Regarding Costandi et al. "Longevity and Utilization Cost of Rechargeable and Non-Rechargeable Spinal Cord Stimulation Implants: A Comparative Study".

I read with interest the manuscript from Costandi et al. entitled "Longevity and Utilization Cost of Rechargeable and Non-Rechargeable Spinal Cord Stimulation Implants: A Comparative Study" (1). The authors discuss cost-effectiveness of non-rechargeable versus rechargeable implantable pulse generators (IPG), and conclude that non-rechargeable SCS systems are more cost-effective from the hospital and ambulatory surgical center perspective. Similar to the authors, I favor continual assessment of the cost-effectiveness of our current neuromodulation offerings and desire to ensure the best patient outcomes while being cognizant of institutional costs. However, this manuscript has a few methodological concerns that deserve mention. First, they used Kemler's European data from 2008 to calculate IPG cost per day (2). After converting from pounds to dollars and accounting for inflation, the final costs were deemed $18,700 for non-rechargeable systems and $36,326 for rechargeable systems. These figures are inaccurate, yet they remain at the core of their conclusion. In the United States the cost differential between non-rechargeable versus rechargeable systems is much narrower, and in some instances, the exact opposite of described with non-rechargeable systems being more expensive (3). This alone makes the manuscript's conclusions unusable. A more reasonable approach would have been to use current contract costs from their institution or consider mean United States costs for these devices. In addition, it's non-traditional to consider facility acquisition costs versus reimbursement rates. Since Medicare reimbursement is the same regardless of device selection, their estimated device costs would have massive financial implications for pain practices.