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STUDY DESIGN: Retrospective administrative claims database analysis. OBJECTIVE: Identify distinct presurgery health care resource utilization (HCRU) patterns among posterior lumbar spinal fusion patients and quantify their association with postsurgery costs. SUMMARY OF BACKGROUND DATA: Presurgical HCRU may be predictive of postsurgical economic outcomes and help health care providers to identify patients who may benefit from innovation in care pathways and/or surgical approach. METHODS: Privately insured patients who received one- to two-level posterior lumbar spinal fusion between 2007 and 2016 were identified from a claims database. Agglomerative hierarchical clustering (HC), an unsupervised machine learning technique, was used to cluster patients by presurgery HCRU across 90 resource categories. A generalized linear model was used to compare 2-year postoperative costs across clusters controlling for age, levels fused, spinal diagnosis, posterolateral/interbody approach, and Elixhauser Comorbidity Index. RESULTS: Among 18,770 patients, 56.1% were female, mean age was 51.3, 79.4% had one-level fusion, and 89.6% had inpatient surgery. Three patient clusters were identified: Clust1 (n = 13,987 [74.5%]), Clust2 (n = 4270 [22.7%]), Clust3 (n = 513 [2.7%]). The largest between-cluster differences were found in mean days supplied for antidepressants (Clust1: 97.1 days, Clust2: 175.2 days, Clust3: 287.1 days), opioids (Clust1: 76.7 days, Clust2: 166.9 days, Clust3: 129.7 days), and anticonvulsants (Clust1: 35.1 days, Clust2: 67.8 days, Clust3: 98.7 days). For mean medical visits, the largest between-cluster differences were for behavioral health (Clust1: 0.14, Clust2: 0.88, Clust3: 16.3) and nonthoracolumbar office visits (Clust1: 7.8, Clust2: 13.4, Clust3: 13.8). Mean (95% confidence interval) adjusted 2-year all-cause postoperative costs were lower for Clust1 ($34,048 [$33,265-$34,84]) versus both Clust2 ($52,505 [$50,306-$54,800]) and Clust3 ($48,452 [$43,007-$54,790]), P < 0.0001. CONCLUSION: Distinct presurgery HCRU clusters were characterized by greater utilization of antidepressants, opioids, and behavioral health services and these clusters were associated with significantly higher 2-year postsurgical costs. LEVEL OF EVIDENCE: 3.

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The economic burden of periprosthetic infections is enormous, but the number of economic studies dealing with this issue is very scarce. This review tries to know the economic literature existing, assess the value of current data, and recognize the less costly and more effective procedures for prevention, diagnosis and treatment of periprosthetic infections. Forty five studies meeting the inclusion criteria and adhering to the quality criteria used were carefully analyzed to extract the economic data of relevance in evaluating the magnitude of problem and the more cost-effective solutions. However, because the heterogeneity and the low-quality of most of these studies meta-analytical technique has not been possible. Instead, the studies have been reviewed descriptively. Optimizing the antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room; detecting and treating the high-risk groups; a quick, simple, reliable, safe, and cost-effective diagnosis, and the rationale management of the instituted infection, specifically using the different procedures according to each particular case, could allow to improve outcomes and produce the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost effectiveness of different interventions to prevent and to treat the periprosthetic infection remains unclear.

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This review summarizes the existing economic literature, assesses the value of current data, and presents procedures that are the less costly and more effective options for the treatment of periprosthetic infections of knee and hip. Optimizing antibiotic use in the prevention and treatment of periprosthetic infection, combined with systemic and behavioral changes in the operating room, the detection and treatment of high-risk patient groups, as well as the rational management of the existing infection by using the different procedures according to each particular case, could allow for improved outcomes and lead to the highest quality of life for patients and the lowest economic impact. Nevertheless, the cost-effectiveness of different interventions to treat periprosthetic infections remains unclear.

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STUDY DESIGN: Retrospective cost-effectiveness analysis. OBJECTIVE: To determine the relative cost-effectiveness of anterior cervical discectomy with fusion (ACDF) using a porous tantalum implant compared with autograft with plating, for single-level cervical disc disease with radiculopathy. SUMMARY OF BACKGROUND DATA: ACDF with autograft as an interbody spacer is a generally accepted method to treat degenerated cervical discs with radiculopathy. Concerns about donor site morbidity and the structural characteristics of autograft stimulated investigations of alternative materials. Techniques may differ in their operative risks, complications, outcomes, and resource use. METHODS: A retrospective review of clinical outcomes and total cost of illness for 5 years postsurgery was performed for 61 consecutive patients enrolled for this study. Twenty-eight patients were treated with single-level ACDF using either a stand-alone, porous tantalum implant, without graft inside the implant, and 33 patients received autograft and plating. A cost-effectiveness analysis comparing the 2 ACDF treatment methods was conducted. This article reports clinical assessments, quality adjusted life years gained, and an incremental cost-effectiveness ratio analysis. RESULTS: Patients in both cohorts reported improved clinical outcomes, including neck disability index, visual analogue scale, Short-Form 36, Odom's clinical assessment, and patient satisfaction at 5 years postindex surgery. The mean cost of illness for the study period, including preoperative through 5 years postoperative assessments, was 6806 per patient treated with tantalum and 10,143 per patient receiving autograft and plate. Quality-adjusted life years (QALY) gained were 9.41 and 7.14 for the tantalum and control cohorts, respectively. The cost per QALY for the tantalum group was 723 and 1420 for the control group. The incremental cost-effectiveness ratio of ACDF with a porous tantalum implant compared with ACDF with autograft and plate was -1473 per patient per year for the duration of this study. CONCLUSION: This cost-effectiveness analysis reports favorable results for ACDF procedures utilizing a tantalum implant. The data reported suggest that using porous tantalum as a stand-alone device is less costly and more effective than autograft and plate in ACDF procedures.

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RNA interference (RNAi) has great potential as a tool for studying gene function in mammals. However, the specificity and magnitude of the in vivo response to RNAi remains to be fully characterized. A molecular and phenotypic comparison of a genetic knockout mouse and the corresponding knockdown version would help clarify the utility of the RNAi approach. Here, we used hydrodynamic delivery of small interfering RNA (siRNA) to knockdown peroxisome proliferator activated receptor alpha (Ppara), a gene that is central to the regulation of fatty acid metabolism. We found that Ppara knockdown in the liver results in a transcript profile and metabolic phenotype that is comparable to those of Ppara-/- mice. Combining the profiles from mice treated with the PPARalpha agonist fenofibrate, we confirmed the specificity of the RNAi response and identified candidate genes proximal to PPARalpha regulation. Ppara knockdown animals developed hypoglycemia and hypertriglyceridemia, phenotypes observed in Ppara-/- mice. In contrast to Ppara-/- mice, fasting was not required to uncover these phenotypes. Together, these data validate the utility of the RNAi approach and suggest that siRNA can be used as a complement to classical knockout technology in gene function studies.

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