Highlights
- •BMP use in spinal fusions decreased from 2006 to 2015 for Medicare patients.
- •There was significant state and region-level geographic variation in BMP use.
- •BMP use was associated with increased hospital costs but similar Medicare payments.
ABSTRACT
BACKGROUND CONTEXT
Bone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends
in BMP use among Medicare patients have not been well-characterized.
PURPOSE
To assess utilization trends, complication, payments, and costs associated with BMP
use in spinal fusion in a Medicare-insured population.
STUDY DESIGN/SETTING
Retrospective cohort study.
PATIENT SAMPLE
Total of 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured
patients, 2006 to 2015.
OUTCOME MEASURES
Utilization trends across time and geography, complications, payments, and costs.
METHODS
Patients were stratified by fusion type and diagnosis. Multivariable logistic and
linear regression were used to adjust for the effect of baseline characteristics on
complications and total payments or cost, respectively.
RESULTS
BMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in
2006 to 12.0% in 2015, most significantly in anterior cervical (7.5%–3.1%), posterior
cervical (17.0%–8.3%), and posterior lumbar fusions (31.5%–15.8%). There are significant
state- and region-level geographic differences in BMP utilization. Across all years,
states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada
(25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi
(10.4%). After multivariate risk adjustment, BMP use was associated with decreased
overall complications in thoracic (odds ratios [OR] [95% confidence intervals [CI]):
0.89 [0.81–0.99]) and anterior lumbar fusions (OR [95% CI]: 0.89 [0.84–0.95]), as
well as increased reoperation rates in anterior cervical (OR [95% CI]: 1.11 [1.04–1.19]),
posterior cervical (OR (95% CI): 1.14 (1.04–1.25)), thoracic (OR (95% CI): 1.32 (1.23–1.41)),
and posterior lumbar fusions (OR (95% CI): 1.11 (1.06–1.16)). BMP use was also associated
with greater total costs, independent of fusion type, after multivariate risk adjustment
(p<.0001). Payments, however, were comparable between groups in anterior and posterior
cervical fusion with or without BMP. BMP use was associated with greater total payments
in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference
in payments was smaller than the associated cost increase in all fusion types.
CONCLUSIONS
BMP use has declined across all fusion types over the last decade, after a peak in
2007. While BMP is associated with greater costs, reimbursement does not increase
proportionally with BMP cost.
Keywords
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Article info
Publication history
Published online: January 26, 2023
Accepted:
January 19,
2023
Received in revised form:
January 18,
2023
Received:
August 3,
2022
Footnotes
FDA device/drug status: Not applicable.
Author disclosures: HW: Nothing to disclose. JYW: Nothing to disclose. KM: Nothing to disclose. CPA: Royalties: Stryker, (F); Royalties: Biomet Zimmer Spine, (C); Royalties: DePuy Synthes, (F); Royalties: NuVasive, (B); Royalties: Next Orthosurgical, (F); Royalties: K2M (None); Royalties: Medicrea, (B); Stock Ownership: Agada Medical, (B); Stock Ownership: Carlsmed, (B); Consulting: DePuy Synthes, (B); Consulting: Medtronic, (B); Consulting: Medicrea, (B); Consulting: K2M, (B); Research Support (Investigator Salary, Staff/Materials): Titan Spine, (E); Research Support (Investigator Salary, Staff/Materials): DePuy Synthes, (None); Research Support (Investigator Salary, Staff/Materials): ISSG (C); Grants: SRS, (None). JKR: Consulting: Stryker (D); Consulting: Alphatec Spine (B); Consulting: NuVasive (C): Consulting: Medtronic (D); Trips/Travel: Stryker (B); Trips/Travel: NuVasive (B); Trips/Travel: Alphatec Spine (B); Trips/Travel: Carlsmed ($22.78); Trips/Travel: DePuy Synthes Sales ($33.79); Trips/Travel: Medtronic (B); Trips/Travel: Medical Device Business Services ($87.31). CCZ: Consulting: Stryker, 7D (C); Speaking and/or Teaching Arrangements: Stryker, 7D, Amgen (B); Research Support (Investigator Salary, Staff/Materials): Stryker (E).
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