Spine Journal - 2026-09-12 - Journal Article
Costs and outcomes of recombinant human bone morphogenetic protein-2 (rhBMP-2) usage in single level posterior or transforaminal lumbar interbody fusion (TLIF) in a propensity score matched national, retrospective cohort.
Chen AR, McDevitt JW, Desai PN, Bennett CF, Pickens AT, Joaquin TA, Rumalla KC, Plantz MA, Compton TM, Hoyt AK, Colman MW, Hsu WK, Patel AA, Divi SN
Topics
Key Takeaway
rhBMP-2 increased index encounter costs by 14% ($4,543.51 attributable to the biologic) in single-level P/TLIF without reducing 90-day readmission, 2-year revision fusion (2.7% vs 3.2%), or 2-year post-discharge costs compared to non-rhBMP-2 controls.
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Summary
This propensity score-matched analysis of the Premier Healthcare database (2016–2022) compared costs and clinical outcomes of single-level P/TLIF with versus without rhBMP-2 in 18,914 patients. rhBMP-2 added $4,543.51 to index encounter costs (14% increase) but produced no statistically significant difference in 90-day readmission (1.25% vs 1.39%), 2-year revision fusion (2.7% vs 3.2%), or 2-year cumulative post-discharge costs after Bonferroni correction. Cox proportional hazards modeling confirmed no protective effect of rhBMP-2 against any adverse outcome.
Key Limitation
Radiographic fusion status is not captured in claims data, so the revision surgery endpoint is a proxy for symptomatic pseudarthrosis and will miss asymptomatic or conservatively managed nonunions, potentially masking a true biological difference between groups.
Original Abstract
BACKGROUND CONTEXT
Recombinant human bone morphogenetic protein-2 (rhBMP-2) is widely used in posterior or transforaminal lumbar interbody fusion (P/TLIF). While rhBMP-2 demonstrates comparable fusion rates to autologous iliac crest bone graft (AICBG), its high cost brings into question its long-term cost effectiveness. This question is particularly pertinent in single-level P/TLIF where AICBG achieves excellent fusion rates.
PURPOSE
To evaluate the costs associated with and clinical outcomes of rhBMP-2 versus non-rhBMP-2 usage in single-level P/TLIF using a propensity score-matched national sample.
STUDY DESIGN/SETTING
Retrospective propensity score-matched cohort study using the Premier Healthcare claims database (2016-2022).
PATIENT SAMPLE
National sample of 9,457 patients who underwent single-level P/TLIF with rhBMP-2 utilization who were one-to-one matched with 9,457 P/TLIF patients without rhBMP-2 based on demographics, Elixhauser comorbidities, and surgical indications.
OUTCOME MEASURES
Primary economic outcomes were index encounter costs by category, and 2-year cumulative post-discharge costs. Primary clinical outcomes were 90-day readmission and 2-year revision fusion incidence. Secondary clinical outcomes were 2-year revision decompression incidence, pseudoarthrosis, seroma, infection, and implant complications.
METHODS
Single level P/TLIF procedures were identified via billing codes for the procedure. rhBMP-2 usage was identified via identification in the itemized billing for each procedure. Propensity scores were estimated from a multivariate logit model and matched using K Nearest Neighbors. Itemized costs were categorized using Premier Healthcare's chargemaster. Survival analysis for clinical outcomes used Kaplan-Meier Curves with log rank test and Cox Proportional Hazard models. A Bonferroni correction was established of p < 0.0035714 for 14 total clinical hypotheses tested.
RESULTS AND CONCLUSIONS
Total initial encounter costs were 14% higher in the rhBMP-2 group, primarily driven by rhBMP-2 usage ($4,543.51). 90-day spine-related readmission rates (1.25% vs 1.39%, log-rank p = 0.447), 2-year revision fusion rates (2.7% vs 3.2%, log-rank p = 0.055), and 2-year revision decompression rates (0.29% vs 0.53%, log-rank p = 0.008) were not statistically significant after Bonferroni correction. Cox proportional hazards modeling also showed no significant protective effect of rhBMP-2 against any adverse outcome after Bonferroni correction. In addition, 2-year cumulative post-discharge costs were not significantly different between groups (p = 0.558). This may be explained by significantly higher median revision fusion costs in the rhBMP-2 group.
CONCLUSIONS
These findings suggest broad usage of rhBMP-2 may not be necessary outside of select high-risk populations. Further prospective evaluation integrating radiographic and patient reports outcomes will be essential to refining the role of rhBMP-2 in modern lumbar fusion surgery.