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Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair. A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow‐up; or 5) had less than one‐year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs. We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n =14,919,No CP: n =61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one‐year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75‐fold increase (p< 0.001) in total inpatient/outpatient costs and a 2.26‐fold increase (p< 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14‐fold increase (p< 0.001) in total inpatient/outpatient costs and 2.00‐fold increase (p< 0.001) in pain prescription costs. Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.

The diagnosis and treatment of complex regional pain syndrome (CRPS) is challenging and there is a paucity of data describing its overall cost burden and quantifying its impact on the US healthcare system. The aim of this study was to assess the prevalence and healthcare utilization costs associated with CRPS. A retrospective longitudinal study was performed using the Truven MarketScan® database to identify patients with a new indexed diagnosis of CRPS (Type I, II, or both) from 2001 to 2012. We collected total, outpatient, and pain prescription costs three years prior to CRPS diagnosis (baseline), at year of CRPS diagnosis, and eight‐year post‐CRPS diagnosis. A longitudinal multivariate analysis was used to model the estimated total and pain prescription cost ratios comparing patients diagnosed before and after CRPS. We included 35,316 patients with a newly indexed diagnosis of CRPS (Type I: n= 18,703, Type II: n= 14,599, Unspecified: n= 2014). Baseline characteristics were similar between the CRPS cohorts. Compared to two‐ and three‐year baseline costs, one‐year prior to diagnosis for all CRPS patients yielded the highest interquartile median [IQR] costs: total costs $7904[$3469, $16,084];outpatient costs $6706[$3119, $12,715];and pain prescription costs $1862[$147, $7649]. At the year of CRPS diagnosis, the median [IQR] costs were significantly higher than baseline costs: total costs $8508[$3943, $16,666]; outpatient costs $7251[$3527, $13,568]; and pain prescription costs $2077[$140, $8856]. Over the eight‐year period after CRPS diagnosis, costs between all the years were similar, ranging from the highest (one‐year) to lowest (seven‐years), $4845 to $3888. The median total cumulative cost 8‐years after CRPS diagnosis was $43,026 and $12,037 for pain prescription costs. [Correction added on 06 November 2017 after first online publication: the preceding sentence has been updated to demonstrate the median cumulative cost in replacement of the additive cumulative mean costs.]. During the CRPS diagnosis period, patients are expected to have a total cost 2.17‐fold and prescription cost 2.56‐fold of their baseline cost annually. Our study demonstrates that there is a significant increase in cost and healthcare resource utilization one‐year prior to and around the time of CRPS diagnosis. Furthermore, there is an increased annual cost post‐diagnosis compared to baseline costs prior to CRPS diagnosis.

Unplanned 30‐day readmission rates contribute significantly to growing national healthcare expenditures. Drivers of unplanned 30‐day readmission after spinal cord stimulator (SCS) implantation are relatively unknown. The aim of this study was to determine drivers of 30‐day unplanned readmission following SCS implantation. The National Readmission Database was queried to identify all patients who underwent SCS implantation for the 2013 calendar year. Patients were grouped by readmission status, “No Readmission” and “Unplanned 30‐day Readmission.” Patient demographics and comorbidities were collected for each patient. The primary outcome of interest was the rate of unplanned 30‐day readmissions and associated driving factors. A multivariate analysis was used to determine independent predictors of unplanned 30‐day readmission after SCS implantation. We identified 1521 patients who underwent SCS implantation, with 113 (7.4%) experiencing an unplanned readmission within 30 days. Baseline patient demographics, comorbidities, and hospital characteristics were similar between both cohorts. The three main drivers for 30‐day readmission after SCS implantation include: 1) infection (not related to SCS device), 2) infection due to device (limited to only hardware infection), and 3) mechanical complication of SCS device. Furthermore, obesity was found to be an independent predictor of 30‐day readmission (OR: 1.86, p= 0.008). Our study suggests that infectious and mechanical complications are the primary drivers of unplanned 30‐day readmission after SCS implantation, with obesity as an independent predictor of unplanned readmission. Given the technological advancements in SCS, repeated studies are necessary to identify factors associated with unplanned 30‐day readmission rates after SCS implantation to improve patient outcomes and reduce associated costs.

Failed back surgery syndrome (FBSS) affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system. The aim of this study was to assess the cost differences across the different insurance providers for FBSS patients. A retrospective longitudinal study was performed using the Truven MarketScan®database to identify FBSS patients from 2001 to 2012. Patients were grouped into Commercial, Medicaid, or Medicare cohorts. We collected one‐year prior to FBSS diagnosis (baseline), then at year of spinal cord stimulation (SCS)‐implantation and nine‐year post‐SCS implantation cost outcomes. We identified 122,827 FBSS patients, with 117,499 patients who did not undergo an SCS‐implantation (Commercial: n= 49,075, Medicaid: n= 23,180, Medicare: n= 45,244) and 5328 who did undergo an SCS implantation (Commercial: n= 2279, Medicaid: n= 1003, Medicare: n= 2046). Baseline characteristics were similar between the cohorts, with the Medicare‐cohort being significantly older. Over the study period, there were significant differences in overall cost metrics between the cohorts who did not undergo SCS implantation with the Medicaid‐cohort had the lowest annual median (interquartile range) total cost (Medicaid: $4530.4 [$1440.6, $11,973.5], Medicare: $7292.0 [$3371.4, $13,989.4], Commercial: $4944.3 [$363.8, $13,294.0], p < 0.0001). However, when comparing the patients who underwent SCS implantation, the commercial‐cohort had the lowest annual median (interquartile range) total costs (Medicaid: $4045.6 [$1146.9, $11,533.9], Medicare: $7158.1 [$3160.4, $13,916.6], Commercial: $2098.1 [$0.0, $8919.6], p < 0.0001). Our study demonstrates a significant difference in overall costs between various insurance providers in the management of FBSS, with Medicaid‐insured patients having lower overall costs compared to Commercial‐ and Medicare‐patients. SCS is cost‐effective across all insurance groups (Commercial > Medicaid > Medicare) beginning at two years and continuing through nine‐year follow‐up. Further studies are necessary to understand the cost differences between these insurance providers, in hopes of reducing unnecessary health care expenditures for patients with FBSS.

Spinal cord stimulation (SCS) has emerged as an appropriate modality of treatment for intractable chronic pain. The present study examines variations in SCS trial‐to‐permanent conversion rates based on provider types performing the procedure. We designed a large, retrospective analysis using the Truven MarketScan data base analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007–2012. Patients were categorized based on provider type performing the implantation including anesthesiologists, neurosurgeons, orthopedic surgeons, and physical medicine and rehabilitation (PM&R). Univariate and multivariate models identified factors associated with successful conversion. A total of 7667 unique instances of SCS implants were identified across five providers. Overall, 4842 (63.2%) of those receiving trials underwent permanent SCS system implantation. Anesthesiology performed the majority of implants (62.8%), followed by neurosurgery (22.0%), orthopedic surgery (10.2%), and PM&R (5.3%). Compared to anesthesiologists, both neurosurgeons (OR 10.99, 95% CI [9.11, 13.25]; p< 0.001) and orthopedic surgeons (OR 4.64, 95% CI [3.81, 5.65]; p< 0.001) had significantly higher conversion rates, while PM&R (OR 0.71, 95% CI [0.58, 0.87]; p= 0.001) had significantly lower. Percutaneous implants comprised 5473 (71.4%) of all implants. Neurosurgeons and orthopedic surgeons performed a significantly greater number of paddle implants among the different providers (p< 0.0001). Explant rates were similar across all cohorts analyzed (average 11.6%; p= 0.546). In this nationwide analysis, our results suggest that over a recent five‐year period, conversion rates are highest when SCS trials are performed by neurosurgeons and orthopedic surgeons. The study has important implications for establishing uniform guidelines for training, patient selection, and education of physicians across multiple disciplines.

Certain patients ultimately undergo explantation of their spinal cord stimulation (SCS) devices. Understanding the predictors and rates of SCS explantation has important implications for healthcare resource utilization (HCRU) and pain management. The present study identifies explant predictors and discerns differences in HCRU for at‐risk populations. We designed a large, retrospective analysis using the Truven MarketScan Database. We included all adult patients who underwent a SCS trial from 2007 to 2012. Patients were grouped into cohorts that remained explant‐free or underwent explantation over a three‐year period, and multivariate models evaluated differences in healthcare resource utilization. A total of 8727 unique instances of trial implants between 2007 and 2012 were identified. Overall, 805 (9.2%) patients underwent device explantation. One year prior to SCS implantation, the explant cohort had significantly higher median baseline costs ($42,140.3 explant vs. $27,821.7 in non‐explant groups; p< 0.0001), total number of pain encounters (180 vs. 103 p< 0.0001), and associated costs ($15,446.9 vs. $9,227.9; p< 0.0001). The explant cohort demonstrated increased use of procedures (19.0 vs. 9.0; p< 0.0001) compared to non‐explanted patients. For each month after initial SCS implantation, explanted patients had a slower decrease in total costs (4% vs. 6% in non‐explant; p< 0.01). At the month of explant, explant patients were expected to have incurred 2.65 times the total cost compared to the non‐explant cohort (CR 2.65, 95% CI [1.83, 3.84]; p< 0.001). Medium volume providers had lower rates of explantation at one‐year and three‐years compared to low volume providers (p= 0.042). Increased age and Charlson index were independent predictors of explantation during the same periods. In this nationwide analysis, we identified that SCS device explantation is correlated with patients who have higher baseline costs, higher total cost post‐SCS implantation, and increased use of procedures to control pain. The higher rates of explantation at three‐years postimplant among low volume providers suggest that variations in provider experience and approach also contributes to differences in explantation rates.

Conversion rates from trial leads to permanent spinal cord stimulation (SCS) systems have important implications for healthcare resource utilization (HCRU) and pain management. We hypothesized that there is a volume‐outcome effect, with chronic pain patients who visit high volume SCS implanters will have higher trial‐to‐permanent conversion rates. We designed a large, retrospective analysis using the Truven MarketScan database analyzing adult SCS patients with provider information available, with or without IPG implantation from the years 2007 to 2012 was designed. Patients were divided into three provider‐based groups: high (>25), medium (9–24), and low (3–8) volume providers. Univariate and multivariate models identified factors associated with successful conversion. A total of 17,850 unique trial implants were performed by 3028 providers. Of 13,879 patients with baseline data available, 8981 (64.7%) progressed to permanent SCS. Higher volume providers were associated with slightly higher conversion rates (65.9% vs. 63.3% low volume, p= 0.029), explant rates (9.2% vs. 7.7% medium volume, p= 0.026), younger age (52.0 ± 13.4 years vs. 53.0 ± 13.4 years, p= 0.0026), Medicare/Medicaid (47.8% vs. 35.0% low volume, p< 0.0001), Southern region (53.5% vs. 38.9% low volume, p< 0.0001), and higher Charlson comorbidity scores (1.0 [SD = 1.4], p= 0.0002). Multivariate regression results showed female gender (1.13 [95% CI: 1.05–1.22], p< 0.001) and high volume providers associated with higher odds of successful trial conversion (1.12 [95% CI: 1.02–1.22], p= 0.014). In this nationwide analysis, high volume providers achieved higher trial‐to‐permanent SCS conversion rates than lower volume providers. The study has implications for both training requirements and referral patterns to delineate minimum implant experience necessary for provider proficiency. Future studies may be useful to understand HCRU differences.

The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique. The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer‐reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations. The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence‐based recommendations should be considered best practices in the clinical implantation of neurostimulation devices. Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.

Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past two decades the INS has established a process to use best evidence to improve care. This article updates work published by the NACC in 2014. NACC authors were chosen based on nomination to the INS executive board and were selected based on publications, academic acumen, international impact, and diversity. In areas in which evidence was lacking, the NACC used expert opinion to reach consensus. The INS has developed recommendations that when properly utilized should improve patient safety and reduce the risk of injury and associated complications with implantable devices. On behalf of INS, the NACC has published recommendations intended to reduce the risk of neurological injuries and complications while implanting stimulators.

The Neurostimulation Appropriateness Consensus Committee (NACC) was formed by the International Neuromodulation Society (INS) in 2012 to evaluate the evidence to reduce the risk of complications and improve the efficacy of neurostimulation. The first series of papers, published in 2014, focused on the general principles of appropriate practice in the surgical implantation of neurostimulation devices. The NACC was reconvened in 2014 to address specific patient care issues, including bleeding and coagulation. The INS strives to improve patient care in an evidence‐based fashion. The NACC members were appointed or recruited by the INS leadership for diverse expertise, including international clinical expertise in many areas of neurostimulation, evidence evaluation, and publication. The group developed best practices based on peer‐reviewed evidence and, in the absence of specific evidence, on expert opinion. Recommendations were based on international evidence in accordance with guideline creation. The NACC has recommended specific measures to reduce the risk of bleeding and neurological injury secondary to impairment of coagulation in the setting of implantable neurostimulation devices in the spine, brain, and periphery.

A shorter delay time from chronic pain diagnosis to spinal cord stimulation (SCS) implantation may make it more likely to achieve lasting therapeutic efficacy with SCS. The objective of this analysis was to determine the impact of pain‐to‐SCS time on patients’ post‐implant healthcare resource utilization (HCRU). A retrospective observational study was performed using a real‐world patient cohort derived from MarketScan®Commercial and Medicare Supplemental claims data bases from April 2008 through March 2013. The predictor variable was the time from the first diagnosis of chronic pain to permanent SCS implant. Using multivariable analysis, we studied the impact of pain‐to‐SCS time on HCRU in the first year post‐implant. For some regression tests, patients were grouped into terciles by HCRU. A total of 762 patients met inclusion criteria, with a median pain‐to‐SCS time of 1.35 years (Q1: 0.8, Q3: 1.9). For every one‐year increase in pain‐to‐SCS time, the odds increased by 33% for being in the high medical expenditures group (defined using the upper tercile: $4133 over above) over the low group (first lower: $603 or less). The odds increased by 39% for being in the high opioid prescriptions group (10–58 prescriptions) over the low group (0–1). The odds increased by 44% and 55%, respectively, for being in the high office visits (8–77) or hospitalizations (3–28) group over the low office visits (0–2) or hospitalizations (0) group. HCRU increased in the year following SCS implantation with longer pain‐to‐SCS time. These results suggest that considering SCS earlier in the care continuum for chronic pain may improve patient outcomes, with reductions in hospitalizations, clinic visits, and opioid usage.