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