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Elsamadicy AA, Koo AB, Sherman JJZ, Sarkozy M, Reeves BC, Craft S, Sayeed S, Sandhu MRS, Hersh AM, Lo SFL, Shin JH, Mendel E, Sciubba DM. Association of frailty with healthcare resource utilization after open thoracic/thoracolumbar posterior spinal fusion for adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07635-2. [PMID: 36949143 DOI: 10.1007/s00586-023-07635-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/24/2023] [Accepted: 03/04/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE The Hospital Frailty Risk Score (HFRS) is a frailty-identifying metric developed using ICD-10-CM codes. While other studies have examined frailty in adult spinal deformity (ASD), the HFRS has not been assessed in this population. The aim of this study was to utilize the HFRS to investigate the impact of frailty on outcomes in ASD patients undergoing posterior spinal fusion (PSF). METHODS A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults with ASD undergoing elective PSF were identified using ICD-10-CM codes. Patients were categorized into HFRS-based frailty cohorts: Low (HFRS < 5) and Intermediate-High (HFRS ≥ 5). Patient demographics, comorbidities, intraoperative variables, and outcomes were assessed. Multivariate regression analyses were used to determine whether HFRS independently predicted extended length of stay (LOS), non-routine discharge, and increased cost. RESULTS Of the 7500 patients identified, 4000 (53.3%) were in the Low HFRS cohort and 3500 (46.7%) were in the Intermediate-High HFRS cohort. On average, age increased progressively with increasing HFRS scores (p < 0.001). The frail cohort experienced more postoperative adverse events (p < 0.001), greater LOS (p < 0.001), accrued greater admission costs (p < 0.001), and had a higher rate of non-routine discharge (p < 0.001). On multivariate analysis, Intermediate-High HFRS was independently associated with extended LOS (OR: 2.58, p < 0.001) and non-routine discharge (OR: 1.63, p < 0.001), though not increased admission cost (OR: 1.01, p = 0.929). CONCLUSION Our study identified HFRS to be significantly associated with prolonged hospitalizations and non-routine discharge. Other factors that were found to be associated with increased healthcare resource utilization include age, Hispanic race, West hospital region, large hospital size, and increasing number of AEs.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Mani Ratnesh S Sandhu
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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Elsamadicy AA, Sandhu MRS, Reeves BC, Freedman IG, Koo AB, Jayaraj C, Hengartner AC, Havlik J, Hersh AM, Pennington Z, Lo SFL, Shin JH, Mendel E, Sciubba DM. Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity. Spine Deform 2023; 11:439-453. [PMID: 36350557 DOI: 10.1007/s43390-022-00609-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/29/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD. METHODS A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost. RESULTS Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis. CONCLUSION Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
| | - Mani Ratnesh S Sandhu
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Christina Jayaraj
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Andrew M Hersh
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, USA
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Elsamadicy AA, Sandhu MRS, Reeves BC, Sherman JJZ, Craft S, Williams M, Shin JH, Sciubba DM. Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity. Clin Neurol Neurosurg 2022; 224:107532. [PMID: 36436433 DOI: 10.1016/j.clineuro.2022.107532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/16/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity. METHODS A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD). RESULTS Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077). CONCLUSION Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States.
| | - Mani Ratnesh S Sandhu
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Mica Williams
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, United States; Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, United States
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Ouyang H, Hu Y, Hu W, Zhang H, Sun Z, Tang Y, Jiang Y, Chen J, Dong S, Li W, Tian Y. Incidences, causes and risk factors of unplanned reoperations within 30 days of spine surgery: a single-center study based on 35,246 patients. Spine J 2022; 22:1811-1819. [PMID: 35878756 DOI: 10.1016/j.spinee.2022.07.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Unplanned reoperation, a quality indicator in spine surgery, has not been sufficiently investigated in a large-scale, single-center study. PURPOSE To assess the incidences, causes, and risk factors of unplanned reoperations within 30 days of spine surgeries in a single-center study. STUDY DESIGN Retrospective observational study. PATIENT SAMPLE A cohort of 35,246 patients who underwent spinal surgery in our hospital were included. OUTCOME MEASURES The rates, chief reasons, and risk factors for unplanned reoperations within 30 days of spine surgery. METHODS We retrospectively analyzed the data for patients who underwent spine surgeries for degenerative spinal disorders, tumor, or deformity and had subsequent unplanned operations within 30 days at a single tertiary academic hospital from January 2016 to July 2021. Univariate and multivariate analyses were performed to assess the incidences, causes, and risk factors. RESULTS Out of 35,246 spinal surgery patients, 297 (0.84%) required unplanned reoperations within 30 days of spine surgery. Patients with a thoracic degenerative disease (3.23%), spinal tumor (1.63%), and spinal deformity (1.50%) had significantly higher rates of reoperation than those with atlantoaxial (0.61%), cervical (0.65%), and lumbar (0.82%) degenerative disease. The common causes for reoperation included epidural hematoma (0.403%), wound infections (0.148%), neurological deficit (0.108%), and pedicle screw malposition (0.077%). Unplanned reoperations were classified as hyperacute (45.45%), acute (30.98%), subacute (15.82%), or chronic (7.74%). Univariate analysis indicated that 20 clinical factors were associated with unplanned reoperation (p<.05). Multivariate Poisson regression analysis revealed that anemia (p<.001), osteoporosis (p=.048), ankylosing spondylitis (p=.008), preoperative foot drop (p=.011), deep venous thrombosis (p<.001), and previous surgical history (p<.001) were independent risk factors for unplanned spinal reoperation. CONCLUSIONS The incidence of unplanned spinal reoperations was 0.84%. The chief common causes were epidural hematoma, wound infections, neurological deficit, and pedicle screw malposition. Anemia, osteoporosis, ankylosing spondylitis, preoperative foot drop, deep venous thrombosis, and previous surgical history led to an increased risk of unplanned reoperation within 30 days of spine surgery.
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Affiliation(s)
- Hanqiang Ouyang
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Yuanyu Hu
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Wenshuang Hu
- Department of Medical Affairs, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Zhuoran Sun
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Yanchao Tang
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Yu Jiang
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Jianming Chen
- Department of Medical Record, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Shu Dong
- Department of Medical Affairs, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China.
| | - Yun Tian
- Department of Orthopedics, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Engineering Research Center of Bone and Joint Precision Medicine, No. 49 North Garden Road, Haidian District, Beijing 100191, China; Beijing Key Laboratory of Spinal Disease Research, No. 49 North Garden Road, Haidian District, Beijing 100191, China.
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Effects of preoperative nutritional status on complications and readmissions after posterior lumbar decompression and fusion for spondylolisthesis: A propensity-score analysis. Clin Neurol Neurosurg 2021; 211:107017. [PMID: 34781222 DOI: 10.1016/j.clineuro.2021.107017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Malnutrition, common in the elderly, may adversely affect healthcare outcomes. In spine surgery, malnutrition is associated with higher rates of perioperative complications, unplanned readmission, and prolonged length of stay (LOS). The aim of this study was to determine the effect of malnutrition on adverse events (AEs), unplanned readmission, and LOS in patients undergoing spine surgery for spondylolisthesis. METHODS A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2016. Adult patients who underwent posterior decompression or fusion for spondylolisthesis were identified using the ICD-9-CM coding systems. Patients were divided into two cohorts based on preoperative serum albumin levels. propensity-score (PS) matching was used to create an age- and sex-matched Nourished cohort. Patient demographics, comorbidities, LOS, and postoperative complications were collected. Multivariate logistic regression analysis was performed to identify predictors of prolonged LOS, unplanned readmission, and AEs. RESULTS Of the 2196 patients identified, 4.5% were malnourished. Patients in the Malnourished cohort were found to have significantly longer average LOS (Malnourished: 4.51 ± 3.1 days vs PS-Matched Not Nourished: 3.7 ± 3.7, p = 0.002), higher rates of AEs (Malnourished: 14.3% vs PS-Matched Nourished: 5.8%, p = 0.007), reoperation (Malnourished: 8.4% vs PS-Matched Nourished: 3.2%, p = 0.026), and unplanned readmission (Malnourished: 15.3% vs PS-Matched Nourished: 6.1%, p = 0.003). On multivariate analysis considering only preoperative data, malnutrition was a significant independent predictor of AEs [OR: 2.13, CI (1.02, 4.46), p = 0.045]. However, after correcting for the occurrence of AEs, malnutrition was not associated with total LOS [aRR: 0.29, CI (-0.37, 0.95), p = 0.392] or 30-day unplanned readmissions [aOR: 2.24, CI (0.89, 5.60), p = 0.086]. CONCLUSION Our study found that malnourished patients undergoing lumbar fusion for spondylolisthesis have significantly higher rates of AEs, unplanned readmission, and prolonged LOS than nourished patients. Further studies are necessary to corroborate our findings.
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Modified-frailty index does not independently predict complications, hospital length of stay or 30-day readmission rates following posterior lumbar decompression and fusion for spondylolisthesis. Spine J 2021; 21:1812-1821. [PMID: 34010683 DOI: 10.1016/j.spinee.2021.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Frailty has been associated with inferior surgical outcomes in various fields of spinal surgery. With increasing healthcare costs, hospital length of stay (LOS) and unplanned readmissions have emerged as clinical proxies reflecting overall value of care. However, there is a paucity of data assessing the impact that baseline frailty has on quality of care in patients with spondylolisthesis. PURPOSE The aim of this study was to investigate the impact that frailty has on LOS, complication rate, and unplanned readmission after posterior lumbar spinal fusion for spondylolisthesis. STUDY DESIGN A retrospective cohort study was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. PATIENT SAMPLE All adult (≥18 years old) patients who underwent lumbar spinal decompression and fusion for spondylolisthesis were identified using ICD-9-CM diagnosis and procedural coding systems. We calculated the modified frailty index (mFI) for each patient using 5 dichotomous comorbidities - diabetes mellitus, congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, and dependent functional status. Each comorbidity is assigned 1 point and the points are summed to give a score between 0 and 5. As in previous literature, we defined a score of 0 as "not frail", 1 as "mild" frailty, and 2 or greater as "moderate to severe" frailty. OUTCOME MEASURES Patient demographics, comorbidities, complications, LOS, readmission, and reoperation were assessed. METHODS A multivariate logistic regression analysis was used to identify independent predictors of adverse events (AEs), extended LOS, complications, and unplanned readmission. RESULTS There were a total of 5,296 patients identified, of which 2,030 (38.3%) were mFI=0, 2,319 (43.8%) patients mFI=1, and 947 (17.9%) were mFI ≥2. The mFI≥2 cohort was older (p≤.001) and had a greater average BMI (p≤.001). The mFI≥2 cohort had a slightly longer hospital stay (3.7 ± 2.3 days vs. mFI=1: 3.5 ± 2.8 days and mFI=0: 3.2 ± 2.1 days,p≤.001). Both surgical AEs and medical AEs were significantly greater in the mFI≥2 cohort than the other cohorts, (2.6% vs. mFI=1: 1.8% and mFI=0: 1.2%,p=.022) and (6.3% vs. mFI=1: 4.8% and mFI=0: 2.6%,p≤.001), respectively. While there was no significant difference in reoperation rates, the mFI≥2 cohort had greater unplanned 30-day readmission rates (8;4% vs. mFI=5.6: 4.8% and mFI=0: 3.4%,p≤.001). However, on multivariate regression analysis, mFI≥2 was not a significant independent predictor of LOS (p=.285), complications (p=.667), or 30-day unplanned readmission (p=.378). CONCLUSIONS Our study indicates that frailty, as measured by the mFI, does not significantly predict LOS, 30-day adverse events, or 30-day unplanned readmission in patients undergoing lumbar spinal decompression and fusion for spondylolisthesis. Further work is needed to better define variable inputs that make up frailty to optimize surgical outcome prediction tools that impact the value of care.
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Elsamadicy AA, Freedman IG, Koo AB, David W, Hengartner AC, Havlik J, Reeves BC, Hersh A, Pennington Z, Kolb L, Laurans M, Shin JH, Sciubba DM. Patient- and hospital-related risk factors for non-routine discharge after lumbar decompression and fusion for spondylolisthesis. Clin Neurol Neurosurg 2021; 209:106902. [PMID: 34481141 DOI: 10.1016/j.clineuro.2021.106902] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In various spinal surgeries, non-routine discharges have been associated with inferior outcomes. However, there exists a paucity of data regarding the relationship between non-routine discharge and quality of care among patients with spondylolisthesis. The aim of this study was to identify independent predictors for non-routine discharge following spinal decompression and fusion for lumbar spondylolisthesis. METHODS A retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. Adult patients (≥18 years old) who underwent spinal decompression and fusion for lumbar spondylolisthesis were identified using ICD-9-CM diagnosis and CPT procedural coding systems. The study population was divided into two cohorts based on discharge disposition: routine (RD) and non-routine discharge (NRD). Patient demographics, comorbidities, adverse events, LOS, reoperation, and readmission were assessed. A multivariate logistic regression model was used to identify the independent predictors of non-home discharge and 30-day unplanned readmission. RESULTS A total of 5252 patients were identified, of which 4316 (82.2%) had a RD and 936 (18.8%) had a NRD. The NRD cohort tended to be older (p < 0.001) and have a higher BMI (p < 0.001). Patients who experienced a NRD had a longer LOS (NRD: 4.7 ± 3.7 days vs RD: 3.1 ± 2.0 days, p < 0.001), a higher proportion of adverse events (p < 0.001), higher rates of reoperation (p = 0.005) and unplanned 30-day readmission rates (p < 0.001). On multivariate regression analysis, age [OR: 1.08, 95% CI (1.06-1.10), p < 0.001], female sex [OR: 2.01, 95% (1.51-2.69), p < 0.001], non-Hispanic Black race/ethnicity [OR: 2.10, 95% CI (1.36-3.24), p = 0.001], BMI [OR: 1.03, 95% CI (1.01-1.05), p = 0.007], dependent functional status [OR: 3.33, 95% CI (1.59 - 6.99), p = 0.001], malnourishment [OR: 2.14, 95% CI (1.27-3.62), p = 0.005], and LOS [OR: 1.26, 95% CI (1.18-1.33), p < 0.001] were all independent predictors for NRD. However, NRD did not independently predict an unplanned 30-day readmission on multivariate analysis. CONCLUSION In our study we found that on univariate analysis NRD was associated with increased adverse events, length of stay and 30-day unplanned readmission. When controlling for patient- and hospital-related factors, we found that female sex, non-Hispanic Black race, BMI, dependent functional status, malnourishment and longer LOS were independently associated with NRD. However, NRD did not independently predict an unplanned 30-day readmission.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Wyatt David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew Hersh
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA
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