Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada M5T 2S8. firstname.lastname@example.org
Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.
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Because relevant changes in the epidemiology of the traumatic spinal cord injury (SCI) has been reported, we sought to examine the demographics, injury characteristics, and clinical outcomes of patients with spine trauma who have been treated in our spine trauma center.
All consecutive patients with acute spine trauma who were admitted in our center from 1996 to 2007 were included. Comparisons among the four triennia were performed for demographics, injury characteristics, and clinical outcomes. Also, our 2001/2002 SCI data were compared with the National Trauma Registry (NTR) dataset.
There were 569 patients (394 males, 175 females; ages from 15 to 102 years, mean age of 50 years) who were admitted with acute spine trauma. Although demographic profile has been steady over the last four triennia, the frequency of more severe spine trauma at the lumbosacral levels due to falls has increased overtime. The mean length of stay and in-hospital mortality rates have not significantly changed during the past 12 years. Our in-hospital mortality rate (4%) was significantly lower than the provincial rate from the Ontario Trauma Registry (7.5%; p = 0.005). Comparisons between our SCI data and the NTR dataset showed significant differences regarding age groups.
Our results indicate that significant differences in the characteristics of acute spine trauma but not demographics have occurred overtime in our institution. Also, there were significant differences between our database and the NTR regarding age distribution. Our reduced in-hospital mortality rates in comparison with the provincial data reinforce the recommendations for early management of SCI patients in a spine trauma center.
Miscoding is a common source of error in population-based registries. Given this, we performed a validation study comparing the Canadian National Trauma Registry (NTR) data based on the 10th Revision of the International Classification of Diseases coding with clinical data from an institutional database.
All patients with acute spine trauma who were admitted to Toronto Western Hospital from May 2003 to April 2007 were included. Accuracy, sensitivity and specificity were estimated having chart data abstraction as the gold standard.
There were 92 patients with spine trauma (50 males, 42 females; ages from 16 to 102 years). The use of the NTR as a spine trauma database has an accuracy of 87%, sensitivity of 89.8% and specificity of 25%. If the same database is considered as a spinal cord injury (complete motor injury) database, there will be a decrease in the precision with an accuracy of 32.6%, sensitivity of 81.3% and specificity of 6.7%.
Our results indicate that the NTR may be relatively more precise when used as a database of spine trauma in comparison with its use as a spinal cord injury database. However, the low specificity suggests that the NTR should be comprehensively validated using data from the other institutions that contribute with data collection for the NTR.