Associated risk factors for extended length of stay following anterior cervical discectomy and fusion for cervical spondylotic myelopathy

Trends and Rates of Reporting of Race, Ethnicity, and Social Determinants of Health in Spine Surgery Randomized Clinical Trials: A Systematic Review

STUDY DESIGN

A systematic review.

OBJECTIVE

We characterized the rates of sociodemographic data and social determinants of health (SDOH) reported in spinal surgery randomized control trials (RCTs) and the association between these RCTs' characteristics and their rates of reporting on race, ethnicity, and SDOH variables.

SUMMARY OF BACKGROUND DATA

Although numerous institutions maintain guidelines and recommendations regarding the inclusion and reporting of sociodemographic and SDOH variables in RCTs, the proportion of studies that ultimately report such information is unclear, particularly in spine surgery.

MATERIALS AND METHODS

We searched the MEDLINE, PubMed, and Embase databases for published results from spinal surgery RCTs from January 2002 through December 2022, and screened studies according to prespecified inclusion criteria regarding analysis and reporting of sociodemographic and SDOH variables.

RESULTS

We analyzed 421 studies. Ninety-six studies (22.8%) reported race, ethnicity, or SDOH covariates. On multivariate analysis, study size [rate ratio (RR)=1.18; 95% CI, 1.06-1.32], public/institutional funding (RR=2.28; 95% CI, 1.29-4.04), and private funding (RR=3.27; 95% CI, 1.87-5.74) were significantly associated with reporting race, ethnicity, or SDOH variables. Study size (RR=1.26; 95% CI, 1.07-1.48) and North American region (RR=21.84; CI, 5.04-94.64) were associated with a higher probability of reporting race and/or ethnicity. Finally, study size (RR=1.27; 95% CI, 1.10-1.46), public/institutional funding (RR=2.68; 95% CI, 1.33-5.39), focus on rehabilitation/therapy intervention (RR=2.70; 95% CI, 1.40-5.21), and nonblinded study groups (RR=2.70; 95% CI, 1.40-5.21) were associated with significantly higher probability of reporting employment status.

CONCLUSION

Rates of reporting race, ethnicity, and SDOH variables were lower in the spinal surgery RCTs in our study than in RCTs in other medical disciplines. These reporting rates did not increase over a 20-year period. Trial characteristics significantly associated with higher rates of reporting were larger study size, North American region, private or public funding, and a focus on behavioral/rehabilitation interventions.

LEVEL OF EVIDENCE

Level III.

Clinicosocial determinants of hospital stay following cervical decompression: A public healthcare perspective and machine learning model

OBJECTIVE

Post-operative length of hospital stay (LOS) is a valuable measure for monitoring quality of care provision, patient recovery, and guiding hospital resource management. But the impact of patient ethnicity, socio-economic deprivation as measured by the indices of multiple deprivation (IMD), and pre-existing health conditions on LOS post-anterior cervical decompression and fusion (ACDF) is under-researched in public healthcare settings.

METHODS

From 2013 to 2023, a retrospective study at a single center reviewed all ACDF procedures. We analyzed 14 non-clinical predictors-including demographics, comorbidities, and socio-economic status-to forecast a categorized LOS: short (≤2 days), medium (2-3 days), or long (>3 days). Three machine learning (ML) models were developed and assessed for their prediction reliability.

RESULTS

2033 ACDF patients were analyzed; 79.44 % had a LOS ≤ 2 days. Significant predictors of LOS included patient sex (HR:0.81[0.74-0.88], p < 0.005), IMD decile (HR:1.38[1.24-1.53], p < 0.005), smoking (HR:1.24[1.12-1.38], p < 0.005), DM (HR:0.70[0.59-0.84], p < 0.005), and COPD (HR:0.66, p = 0.01). Asian patients had the highest mean LOS (p = 0.003). Testing on 407 patients, the XGBoost model achieved 80.95 % accuracy, 71.52 % sensitivity, 85.76 % specificity, 71.52 % positive predictive value, and a micro F1 score of 0.715. This model is available at: https://acdflos.streamlit.app.

CONCLUSIONS

Utilizing non-clinical pre-operative parameters such as patient ethnicity, socio-economic deprivation index, and baseline comorbidities, our ML model effectively predicts postoperative LOS for patient undergoing ACDF surgeries. Yet, as the healthcare landscape evolves, such tools will require further refinement to integrate peri and post-operative variables, ensuring a holistic decision support tool.

Factors Predisposing Patients to Nonhome Discharge After Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis

OBJECTIVE

The objective of this study is to evaluate factors associated with discharge to subacute care after surgery for degenerative cervical myelopathy.

DESIGN

This is a retrospective chart review of adults who underwent cervical spine surgery for degenerative cervical myelopathy between 2014 and 2020 ( N = 135).

RESULTS

Patients discharged to a subacute setting were older (68.1 ± 8.6 vs. 64.1 yrs ± 8.8, P = 0.01), more likely to be unmarried (55.8% vs. 33.7% married, P = 0.01), and more likely to have Medicare or Medicaid (83.7% vs. 65.9% private insurance, P = 0.03) than patients discharged home. A posterior surgical approach was associated with discharge to a subacute setting (62.8% vs. 43.5% anterior approach, P = 0.04). A total of 87.8% of patients discharged to a subacute setting required moderate or maximum assistance for bed mobility versus 26.6% of patients discharged home ( P < 0.0001). Compared with patients discharged home, patients discharged to a subacute setting ambulated a shorter distance in their first physical therapy evaluation after surgery (8.9 ± 35.8 vs. 53.7 ± 61.78 m in the home discharge group, P < 0.0001).

CONCLUSIONS

Analysis of these factors may guide discussions about patient expectations for postoperative discharge placement.

The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF)

Background

Anterior cervical discectomy and fusion (ACDF) is a reliable procedure commonly performed in older patients with degenerative diseases of the cervical spine. Over 130,000 procedures are performed every year with an annual increase of 5%, and overall morbidity rates can reach as high as 19.3%, indicating a need for surgeons to gauge their patients' risk for adverse outcomes. Frailty is an age-associated decline in functioning of multiple organ systems and has been shown to predict adverse outcomes following various spine procedures. There have been several proposed frailty indices of various factors including the 11-factor modified frailty index (mFI-11), which has been shown to be an effective tool for predicting complications in patients undergoing ACDF. However, there is a paucity of literature assessing the utility of the 5-factor modified frailty index (mFI-5) as a risk stratification tool for patients undergoing ACDF. The purpose of this study was to analyze the predictive capability of the mFI-5 score for 30-day postoperative adverse events following elective ACDF.

Methods

A retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2019. Patients older than 50 years of age who underwent elective ACDF were identified using Current Procedural Terminology ([CPT] codes 22554, 22551, 22552, and 63075). Exclusion criteria removed patients under the age of 51, as well as those with fractures, sepsis, disseminated cancer, a prior operation in the last 30 days, ascites, wound infection, or an emergency surgery. Patients were grouped using mFI scores of 1, 2, and 3+. Univariate analysis, using chi-squared and one-way analysis of variance (ANOVA) tests, was conducted to compare demographics, comorbidities, and postoperative complications across the varying cohorts based on mFI-5 scores. Multivariate logistic regression, including patient demographics and preoperative comorbidities as covariates, was performed to evaluate if mFI-5 scores were independent predictors of 30-day postoperative adverse events. Covariates including race, BMI, sex, ASA, and comorbidities were included in regression models.

Results

The 45,991 patients were identified and allocated in cohorts based on mFI-5 score. Rates for superficial surgical site infection (SSI), organ/deep space SSI, pneumonia, progressive renal insufficiency, acute renal failure (ARF), urinary tract infection (UTI), stroke/cardiovascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, bleeding requiring transfusions, deep vein thrombosis/thrombophlebitis, sepsis, septic shock, readmissions, reoperation, and mortality incrementally increased with mFI-5 scores from 0 to 3+. Multivariate regression analysis revealed that mFI-5 scores 1 to 3+ increased the odds, in a stepwise manner, of total complications, cardiac arrest requiring CPR, pneumonia and mortality. MFI-5 scores of 2 and 3+ were independent predictors of readmission (2: OR=1.5, p<.001; 3+: OR=2.0, p<.001) and myocardial infarction (2: OR=3.4, p=.001; 3+: OR=6.9, p<.001). A score of 3+ increased the odds of ARF (OR=9.7, p=.022), septic shock (OR=3.6, p=.036), UTI (OR=2.1, p=.007), bleeding requiring transfusions (OR=2.1, p=.016), and reoperations (OR=1.7, p=.004).

Conclusion

mFI-5 score is a quick and viable option for surgeons to use as an assessment tool to stratify high risk patients undergoing elective ACDF, as increasing mFI-5 scores showed significantly higher rates of all adverse outcomes accounted for in this study, except for deep incisional SSI, wound disruption, and PE. Additionally, moderate to severe mFI-5 scores of 2 or 3+ were independent predictors for 30-day postoperative ARF, UTI, MI, bleeding requiring transfusions, septic shock, reoperation, and readmissions following elective ACDF surgery in adults over 50 years old.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Safety and Efficacy of Zero-Profile Polyetheretherketone (PEEK) Cages Filled with Biphasic Calcium Phosphate (BCP) in Anterior Cervical Discectomy and Fusion (ACDF): A Case Series

Background: In the evolving landscape of anterior cervical discectomy and fusion (ACDF), the integration of biomechanical advancements and proper fusion-enhancing materials is crucial for optimizing patient outcomes. This case series evaluates the efficacy and clinical implications of employing zero-profile polyetheretherketone (PEEK) cages filled with biphasic calcium phosphate (BCP) in ACDF procedures, focusing on fusion and subsidence rates alongside patient disability, residual pain, and quality of life. Methods: This case series comprises 76 consecutive patients, with a median follow-up of 581 days. The Bridwell classification system was used for assessing fusion rates while subsidence occurrence was recorded, correlating these radiographic outcomes with clinical implications. Results: The results demonstrated a satisfactory fusion rate (76.4% for grades I and II). The subsidence rate was low (6.74% of segments). Significant clinical improvements were observed in pain, disability, and quality-of-life metrics, aligning with the minimum clinically important difference thresholds; however, subgroup analyses demonstrated that subsidence or pseudoarthrosis group improvement of PROMs was not statistically significant with respect to baseline. ANOVA analyses documented that subsidence has a significant weight over final follow-up pain and disability outcomes. No dysphagia cases were reported. Conclusions: These findings underscore the efficacy of zero-profile PEEK cages filled with BCP in ACDF, highlighting their potential to improve patient outcomes while minimizing complications. Pseudoarthrosis and subsidence have major implications over long-term PROMs. The study reinforces the importance of selecting appropriate surgical materials to enhance the success of ACDF procedures.

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis

Background

Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.

Methods

A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.

Results

Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).

Conclusions

Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis

INTRODUCTION

The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM).

METHODS

Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs.

RESULTS

A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052).

CONCLUSIONS

Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Socioeconomic Influence on Cervical Fusion Outcomes

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

The aim of this study was to compare postoperative outcomes following cervical fusion based on socioeconomic status (SES) variables including race, education, net worth, and homeownership status.

SUMMARY OF BACKGROUND DATA

Previous studies have demonstrated the effects of patient race and income on outcomes following cervical fusion procedures. However, no study to date has comprehensively examined the impact of multiple SES variables. We hypothesized that race, education, net worth, and homeownership influence important outcomes following cervical fusion.

MATERIALS AND METHODS

Optum's de-identified Clinformatics Data Mart (CDM) database was queried for patients undergoing first-time inpatient cervical fusion from 2003 to 2021. Patient demographics, SES variables, and the Charlson comorbidity index were obtained. Primary outcomes were hospital length of stay and 30-day rates of reoperation, readmission, and postoperative complications. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges.

RESULTS

A total of 111,914 patients underwent cervical spinal fusion from 2003 to 2021. Multivariate analysis revealed that after controlling for age, sex, and Charlson comorbidity index, Black race was associated with a higher rate of 30-day readmissions [odds ratio (OR): 1.11, 95% CI: 1.03-1.20]. Lower net worth (vs. >$500K) and renting (vs. owning a home) were significantly associated with both higher rates of 30-day readmissions (OR: 1.29, 95% CI: 1.17-1.41; OR: 1.34, 95% CI: 1.22-1.49), and emergency room visits (OR: 1.29, 95% CI: 1.18-1.42; OR: 1.11, 95% CI: 1.00-1.23). Lower net worth (vs. >$500K) was also associated with increased complications (OR: 1.22, 95% CI: 1.14-1.31).

CONCLUSION

Socioeconomic variables, including patient race, education, and net worth, influence postoperative metrics in cervical spinal fusion surgery. Future studies should focus on developing and implementing targeted interventions based on patient SES to reduce disparity.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI.

METHODS

The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05.

RESULTS

Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003).

CONCLUSIONS

Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic

BACKGROUND

Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic.

METHODS

We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables.

RESULTS

Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased.

CONCLUSIONS

We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S.

POPULATION

Reliable Prediction of Discharge Disposition Following Cervical Spine Surgery With Ensemble Machine Learning and Validation on a National Cohort

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The purpose of this study is to develop a machine learning algorithm to predict nonhome discharge after cervical spine surgery that is validated and usable on a national scale to ensure generalizability and elucidate candidate drivers for prediction.

SUMMARY OF BACKGROUND DATA

Excessive length of hospital stay can be attributed to delays in postoperative referrals to intermediate care rehabilitation centers or skilled nursing facilities. Accurate preoperative prediction of patients who may require access to these resources can facilitate a more efficient referral and discharge process, thereby reducing hospital and patient costs in addition to minimizing the risk of hospital-acquired complications.

METHODS

Electronic medical records were retrospectively reviewed from a single-center data warehouse (SCDW) to identify patients undergoing cervical spine surgeries between 2008 and 2019 for machine learning algorithm development and internal validation. The National Inpatient Sample (NIS) database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for external validation of algorithm performance. Gradient-boosted trees were constructed to predict nonhome discharge across patient cohorts. The area under the receiver operating characteristic curve (AUROC) was used to measure model performance. SHAP values were used to identify nonlinear risk factors for nonhome discharge and to interpret algorithm predictions.

RESULTS

A total of 3523 cases of cervical spine fusion surgeries were included from the SCDW data set, and 311,582 cases were isolated from NIS. The model demonstrated robust prediction of nonhome discharge across all cohorts, achieving an area under the receiver operating characteristic curve of 0.87 (SD=0.01) on both the SCDW and nationwide NIS test sets. Anterior approach only, age, elective admission status, Medicare insurance status, and total Elixhauser Comorbidity Index score were the most important predictors of discharge destination.

CONCLUSIONS

Machine learning algorithms reliably predict nonhome discharge across single-center and national cohorts and identify preoperative features of importance following cervical spine fusion surgery.

Impact of Preoperative Frailty on Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Anterior vs. Posterior Cervical Surgery

Introduction: Frailty has been shown to negatively influence patient outcomes across many disease processes, including in the cervical spondylotic myelopathy (CSM) population. The aim of this study was to assess the impact that frailty has on patients with CSM who undergo anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF). Materials and Methods: A retrospective cohort study was performed using the 2016-2019 national inpatient sample. Adult patients (≥18 years old) undergoing ACDF only or PCDF only for CSM were identified using ICD codes. The patients were categorized based on receipt of ACDF or PCDF and pre-operative frailty status using the 11-item modified frailty index (mFI-11): pre-Frail (mFI = 1), frail (mFI = 2), or severely frail (mFI ≥ 3). Patient demographics, comorbidities, operative characteristics, perioperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS) and non-routine discharge (NRD). Results: A total of 37,990 patients were identified, of which 16,665 (43.9%) were in the pre-frail cohort, 12,985 (34.2%) were in the frail cohort, and 8340 (22.0%) were in the severely frail cohort. The prevalence of many comorbidities varied significantly between frailty cohorts. Across all three frailty cohorts, the incidence of AEs was greater in patients who underwent PCDF, with dysphagia being significantly more common in patients who underwent ACDF. Additionally, the rate of adverse events significantly increased between ACDF and PCDF with respect to increasing frailty (p < 0.001). Regarding healthcare resource utilization, LOS and rate of NRD were significantly greater in patients who underwent PCDF in all three frailty cohorts, with these metrics increasing with frailty in both ACDF and PCDF cohorts (LOS: p < 0.001); NRD: p < 0.001). On a multivariate analysis of patients who underwent ACDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.39, p < 0.001; (severely frail) OR: 2.25, p < 0.001] and NRD [(frail) OR: 1.49, p < 0.001; (severely frail) OR: 2.22, p < 0.001]. Similarly, in patients who underwent PCDF, frailty and severe frailty were found to be independent predictors of extended LOS [(frail) OR: 1.58, p < 0.001; (severely frail) OR: 2.45, p < 0.001] and NRD [(frail) OR: 1.55, p < 0.001; (severely frail) OR: 1.63, p < 0.001]. Conclusions: Our study suggests that preoperative frailty may impact outcomes after surgical treatment for CSM, with more frail patients having greater health care utilization and a higher rate of adverse events. The patients undergoing PCDF ensued increased health care utilization, compared to ACDF, whereas severely frail patients undergoing PCDF tended to have the longest length of stay and highest rate of non-routine discharge. Additional prospective studies are necessary to directly compare ACDF and PCDF in frail patients with CSM.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Socioeconomic Effects on Lumbar Fusion Outcomes

BACKGROUND

Recent studies suggest that socioeconomic status (SES) influences outcomes after spinal fusion. The influence of SES on postoperative outcomes is increasingly relevant as rates of lumbar fusion rise.

OBJECTIVE

To determine the influence of SES variables including race, education, net worth, and homeownership on postoperative outcomes.

METHODS

Optum's deidentified Clinformatics Data Mart Database was used to conduct a retrospective review of SES variables for patients undergoing first-time, inpatient lumbar fusion from 2003 to 2021. Primary outcomes included hospital length of stay (LOS) and 30-day reoperation, readmission, and postoperative complication rates. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges.

RESULTS

In total, 217 204 patients were identified. On multivariate analysis, Asian, Black, and Hispanic races were associated with increased LOS (Coeff. [coefficient] 0.92, 95% CI 0.68-1.15; Coeff. 0.61, 95% CI 0.51-0.71; Coeff. 0.43, 95% CI 0.32-0.55). Less than 12th grade education (vs greater than a bachelor's degree) was associated with increased odds of reoperation (OR [odds ratio] 1.88, 95% CI 1.03-3.42). Decreased net worth was associated with increased odds of readmission (OR 1.32, 95% CI 1.25-1.40) and complication (OR 1.14, 95% CI 1.10-1.20). Renting a home (vs homeownership) was associated with increased LOS, readmissions, and total charges (Coeff. 0.30, 95% CI 0.17-0.43; OR 1.19, 95% CI 1.11-1.30; Coeff. 13 200, 95% CI 9000-17 000).

CONCLUSION

Black race, less than 12th grade education, <$25K net worth, and lack of homeownership were associated with poorer postoperative outcomes and increased costs. Increasing perioperative support for patients with these sociodemographic risk factors may improve postoperative outcomes.

Neighborhood-level socioeconomic status, extended length of stay, and discharge disposition following elective lumbar spine surgery

Background

In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery.

Methods

We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively.

Results

779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge.

Conclusions

Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

Neighborhood-level Socioeconomic Status Predicts Extended Length of Stay Following Elective Anterior Cervical Spine Surgery

BACKGROUND

A significant portion of healthcare spending is driven by a small percentage of the overall population. Understanding risk factors predisposing patients to disproportionate utilization of healthcare resources is critical. Our objective was to identify risk factors leading to a prolonged length of stay (LOS) following cervical spine surgery.

METHODS

A single center cohort analysis was performed on patients who underwent elective anterior spine surgery from 2015-2021. Multivariate logistic regression evaluated the effects of sociodemographic factors including Area of Deprivation Index (quantifies income, education, employment, and housing quality), procedural, and discharge characteristics on postoperative LOS. Extended LOS was defined as greater than the 90^th percentile in midnights for the study population (greater than or equal to three midnights).

RESULTS

There were 686 patients included in the study, with a mean age of 57 years (range 26-92), median of 1 level (1-4) fused, and median LOS of 1 midnight (IQR 1,2). After adjusting for confounders, patients had increased odds of extended LOS if they were highly disadvantaged on the Area of Deprivation Index (ADI, OR=2.24, 95% CI=1.04 - 4.82; p=.039); had surgery on Thursday or Friday (OR=1.94; 1.01 - 3.72; p=.046); had a corpectomy performed (OR=2.81; 1.26 - 6.28; p=.012); or discharged not to home (OR=8.24; 2.88 - 23.56; p<.001). Patients with extended LOS were more likely to present to the emergency department or be re-admitted within 30 days after discharge (p=.024).

CONCLUSION

After adjusting for potential cofounders, patients most disadvantaged on ADI were more likely to have an extended LOS.

Clinical outcomes after 4- and 5-level Anterior Cervical Discectomy and Fusion for treatment of symptomatic multilevel cervical spondylosis

OBJECTIVE

There are limited patient-reported outcome measure (PROM) data on 4- and 5-level ACDF. The largest series to date solely focused on complications. This retrospective series evaluates PROMs after 4- and 5-level ACDF.

METHODS

Pertinent data from adult patients treated with a 4- or 5-level ACDF in 2011-2019 were analyzed. PROMs and minimal clinically important differences (MCID) were assessed. Factors associated with favorable and unfavorable outcomes were identified.

RESULTS

There were thirty-four patients (thirty underwent 4-level and four underwent 5-level ACDFs) with mean age of 59.6; 55.9% were women. At 3 months, there were significant improvements in PROMs except SF-12 MCS with modest improvement. At 12 months, there were significant improvements in PROMs except SF-12 PCS with moderate improvement. The proportions of patients that met the MCID cut-offs ranged from 35.3% (NRS-neck) to 75% (VR-12 PCS) at 3 months and 38.2% (NRS-arm) to 65.5% (VR-12 MCS) at 12 months. Shorter symptom duration was associated with significantly reduced postoperative pain and NDI scores. Shorter length of stay was associated with significantly improved postoperative functional outcomes. 4-level compared 5-level ACDF patients achieved better postoperative PROMs. Shorter procedure duration was associated with improved PROMs at 3 months. No patients returned to the operating room within 30 days. Patients that required reoperation achieved significantly inferior NDI, NRS-neck, and SF-12 PCS at 3 months.

CONCLUSIONS

This study demonstrated satisfactory PROMs up to 12 months after 4- and 5-level ACDF despite the complication rate. With thorough preoperative planning and meticulous technique, performing this procedure in carefully selected patients may be associated with acceptable PROM.

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis

BACKGROUND

As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost.

CONCLUSION

Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Association Between Patient Diversity in Hospitals and Racial/Ethnic Differences in Patient Length of Stay

BACKGROUND

Hospitals serving a disproportionate share of racial/ethnic minorities have been shown to have poorer quality outcomes. It is unknown whether efficiencies in inpatient care, measured by length of stay (LOS), differ based on the proportion patients served by a hospital who are minorities.

OBJECTIVE

To examine the association between the racial/ethnic diversity of a hospital's patients and disparities in LOS.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

One million five hundred forty-six thousand nine hundred fifty-five admissions using the 2017 New York State Inpatient Database from the Healthcare Cost and Utilization Project.

MAIN MEASURE

Differences in mean adjusted LOS (ALOS) between White and Black, Hispanic, and Other (Asian, Pacific Islander, Native American, and Other) admissions by Racial/Ethnic Diversity Index (proportion of non-White patients admitted to total patients admitted to that same hospital) in quintiles (Q1 to Q5), stratified by discharge destination. Mean LOS was adjusted for patient demographic, clinical, and admission characteristics and for individual intercepts for each hospital.

KEY RESULTS

In both unadjusted and adjusted analysis, Black-White and Other-White mean LOS differences were smallest in the most diverse hospitals (Black-White: unadjusted, -0.07 days [-0.1 to -0.04], and adjusted, 0.16 days [95% CI: 0.16 to 0.16]; Other-White: unadjusted, -0.74 days [95% CI: -0.77 to -0.71], and adjusted, 0.01 days [95% CI: 0.01 to 0.02]). For Hispanic patients, in unadjusted analysis, the mean LOS difference was greatest in the most diverse hospitals (-0.92 days, 95% CI: -0.95 to -0.89) but after adjustment, this was no longer the case. Similar patterns across all racial/ethnic groups were observed after analyses were stratified by discharge destination.

CONCLUSION

Mean adjusted LOS differences between White and Black patients, and White and patients of Other race was smallest in most diverse hospitals, but not differences between Hispanic and White patients. These findings may reflect specific structural factors which affect racial/ethnic differences in patient LOS.

Early Outcomes of Elective Anterior Cervical Diskectomy and Fusion for Degenerative Spine Disease Correlate With the Specialty of the Surgeon Performing the Procedure

BACKGROUND

Comparative effectiveness research has a vital role in recent health reform and policies. Specialty training is one of these provider-side variables, and surgeons who were trained in different specialties may have different outcomes on performing the same procedure.

OBJECTIVE

To investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective anterior cervical diskectomy and fusion (ACDF) for degenerative spine diseases.

METHODS

This was a retrospective, 1:1 propensity score-matched cohort study. In total, 21 211 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were performed.

RESULTS

In both groups (single-level/multilevel ACDF), patients operated on by neurosurgeons had longer operation time (133 vs 104 min/164 vs 138 min), shorter total hospital stay (24 vs 41 h/25 vs 46 h), and lower rates of return to operating room (0.7% vs 2.1%/0.6% vs 2.4%), nonhome discharge (1.2% vs 4.6%/1.0% vs 4.9%), discharge after postoperative day 1 (6.7% vs 11.9%/10.1% vs 18.9%), perioperative blood transfusion (0.4% vs 2.1%/0.6% vs 3.1%), and sepsis (0.2% vs 0.7%/0.1% vs 0.7%; P < .05). In the single-level ACDF group, patients operated on by neurosurgeons had lower readmission (1.9% vs 4.1%) and unplanned intubation rates (0.1% vs 1.1%; P < .05). Other outcome measures and mortality rates were similar among the 2 cohorts in both groups.

CONCLUSION

Our analysis found significant differences in early perioperative outcomes of patients undergoing ACDF by neurosurgeons and orthopedic surgeons. These differences might have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

Independent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The prevalence of obesity continues to rise in the United States at a disparaging rate. Although previous studies have attempted to identify the influence obesity has on short-term outcomes following elective spine surgery, few studies have assessed the impact on discharge disposition following anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). The aim of this study was to determine whether obesity impacts the hospital management, cost, and discharge disposition after elective ACDF for adult CSM.

METHODS

The National Inpatient Sample database was queried using the International Classification of Diseases, 10th revision, Clinical Modification, coding system to identify all (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF for the years 2016 and 2017. Discharge weights were used to estimate national demographics, Elixhauser comorbidities, complications, length of stay, total cost of admission, and discharge disposition.

RESULTS

There were 17,385 patients included in the study, of whom 3035 (17.4%) had obesity (no obesity: 14,350; obesity: 3035). The cohort with obesity had a significantly greater proportion of patients with 3 or more comorbidities compared with the cohort with no obesity (no obesity: 28.1% vs. obesity: 43.5%, P < 0.001). The overall complication rates were greater in the cohort with obesity (no obesity: 10.3% vs. obesity: 14.3%, P = 0.003). On average, the cohort with obesity incurred a total cost of admission $1154 greater than the cost of the cohort with no obesity (no obesity: $19,732 ± 11,605 vs. obesity: $20,886 ± 10,883, P = 0.034) and a significantly greater proportion of nonroutine discharges (no obesity: 16.6% vs. obesity: 24.2%, P < 0.001). In multivariate regression analysis, obesity, age, race, health care coverage, hospital bed size, region, comorbidity, and complication rates all were independently associated with nonroutine discharge disposition.

CONCLUSIONS

Our study demonstrates that obesity is an independent predictor for nonroutine discharge disposition following elective anterior cervical discectomy and fusion for cervical spondylotic myelopathy.