Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery

Amit Jain, Samrat Yeramaneni, Khaled M. Kebaish, Micheal Raad, Jeffrey L. Gum, Eric O. Klineberg, Hamid Hassanzadeh, Michael P. Kelly, Peter G. Passias, Christopher P. Ames, Justin S. Smith, Christopher I. Shaffrey, Shay Bess, Virginie Lafage, Steve Glassman, Leah Y. Carreon, Richard A. Hostin

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Study Design.Economic modeling of data from a multicenter, prospective registry.Objective.The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.Summary of Background Data.ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.Methods.Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).Results.BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients.Conclusion.BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.Level of Evidence: 2.

Original languageEnglish (US)
Pages (from-to)1009-1015
Number of pages7
Issue number14
StatePublished - Jul 15 2020


  • Monte Carlo simulation
  • adult spinal deformity
  • cost-utility analysis
  • health economics
  • health utility
  • nonunion
  • pseudarthrosis
  • recombinant human bone morphogenetic protein-2
  • reoperation
  • revision surgery

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Clinical Neurology


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