Comparing Clinical and Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion Among Patients Aged 65 and Older Based on Insurance Type.

STUDY

DESIGN

Retrospective cohort.

OBJECTIVE

Evaluate the impact of insurance type on outcomes of ACDF among patients 65 years or older.

SUMMARY OF BACKGROUND DATA: Despite a 38.7% inflation-adjusted decrease in reimbursement for ACDF procedures in Medicare patients aged 65 years and older over the past decade, ACDF volume has increased by 24%. Value-based care studies have investigated Medicare insurance as a predictor of postoperative outcomes. However, literature examining PROMs by Medicare status, especially for elderly patients, remains limited.

METHODS

Patients aged 65 years or older who underwent 1-3 level ACDF (2014-2023) with Medicare, Medicare Advantage, or private insurance were included. Patients were excluded for ACDF performed for trauma/infection/tumor. The area deprivation index (ADI) was used to measure socioeconomic status by ZIP code. Outcomes included 30/90-day readmissions, 1-year reoperations, and PROMs-mental (MCS-12) and physical component summary (PCS-12), visual analog scale (VAS) neck and arm, neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scale. Achievement of the minimum clinically important difference (MCID) was compared between groups.

RESULTS

Three hundred three patients were included. Private insurance patients were younger than Medicare (68.8 vs. 71.8 y, P<0.001) and Medicare Advantage (68.8 vs. 70.6 y, P=0.002) patients, but otherwise the groups were demographically/surgically similar and performed similarly in postoperative outcomes and MCID achievement. Private insurance patients had worse preoperative scores and greater improvement at 1 year in NDI compared with Medicare and Medicare Advantage patients. Delta VAS arm scores were better for private insurance and Medicare Advantage patients compared with Medicare patients. However, linear regression did not show insurance as independently predictive of 1-year delta NDI scores or VAS arm scores when controlling for age, ADI percentile, number of levels fused, and preoperative scores.

CONCLUSIONS

Medicare status does not appear to impact short-term adverse outcomes or 1-year revision among elderly ACDF patients. Neither Medicare nor Medicare Advantage insurance was independently predictive of worse improvement on VAS arm or mJOA scores when controlling for relevant confounders.