Navigated and Robotic-Assisted Pedicle Screw Placement Are More Cost-Effective Than Freehand Technique for Posterior Spinal Fusion in Idiopathic Scoliosis

STUDY DESIGN: Retrospective cost-analysis study. OBJECTIVE: The primary aim of this study was to determine the cost-effectiveness from a public payer's perspective between RAN, NAV, and FH. BACKGROUND: Robotic-assisted navigation (RAN) and image-guided intraoperative navigation (NAV) are associated with higher pedicle screw placement accuracy and lower complication rates than freehand (FH) technique to treat idiopathic scoliosis. However, RAN and NAV are underutilized and payer coverage remains limited. METHODS: A Markov decision-analysis model for a cost-utility analysis of FH/NAV/RAN for patients with IS was created, and a probability sensitivity analysis was performed. Probabilities of health states, associated reimbursement costs, and quality-adjusted life years (QALYs) were estimated from literature. For each technique, incremental cost-utility ratio (ICURs), net costs, incremental net monetary benefit, net monetary benefit, and QALYs were calculated. Cost-effectiveness acceptability (CEA) curve analysis was performed by varying WTPT between 10, 000 and 250, 000. Deterministic sensitivity analysis (DSA) was performed by varying probabilities, QALYs, and costs. For cost-effective treatment strategies, cost savings to payers, if present, were calculated over a seven-year horizon. RESULTS: When compared with FH technique, the ICUR of RAN (10, 672/QALY) and NAV (-108, 831/QALY) were below the societal willingness-to-pay threshold (WTPT) of 50, 000. RAN was not more cost-effective than NAV (ICUR: 255, 518/QALY) at a WTPT of 50, 000. However, CEA demonstrated that RAN was the most cost-effective strategy for all WTPTs above 50, 000. The mean cost of NAV per patient was lower than FH by 3610 (95% CI: 3419-3801; P < 0. 001). Mean cost of RAN per patient was higher than FH by 527 (95% CI: 267-786; P < 0. 001) and NAV by 4137 (95% CI: 3953-4320; P < 0. 001). DSA demonstrated sensitivity to < 25% of variables. CONCLUSIONS: NAV and RAN are both more cost-effective than FH. NAV can save payers 45 million over seven years. Payers should consider increasing reimbursement coverage for NAV and RAN. LEVEL OF EVIDENCE: Level III.