve across multiple organ
systems (= frailty)• Scoring 5 items:
1. diabetes melllitus2. congestive heart failure3. hypertension requiring medication4. history of COPD5. functional health status before surgery
* Leven, Dante M., et al. 2016
ASA-score
Comorbidities
• Surgical invasiveness• ASD-specific Surgical Invasiveness score (ASD-S)*
• Measures the invasiveness of the surgery• Scoresystem based on different surgical components
*Neuman, Brian J., et al. 2017
2. Clinical data SurgicalInvasiveness
• Peri- and postoperative complications during 1 year post-surgical follow-up
• Surgical complications• (eg. CSF leak, Neurologic injury, Surgical site infection, Bowel/bladder disfunction…)
• General complications• (eg. Thromboembolism, Acute Myocardial Infarction, Anaemia…)
2. Clinical data
Complications
3. Clinical cost dataData via the Activity Center – Care Program (AC-CP) model of University Hospitals Leuven
• Top-down (Time-Driven) Activity Based Costing model• Bill of Activities (BoA) expressed in costs
Included Excluded
Direct costs of clinical care• Nursing, other non-medical care staff• Medical staff• Drugs• (Spinal) implants• Costs of other materials• Costs of specific
equipment/infrastructure(depreciation)
• Indirect costs (General overhead)• Costs of non-specific equipment &
infrastructure
AC-CP model is able to drop clinical cost data in relation to bill of activities with respect to
• Preparation phase• Costs of out-patient contacts of relevant clinical divisions• 3 months before planning of index surgery
• First hospitalization• Includes index surgery• all direct clinical costs
• Follow-up• Costs of out-patient contacts of relevant departments• Costs of included planned follow-up or revision surgery and associated hospitalization• 1 year after index surgery
3. Clinical cost data
C. Results
ACCP
OutcomeProcess
Patient
1. ASD Care pathway: key activities
Outcome
Patient
ACCP
Process
ACCP
1. ASD Care pathway: key activities
Medical Imaging
preoperative anesthetic
assessment
Other preop assessments
needed?
Other preop assessments* depending on
patient characteristics
Preop consultation
surgeon
yes
no
Neurological tests
* bone densitometry, diagnostic testing, geriatric consult, Consult social worker
Medical imaging Decision to perform SurgeryIntake consultation
Preparation Phase
Intensive Care
Ward
Medical Imaging
Planned surgery
Index Surgery Post-Anaeshesia care Unit
Post-Anaeshesia care Unit
Intensive Care
Revision surgery Post-Anaeshesia care Unit
Intensive Care
Initial Intervention
1. ASD Care pathway: key activities
Follow-up Consultation
(3m)
Medical imaging
Follow-up Consultation
(6m)
Medical imaging
Planned surgeryPost-
Anaeshesia care Unit
Intensive Care
revision surgeryPost-
Anaeshesia care Unit
Intensive Care
complications
Ward
Ward
follow-up of complications
Standard fo llow-up Standard fo llow-up
Follow-up Consultation
(1y)
Medical imaging
Standard fo llow-up
1 year Follow-up
1. ASD Care pathway: key activities
Subgroups
Standard trajectory
Trajectory withmultiple plannedsurgeries
Trajectory withat least 1 revisionsurgery
n
74
19
20
113
Follow-Up
Preperation Follow-Up Index Surgery Second Surgery
Follow-Up Revision Surgery
Mean number of interventions
1,0
2,0
2,4
1,46
1
2
3
1. ASD Care pathway: different subgroups
2. Clinical data: results
OutcomeProcess
Patientn=113
ACCP
2. Clinical data: results
Demographics Comorbidities
Surgical Invasiveness Complications
ASD patient
Female 29,2 %Male 70,8 %
Smoking 22 %Non-smoking 78 %
< 18,5: 3,5 %18,5 – 24,9: 53,1 %24,9 - 29,9: 25,7 %30,0 – 34,9: 14,2 %35,0 < 3,5 %
Walking without device 77,0 %Walking with device 19,5 %Weelchair bound 3,5 %
Living independently 77,9 %Living partially dependent 16,8 % Living dependently 5,3 %
Mean = 66 yStd. Dev. = 17 yN = 113
Demographics
Most common comorbidities
comorbidities number of people %
Arterial hypertension 27 23,9%
Osteoporosis 17 15,0%
Diabetes mellitus 11 9,7 %
Depression 8 7,0%
CVA/TIA 7 6,0%
83,2 % of all patients had at least 1 comorbidity.
Comorbidities
0
5
10
15
20
25
30
35
0 1 2 3 4 5 6 7 8
num
ber o
f pat
ient
s
number of comorbidities
number of comorbidities per patient
Comorbidities
m-frailty index per subgroup
72,6%
67,4%
35,7%
17,7%
11,6%
28,6%
9,7%
20,9%
35,7%
0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% 80,0% 90,0% 100,0%
a
b
c
1
2
3
Non FrailScore=0
FrailScore=1
Severily FrailScore≥2
Standard trajectory (74)
Trajectory with multiple planned surgeries (19)
Trajectory with at least1 revision surgery (20)
Comorbidities
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4
% of patients with n surgical episodes
Number of surgical episodes
% o
f pat
ient
sSurgical
Invasiveness
Mean 32,9Standard error 1,16Median 33Modus 40Standard Deviation 12,37
SurgicalInvasiveness
% of patientsduring/after initial
intervention
Most frequent
Intra-operative adverse event 24 % Dura Lesion
Intra-operative general complication 14 % Anaesthesiological
Post-operative surgical complications 42 % Bowel or Bladder disfunction
Post-operative general complications 55 % Anaemia / electrolyte imbalance
Complications
• Top-down (Time-Driven) Activity Based Costing model
n = 113
3. Clinical Cost data
Subgroups n
Standard trajectory
Trajectory with multiple planned surgeries
Trajectory with at least1 revision surgery
74 € 22 337
19 € 30 169
20 € 43 998
113 € 27 488
Follow-Up
Preperation Follow-Up Index Surgery Second Surgery
Follow-Up Revision Surgery
Average direct clinical cost
1
2
3
3. Clinical Cost data: resource consumption
Medical Imaging
preoperative anesthetic
assessment
Other preop assessments
needed?
Other preop assessments* depending on
patient characteristics
Intensive Care
Ward
Medical Imaging
Planned surgery
Follow-up Consult (3m)
Medical imaging
Follow-up Consult (6m)
Medical imaging Index Surgery Post-Anaeshesia
care Unit Preop consult
surgeon
yes
no
Post-Anaeshesia care Unit
Intensive Care
Planned surgeryPost-
Anaeshesia care Unit
Intensive Care
revision surgeryPost-
Anaeshesia care Unit
Intensive Care
complications
Ward
Ward
follow-up of complications
Standard fo llow-up Standard fo llow-up
Neurological tests
* bone densitometry, diagnostic testing, geriatric consult, Consult social worker
Follow-up Consult (1y)
Medical imaging
Standard fo llow-up
Revision surgery Post-Anaeshesia care Unit
Intensive Care
Medical imaging
yesyes
Decision to perform SurgeryIntake consult
4,2 % 93,4 % 2,4 %
Preparation Phase Initial Intervention Follow-up
3,3 % 73,8 % 22,9 %
1,8 % 54,3 % 43,9 %
3,6% 76,8% 19,6%
Subgroups
Standard trajectory (74)
Trajectory with multiple planned surgeries (19)
Trajectory with at least1 revision surgery (20)
1
2
3
Total group (113)
3. Clinical Cost data: resource consumption
Preparing Initial intervention Follow-up
Medical imaging 100% 100% 100%Function measurement 65% 31% 12%
Ward 0% 100% 28%ICU 0% 14% 2%Lab 95% 100% 48%
Operating theatre (OT) 0% 100% 29%Physiotherapy 1% 33% 9%
Consultation 100% 6% 100%Emergency department 0% 0% 3%
% of patients with AC visit
3. Clinical Cost data: bill of activities
3. Clinical Cost data: cost proportions
OutcomeProcess
Patient
ACCP
3. Clinical Cost data: interactions
Subgroup 1 (n=74) Subgroup 2 (n=19) Subgroup 3 (n=20)
3. Clinical Cost data: variability in costs between patients
Mean 22337,4 30169,9 43998,2Standard Error 632,9 1303,0 5547,0Standard Deviation 5444,7 5679,5 24806,8
n=60 n=39 n=14
Non Frail Frail Severily Frail
3. Clinical Cost data: variability in costs between patients
3. Clinical Cost data: variability in costs between activities
n = 113
Statistics:Univariate regression
Kruskal Wallis testMultivariate regressions
1. age2. mobility status3. functional status4. cardiovascular disorder5. ASA score6. modified Frailty Index7. Surgical Invasiveness Score combined8. Post-operative Surgical complications9. Post-operative General Complications
P<0,05
3. Clinical Cost data: significant variables related toclinical cost of entire ASD care pathway
Stepwise Forward Regression Model 1 Model 2 Model 3 Model 4
Intercept 9812 8560 -3176 -2129SI-score combined 482 440 432 437Mobility Status (1) 8609 6587 6254Mobility Status (2) 15612 19483 19215Age 219 160Cardiovascular Disorder 4903
R² 0,281 0,371 0,432 0,456*Adjusted R² 0,274 0,36 0,416 0,436Se 11936,32 11210,27 10707,44 10521,72P-value <0,001 <0,001 <0,001 <0,001
EstimatedClinical cost
of care pathway
= -2129 + 52 * 437 + 1 * 19215 + 64 * 160 + 1 * 4903
Example patient:A patient with a SI-score combined of 52 who is wheelchair bound, 64 years old andhas a cardiovascular disorder:
= € 57 802
3. Clinical Cost data: predictive statistical modelling of clinical cost of entire ASD care pathway
Statistics:Univariate regression
Kruskal Wallis testMultivariate regressions
Indipendent T-testsOne-Way Anova
Clinical cost of Preparation Phase Clinical cost of Surgery Clincial cost of Index Hospitalization Clinical cost of Follow-up
Age Functional status Age Age
Skeleton disorder Surgical invasiveness Score Mobility status BMI
Endocrinological disorder Surgical invasiveness Score combined Functional status Endocrinological disorder
cardiovascular disorder Skeleton disorder Modified Frailty Index
ASA score Endocrinological disorder Sugcial Invasiveness Score Combined
Surgical Invasiveness Score Cardiovasciular disorder
Surgical Invasiveness Score combined Modified Frailty Index
Post-operative Surgical complications
Post-operative General ComplicationsP<0,05
3. Clinical Cost data: significant variables related toclinical cost of different steps in ASD care pathway
P<0,05
What are the key activities in the care pathway for ASD patients in UZL?
Which activities of the care pathway contribute most to the direct clinical cost?
Is there variability in costs between patients & activities?
Can the variability in clinical costs be explained by patient and interventioncharacteristics?
Question 1
Question 2
Question 3
Question 4
E. Conclusion
ACCP
OutcomeProcess
Patient
Value-Equation
ACCP
E. Future Perspectives
E. Future Perspectives1. Organize
into integratedASD practiceunits (IPUS)
2. Measureoutcomes andcosts for every
ASD patient
3. Move tobundled
payments forASD care
cycles
4. IntegrateASD care
delivery acrossseperatefacilities
5. Expandexcellent ASD
services acrossgeography
Value based ASD careAdapted from Michael Porter 2013