{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T12:35:58Z","timestamp":1780490158927,"version":"3.54.1"},"reference-count":31,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,11,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>Posterior lumbar interbody fusion (PLIF) and\/or transforaminal lumbar interbody fusion (TLIF), referred to as \"PLIF\/TLIF,\" is a commonly performed operation for lumbar spondylolisthesis. Its long-term cost-effectiveness has not been well described. The aim of this study was to determine the 5-year cost-effectiveness of PLIF\/TLIF for grade 1 degenerative lumbar spondylolisthesis using prospective data collected from the multicenter Quality Outcomes Database (QOD).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>Patients enrolled in the prospective, multicenter QOD grade 1 lumbar spondylolisthesis module were included if they underwent single-stage PLIF\/TLIF. EQ-5D scores at baseline, 3 months, 12 months, 24 months, 36 months, and 60 months were used to calculate gains in quality-adjusted life years (QALYs) associated with surgery relative to preoperative baseline. Healthcare-related costs associated with the index surgery and related reoperations were calculated using Medicare reimbursement\u2013based cost estimates and validated using price transparency diagnosis-related group (DRG) charges and Medicare charge-to-cost ratios (CCRs). Cost per QALY gained over 60 months postoperatively was assessed.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>Across 12 surgical centers, 385 patients were identified. The mean patient age was 60.2 (95% CI 59.1\u201361.3) years, and 38% of patients were male. The reoperation rate was 5.7%. DRG 460 cost estimates were stable between our Medicare reimbursement\u2013based models and the CCR-based model, validating the focus on Medicare reimbursement. Across the entire cohort, the mean QALY gain at 60 months postoperatively was 1.07 (95% CI 0.97\u20131.18), and the mean cost of PLIF\/TLIF was $31,634. PLIF\/TLIF was associated with a mean 60-month cost per QALY gained of $29,511. Among patients who did not undergo reoperation (n = 363), the mean 60-month QALY gain was 1.10 (95% CI 0.99\u20131.20), and cost per QALY gained was $27,591. Among those who underwent reoperation (n = 22), the mean 60-month QALY gain was 0.68 (95% CI 0.21\u20131.15), and the cost per QALY gained was $80,580.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>PLIF\/TLIF for degenerative grade 1 lumbar spondylolisthesis was associated with a mean 60-month cost per QALY gained of $29,511 with Medicare fees. This is far below the well-established societal willingness-to-pay threshold of $100,000, suggesting long-term cost-effectiveness. PLIF\/TLIF remains cost-effective for patients who undergo reoperation.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2024.5.spine24112","type":"journal-article","created":{"date-parts":[[2024,8,17]],"date-time":"2024-08-17T01:55:55Z","timestamp":1723859755000},"page":"596-603","source":"Crossref","is-referenced-by-count":3,"title":["Cost-effectiveness of posterior lumbar interbody fusion and\/or transforaminal lumbar interbody fusion for grade 1 lumbar spondylolisthesis: a 5-year Quality Outcomes Database study"],"prefix":"10.3171","volume":"41","author":[{"given":"Timothy J.","family":"Yee","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Campbell","family":"Liles","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah E.","family":"Johnson","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vardhaan S.","family":"Ambati","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony M.","family":"DiGiorgio","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nima","family":"Alan","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Domagoj","family":"Coric","sequence":"additional","affiliation":[{"name":"Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric A.","family":"Potts","sequence":"additional","affiliation":[{"name":"Goodman Campbell Brain and Spine, Carmel, Indiana;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica F.","family":"Bisson","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah, Salt Lake City, Utah;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John J.","family":"Knightly","sequence":"additional","affiliation":[{"name":"Maxim Spine, Morristown, New Jersey;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kai-Ming G.","family":"Fu","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Weill Cornell Medicine, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin T.","family":"Foley","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Tennessee, Memphis, Tennessee;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark E.","family":"Shaffrey","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamad","family":"Bydon","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dean","family":"Chou","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Columbia University Medical Center, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew K.","family":"Chan","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Columbia University Medical Center, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott","family":"Meyer","sequence":"additional","affiliation":[{"name":"Maxim Spine, Morristown, New Jersey;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony L.","family":"Asher","sequence":"additional","affiliation":[{"name":"Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher I.","family":"Shaffrey","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Duke University, Durham, North Carolina;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan R.","family":"Slotkin","sequence":"additional","affiliation":[{"name":"Geisinger Neuroscience Institute, Danville, Pennsylvania;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael Y.","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of Miami, Florida;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Regis W.","family":"Haid","sequence":"additional","affiliation":[{"name":"Atlanta Brain and Spine, Atlanta, Georgia; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven D.","family":"Glassman","sequence":"additional","affiliation":[{"name":"Norton Leatherman Spine Center, Louisville, Kentucky"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S.","family":"Virk","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, Weill Cornell Medicine, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Praveen V.","family":"Mummaneni","sequence":"additional","affiliation":[{"name":"Department of Neurological 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Neurosurg Focus. 2017;43(2):E11."},{"issue":"2","key":"b2","series-title":"Spine (Phila Pa 1976)","first-page":"199","article-title":"Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population","volume":"34","author":"Kalichman L","year":"2009","unstructured":"Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine (Phila Pa 1976). 2009; 34(2):199\u2013205."},{"issue":"3","key":"b3","series-title":"Neurosurg Clin N Am","first-page":"353","article-title":"Summary of guidelines for the treatment of lumbar spondylolisthesis","volume":"30","author":"Chan AK","year":"2019","unstructured":"Chan AK, Sharma V, Robinson LC, Mummaneni PV. Summary of guidelines for the treatment of lumbar spondylolisthesis. Neurosurg Clin N Am. 2019;30(3):353\u2013364."},{"issue":"15","key":"b4","series-title":"N Engl J Med","first-page":"1424","article-title":"Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis","volume":"374","author":"Ghogawala Z","year":"2016","unstructured":"Ghogawala Z, Dziura J, Butler WE,  Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med. 2016;374(15):1424\u20131434."},{"issue":"1","key":"b5","series-title":"Neurosurg Focus","first-page":"E2","article-title":"Minimally invasive versus open transforaminal lumbar interbody fusion for grade I lumbar spondylolisthesis: 5-year follow-up from the prospective multicenter Quality Outcomes Database registry","volume":"54","author":"Chan AK","year":"2023","unstructured":"Chan AK, Bydon M, Bisson EF,  Minimally invasive versus open transforaminal lumbar interbody fusion for grade I lumbar spondylolisthesis: 5-year follow-up from the prospective multicenter Quality Outcomes Database registry. Neurosurg Focus. 2023;54(1):E2."},{"issue":"4","key":"b6","series-title":"J Spinal Disord Tech","first-page":"337","article-title":"Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients","volume":"18","author":"Potter BK","year":"2005","unstructured":"Potter BK, Freedman BA, Verwiebe EG, Hall JM, Polly DW Jr, Kuklo TR. Transforaminal lumbar interbody fusion: clinical and radiographic results and complications in 100 consecutive patients. J Spinal Disord Tech. 2005;18(4):337\u2013346."},{"issue":"3","key":"b7","series-title":"Singapore Med J","first-page":"183","article-title":"Comparison of clinical and radiological results of posterolateral fusion, posterior lumbar interbody fusion and transforaminal lumbar interbody fusion techniques in the treatment of degenerative lumbar spine","volume":"53","author":"Audat Z","year":"2012","unstructured":"Audat Z, Moutasem O, Yousef K, Mohammad B. Comparison of clinical and radiological results of posterolateral fusion, posterior lumbar interbody fusion and transforaminal lumbar interbody fusion techniques in the treatment of degenerative lumbar spine. Singapore Med J. 2012;53(3):183\u2013187."},{"issue":"2","key":"b8","series-title":"J Neurosurg Spine","first-page":"138","article-title":"Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis","volume":"15","author":"Adogwa O","year":"2011","unstructured":"Adogwa O, Parker SL, Davis BJ,  Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis. J Neurosurg Spine. 2011;15(2):138\u2013143."},{"issue":"1-2","key":"b9","series-title":"World Neurosurg","first-page":"230","article-title":"Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis","volume":"82","author":"Parker SL","year":"2014","unstructured":"Parker SL, Mendenhall SK, Shau DN,  Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg. 2014;82(1-2):230\u2013238."},{"issue":"6","key":"b10","series-title":"Spine J","first-page":"945","article-title":"Cost-effectiveness of open transforaminal lumbar interbody fusion (OTLIF) versus minimally invasive transforaminal lumbar interbody fusion (MITLIF): a systematic review and meta-analysis","volume":"21","author":"Droeghaag R","year":"2021","unstructured":"Droeghaag R, Hermans SMM, Caelers IJMH, Evers SMAA, van Hemert WLW, van Santbrink H. Cost-effectiveness of open transforaminal lumbar interbody fusion (OTLIF) versus minimally invasive transforaminal lumbar interbody fusion (MITLIF): a systematic review and meta-analysis. Spine J. 2021;21(6):945\u2013954."},{"issue":"5","key":"b11","series-title":"Eur Spine J","first-page":"1137","article-title":"Transforaminal lumbar interbody fusion vs. posterolateral instrumented fusion: cost-utility evaluation along side an RCT with a 2-year follow-up","volume":"23","author":"Christensen A","year":"2014","unstructured":"Christensen A, H\u00f8y K, B\u00fcnger C,  Transforaminal lumbar interbody fusion vs. posterolateral instrumented fusion: cost-utility evaluation along side an RCT with a 2-year follow-up. Eur Spine J. 2014;23(5):1137\u20131143."},{"key":"b12","series-title":"Methods for the Economic Evaluation of Health Care Programmes","first-page":"8","article-title":"Introduction to economic evaluation","author":"Drummond MF","year":"2015","unstructured":"Drummond MF, Sculpher MJ, Claxton K, Stoddart GL. Torrance GW, eds. Introduction to economic evaluation. In: Methods for the Economic Evaluation of Health Care Programmes. 4th ed. Oxford University Press; 2015:8-10."},{"issue":"6725","key":"b13","series-title":"BMJ","first-page":"680","article-title":"Analysis of serial measurements in medical research","volume":"300","author":"Senn S","year":"1990","unstructured":"Senn S. Analysis of serial measurements in medical research. BMJ. 1990;300(6725):680."},{"issue":"3","key":"b14","series-title":"Health Policy","first-page":"199","article-title":"EuroQol\u2014a new facility for the measurement of health-related quality of life","volume":"16","year":"1990","unstructured":"EuroQol Group. EuroQol\u2014a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199\u2013208."},{"issue":"3","key":"b15","series-title":"J Stat Softw","first-page":"1","article-title":"mice: multivariate imputation by chained equations in R","volume":"45","author":"van Buuren S","year":"2011","unstructured":"van Buuren S, Groothuis-Oudshoorn K. mice: multivariate imputation by chained equations in R. J Stat Softw. 2011;45(3):1\u201367."},{"key":"b16","article-title":"CMS Web Pricer. CMS.gov","unstructured":"CMS Web Pricer. CMS.gov. Accessed May 29, 2024. https:\/\/webpricer.mps.cms.gov\/#\/"},{"key":"b17","article-title":"Search the Physician Fee Schedule. CMS.gov","unstructured":"Search the Physician Fee Schedule. CMS.gov. Accessed May 29, 2024. https:\/\/www.cms.gov\/medicare\/physician-fee-schedule\/search?Y=0&T=4&HT=0&CT=3&H1=22633&M=5"},{"key":"b18","article-title":"CMS.gov","unstructured":"Anesthesiologists Center. CMS.gov. Accessed May 29, 2024. https:\/\/www.cms.gov\/medicare\/payment\/fee-schedules\/physician\/anesthesiologists-center"},{"key":"b19","article-title":"Hospital expenses per inpatient day across 50 states. Becker\u2019s Hospital CFO Report","author":"Gamble M","year":"2024","unstructured":"Gamble M. Hospital expenses per inpatient day across 50 states. Becker\u2019s Hospital CFO Report. February 28, 2024. Accessed May 29, 2024. https:\/\/www.beckershospitalreview.com\/finance\/hospital-expenses-per-inpatient-day-across-50-states-2024.html"},{"key":"b20","article-title":"Fact sheet: underpayment by Medicare and Medicaid","unstructured":"Fact sheet: underpayment by Medicare and Medicaid. American Hospital Association. Accessed May 29, 2024. https:\/\/www.aha.org\/fact-sheets\/2020-01-07-fact-sheet-underpayment-medicare-and-medicaid"},{"key":"b21","article-title":"Hospital Provider Cost Report. Data.CMS.gov","unstructured":"Hospital Provider Cost Report. Data.CMS.gov. Accessed May 29, 2024. https:\/\/data.cms.gov\/provider-compliance\/cost-report\/hospital-provider-cost-report\/data"},{"key":"b22","article-title":"Turquoise Health","unstructured":"Turquoise Health. Accessed May 29, 2024. https:\/\/turquoise.health\/patients"},{"issue":"6","key":"b23","series-title":"Health Aff (Millwood)","first-page":"922","article-title":"Extreme markup: the fifty US hospitals with the highest charge-to-cost ratios","volume":"34","author":"Bai G","year":"2015","unstructured":"Bai G, Anderson GF. Extreme markup: the fifty US hospitals with the highest charge-to-cost ratios. Health Aff (Millwood). 2015;34(6):922\u2013928."},{"issue":"12","key":"b24","series-title":"JAMA Netw Open","first-page":"e2140526","article-title":"Comparison of US hospital cash prices and commercial negotiated prices for 70 services","volume":"4","author":"Jiang JX","year":"2021","unstructured":"Jiang JX, Makary MA, Bai G. Comparison of US hospital cash prices and commercial negotiated prices for 70 services. 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J Vasc Surg. 2020;72(3):1068\u20131074."},{"issue":"6","key":"b29","series-title":"J Neurosurg Spine","first-page":"916","article-title":"Modeled cost-effectiveness of transforaminal lumbar interbody fusion compared with posterolateral fusion for spondylolisthesis using N2QOD data","volume":"24","author":"Carreon LY","year":"2016","unstructured":"Carreon LY, Glassman SD, Ghogawala Z, Mummaneni PV, McGirt MJ, Asher AL. Modeled cost-effectiveness of transforaminal lumbar interbody fusion compared with posterolateral fusion for spondylolisthesis using N2QOD data. J Neurosurg Spine. 2016;24(6):916\u2013921."},{"issue":"9","key":"b30","series-title":"Spine (Phila Pa 1976)","first-page":"769","article-title":"The cost effectiveness of single-level instrumented posterolateral lumbar fusion at 5 years after surgery","volume":"37","author":"Glassman SD","year":"2012","unstructured":"Glassman SD, Polly DW, Dimar JR, Carreon LY. 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