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Fortier L, Sinkler MA, De Witt AJ, Wenger DM, Imani F, Morsali SF, Urits I, Viswanath O, Kaye AD. The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature. Anesth Pain Med 2023; 13:e136563. [PMID: 38024004 PMCID: PMC10676665 DOI: 10.5812/aapm-136563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/26/2023] [Accepted: 06/11/2023] [Indexed: 12/01/2023] Open
Abstract
There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.
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Affiliation(s)
- Luc Fortier
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Margaret A. Sinkler
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Audrey J. De Witt
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | | | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Fatemeh Morsali
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
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Rodrigues AJ, Varshneya K, Schonfeld E, Malhotra S, Stienen MN, Veeravagu A. Chronic Opioid Use Prior to ACDF Surgery Is Associated with Inferior Postoperative Outcomes: A Propensity-Matched Study of 17,443 Chronic Opioid Users. World Neurosurg 2022; 166:e294-e305. [PMID: 35809840 DOI: 10.1016/j.wneu.2022.07.002] [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: 05/18/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Candidates for anterior cervical discectomy and fusion (ACDF) have a higher rate of opioid use than does the public, but studies on preoperative opioid use have not been conducted. We aimed to understand how preoperative opioid use affects post-ACDF outcomes. METHODS The MarketScan Database was queried from 2007 to 2015 to identify adult patients who underwent an ACDF. Patients were classified into separate cohorts based on the number of separate opioid prescriptions in the year before their ACDF. Ninety-day postoperative complications, postoperative readmission, reoperation, and total inpatient costs were compared between opioid strata. Propensity score-matched patient cohorts were calculated to balance comorbidities across groups. RESULTS Of 81,671 ACDF patients, 31,312 (38.3%) were nonusers, 30,302 (37.1%) were mild users, and 20,057 (24.6%) were chronic users. Chronic opioid users had a higher comorbidity burden, on average, than patients with less frequent opioid use (P < 0.001). Chronic opioid users had higher rates of postoperative complications (9.1%) than mild opioid users (6.0%) and nonusers (5.3%) (P < 0.001) and higher rates of readmission and reoperation. After balancing opioid nonusers versus chronic opioid users along with demographic characteristics, preoperative comorbidity, and operative characteristics, postoperative complications remained elevated for chronic opioid users relative to opioid nonusers (8.6% vs. 5.7%; P < 0.001), as did rates of readmission and reoperation. CONCLUSIONS Chronic opioid users had more comorbidities than opioid nonusers and mild opioid users, longer hospitalizations, and higher rates of postoperative complication, readmission, and reoperation. After balancing patients across covariates, the outcome differences persisted, suggesting a durable association between preoperative opioid use and negative postoperative outcomes.
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Affiliation(s)
- Adrian J Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Shreya Malhotra
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, California.
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Lu CX, Huang ZB, Chen XM, Wu XD. Predicting prolonged postoperative length of stay risk in patients undergoing lumbar fusion surgery: Development and assessment of a novel predictive nomogram. Front Surg 2022; 9:925354. [PMID: 36051703 PMCID: PMC9426777 DOI: 10.3389/fsurg.2022.925354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe purpose of this study was to develop and internally validate a prediction nomogram model in patients undergoing lumbar fusion surgery.MethodsA total of 310 patients undergoing lumbar fusion surgery were reviewed, and the median and quartile interval were used to describe postoperative length of stay (PLOS). Patients with PLOS > P75 were defined as prolonged PLOS. The least absolute shrinkage and selection operator (LASSO) regression was used to filter variables for building the prolonged PLOS risk model. Multivariable logistic regression analysis was applied to build a predictive model using the variables selected in the LASSO regression model. The area under the ROC curve (AUC) of the predicting model was calculated and significant test was performed. The Kappa consistency test between the predictive model and the actual diagnosis was performed. Discrimination, calibration, and the clinical usefulness of the predicting model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was assessed using the bootstrapping validation.ResultsAccording to the interquartile range of PLOS in a total of 310 patients, the PLOS of 235 patients was ≤P75 (7 days) (normal PLOS), and the PLOS of 75 patients was > P75 (prolonged PLOS). The LASSO selected predictors that were used to build the prediction nomogram included BMI, diabetes, hypertension, duration of surgery, duration of anesthesia, anesthesia type, intraoperative blood loss, sufentanil for postoperative analgesia, and postoperative complication. The model displayed good discrimination with an AUC value of 0.807 (95% CI: 0.758–0.849, P < 0.001), a Kappa value of 0.5186 (cutoff value, 0.2445, P < 0.001), and good calibration. A high C-index value of 0.776 could still be reached in the interval validation. Decision curve analysis showed that the prolonged PLOS nomogram was clinically useful when intervention was decided at the prolonged PLOS possibility threshold of 3%.ConclusionsThis study developed a novel nomogram with a relatively good accuracy to help clinicians access the risk of prolonged PLOS in lumbar fusion surgery patients. By an estimate of individual risk, surgeons and anesthesiologists may shorten PLOS and accelerate postoperative recovery of lumbar fusion surgery through more accurate individualized treatment.
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Affiliation(s)
- Chen-Xin Lu
- Department of Anesthesiology, Fuzhou Second Hospital, Fuzhou, China
| | - Zhi-Bin Huang
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
| | - Xiao-Mei Chen
- Department of Anesthesiology, Fuzhou Second Hospital, Fuzhou, China
- Correspondence: Xiao-Dan Wu Xiao-Mei Chen
| | - Xiao-Dan Wu
- Department of Anesthesiology, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Medical University, Fuzhou, China
- Correspondence: Xiao-Dan Wu Xiao-Mei Chen
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Hamilton T, Macki M, Oh SY, Bazydlo M, Schultz L, Zakaria HM, Khalil JG, Perez-Cruet M, Aleem I, Park P, Easton R, Nerenz DR, Schwalb J, Abdulhak M, Chang V. The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study. J Neurosurg Spine 2021:1-9. [PMID: 34891131 DOI: 10.3171/2021.9.spine21421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)-level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.
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Affiliation(s)
| | | | - Seok Yoon Oh
- 2Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | | | - Lonni Schultz
- Departments of1Neurosurgery and.,3Public Health Sciences, and
| | | | | | | | | | - Paul Park
- 7Neurosurgery, University of Michigan Hospital, Ann Arbor
| | - Richard Easton
- 8Department of Orthopedic Surgery, William Beaumont Hospital-Troy, Michigan; and
| | - David R Nerenz
- 9Center for Health Services Research, Henry Ford Hospital, Detroit
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Vraa ML, Myers CA, Young JL, Rhon DI. More Than 1 in 3 Patients With Chronic Low Back Pain Continue to Use Opioids Long-term After Spinal Fusion: A Systematic Review. Clin J Pain 2021; 38:222-230. [PMID: 34856579 DOI: 10.1097/ajp.0000000000001006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/02/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A common expectation for patients after elective spine surgery is that the procedure will result in pain reduction and minimize the need for pain medication. Most studies report changes in pain and function after spine surgery, but few report the extent of opioid use after surgery. This systematic review aims to identify the rates of opioid use after lumbar spine fusion. MATERIALS AND METHODS PubMed, CINAHL, Cochrane Central Register of Controlled Trials, and Ovid Medline were searched to identify studies published between January 1, 2005 and June 30, 2020 that assessed the effectiveness of lumbar fusion for the management of low back pain. RESULTS Of 6872 abstracts initially identified, 329 studies met the final inclusion criteria, and only 32 (9.7%) reported any postoperative opioid use. Long-term opioid use after surgery persists for more than 1 in 3 patients with usage ranging from 6 to 85.9% and a pooled mean of 35.0% based on data from 21 studies (6.4% of all lumbar fusion studies). DISCUSSION Overall, opioid use is not reported in the majority of lumbar fusion trials. Patients may expect a reduced need for opioid-based pain management after surgery, but the limited data available suggests long-term use is common. Lack of consistent reporting of these outcomes limits definitive conclusions regarding the efficacy of spinal fusion for reducing long-term opioid. Patient decisions about undergoing surgery may be altered if they had realistic expectations about rates of postsurgical opioid use. Spine surgery trials should track opioid utilization out to a minimum of 6 months after surgery as a core outcome.
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Affiliation(s)
- Matthew L Vraa
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Physical Therapy Program, Northwest University, Kirkland, WA
| | - Christina A Myers
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Physical Therapy, South College, Knoxville, TN
| | - Jodi L Young
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
| | - Daniel I Rhon
- Doctorate of Science in Physical Therapy Program, Bellin College, Green Bay, WI
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, MD
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Kim HC, An SB, Jeon H, Kim TW, Oh JK, Shin DA, Yi S, Kim KN, Lee PH, Kang SY, Ha Y. Preoperative Cognitive Impairment as a Predictor of Postoperative Outcomes in Elderly Patients Undergoing Spinal Surgery for Degenerative Spinal Disease. J Clin Med 2021; 10:jcm10071385. [PMID: 33808297 PMCID: PMC8037175 DOI: 10.3390/jcm10071385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/19/2022] Open
Abstract
Cognitive status has been reported to affect the peri-operative and post-operative outcomes of certain surgical procedures. This prospective study investigated the effect of preoperative cognitive impairment on the postoperative course of elderly patients (n = 122, >65 years), following spine surgery for degenerative spinal disease. Data on demographic characteristics, medical history, and blood analysis results were collected. Preoperative cognition was assessed using the mini-mental state examination, and patients were divided into three groups: normal cognition, mild cognitive impairment, and moderate-to-severe cognitive impairment. Discharge destinations (p = 0.014) and postoperative cardiopulmonary complications (p = 0.037) significantly differed based on the cognitive status. Operation time (p = 0.049), white blood cell count (p = 0.022), platelet count (p = 0.013), the mini-mental state examination score (p = 0.033), and the Beck Depression Inventory score (p = 0.041) were significantly associated with the length of hospital stay. Our investigation demonstrated that improved understanding of preoperative cognitive status may be helpful in surgical decision-making and postoperative care of elderly patients with degenerative spinal disease.
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Affiliation(s)
- Hyung Cheol Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Seong Bae An
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Hyeongseok Jeon
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Tae Woo Kim
- Department of Neurosurgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Korea;
| | - Jae Keun Oh
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea;
| | - Dong Ah Shin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Seong Yi
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Keung Nyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
| | - Phil Hyu Lee
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do 14068, Korea;
| | - Suk Yun Kang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong 18450, Korea
- Correspondence: (S.Y.K.); (Y.H.)
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (H.C.K.); (S.B.A.); (H.J.); (D.A.S.); (S.Y.); (K.N.K.)
- Correspondence: (S.Y.K.); (Y.H.)
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Chapman EK, Doctor T, Gal JS, Martini ML, Shuman WH, Neifert SN, Gilligan JT, Yuk FJ, Zimering JH, Schupper AJ, Caridi JM. Comparison of Surgical Outcomes of Microdiskectomy Procedures by Patient Admission Status. World Neurosurg 2021; 150:e38-e44. [PMID: 33610871 DOI: 10.1016/j.wneu.2021.02.039] [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: 12/02/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to compare the cost and in-hospital outcomes following lumbar microdiskectomy procedures by admission type. METHODS Patients undergoing lumbar microdiskectomy at a single institution from 2008 to 2016 following an elective admission (EL) were compared against those who were admitted from the emergency department (ED) or from elsewhere within or outside the hospital system (TR) for their perioperative outcomes and cost. Multivariable modeling controlled for age, sex, self-reported race, Elixhauser comorbidity score, payer type, number of segments, and procedure length. RESULTS Of the 1249 patients included in this study, 1116 (89.4%) were admitted electively while 123 (9.8%) were admitted from the ED and 10 (0.8%) were transferred from other hospitals. EL patients had significantly lower comorbidity burdens (P < 0.0001). Univariate and multivariable analyses revealed that transfer admission patients experienced significantly longer hospitalizations (ED: +1.7 days; P < 0.0001; TR: +5.3 days; P < 0.0001) and higher direct costs (ED: $1889; P < 0.0001; TR: $7001; P < 0.0001) compared with EL patients. Despite these risks, ED and TR patients only had increased odds of nonhome discharge compared with EL patients (ED: 3.4; P = 0.002; TR: 7.9; P = 0.02). CONCLUSIONS Patients admitted as transfers and from the ED had significantly increased hospitalization lengths of stay and direct costs compared with electively admitted patients.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesia, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey T Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey H Zimering
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Cook CE, Garcia AN, Shaffrey C, Gottfried O. The Influence of Unemployment and Disability Status on Clinical Outcomes in Patients Receiving Surgery for Low Back-Related Disorders: An Observational Study. Spine Surg Relat Res 2020; 5:182-188. [PMID: 34179556 PMCID: PMC8208951 DOI: 10.22603/ssrr.2020-0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/14/2020] [Indexed: 11/08/2022] Open
Abstract
Introduction Employment status plays an essential role as a social determinant of health. Unemployed are more likely to have a longer length of hospital stay and a nearly twofold greater rate of 30 day readmission than those who were well employed at the time of back surgery. This study aimed to investigate whether employment status influenced post-surgery outcomes and if so, the differences were clinically meaningful among groups. Methods This retrospective observational study used data from the Quality Outcomes Database Lumbar Registry. Data refinement was used to isolate individuals 18 to 64 who received primary spine surgeries and had a designation of employed, unemployed, or disabled. Outcomes included 12 and 24 month back and leg pain, disability, patient satisfaction, and quality of life. Differences in descriptive variables, comorbidities, and outcomes measures (at 12 and 24 months) were analyzed using chi-square and linear mixed-effects modeling. When differences were present among groups, we evaluated whether they were clinically significant or not. Results Differences (between employed, unemployed, and disabled) among baseline characteristics and comorbidities were present in nearly every category (p<0.01). In all cases, those who were disabled represented the least healthy, followed by unemployed, and then employed. Clinically meaningful differences for all outcomes were present at 12 and 24 months (p<0.01). In post hoc analyses, differences between each group at nearly all periods were found. Conclusions The findings support that the health-related characteristics are markedly different among employment status groups. Group designation strongly differentiated outcomes. These findings suggest that disability and unemployment should be considered when determining prognosis of the individual.
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Affiliation(s)
- Chad E Cook
- Duke University Division of Physical Therapy, Duke Department of Orthopaedic Surgery, Duke Clinical Research Institute, Durham, USA
| | - Alessandra N Garcia
- Physical Therapy Program, College of Pharmacy and Health Sciences, Campbell University, Lillington, USA
| | - Christopher Shaffrey
- Duke Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, USA
| | - Oren Gottfried
- Department of Neurosurgery, Duke University Medical Center, Durham, USA
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Mitchell SM, White AM, Campbell DH, Chung A, Chutkan N. Inpatient Outcomes in Dialysis Dependent Patients Undergoing Elective Cervical Spine Surgery for Degenerative Cervical Conditions. Global Spine J 2020; 10:856-862. [PMID: 32905731 PMCID: PMC7485067 DOI: 10.1177/2192568219883257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate inpatient outcomes in dialysis dependent patients undergoing elective cervical spine surgery. METHODS A total of 1605 dialysis dependent patients undergoing elective primary or revision cervical spine surgery for degenerative conditions were identified from the National Inpatient sample from 2002 to 2012 and compared to 1 450 642 nondialysis-dependent patients undergoing the same procedures. The National Inpatient Sample is a de-identified database; thus, no institutional review board approval was needed. RESULTS Dialysis dependence was associated with higher inpatient mortality rates (7.5% vs 1.9%; P < .001) as well as both major (17.3% vs 0.6%; P < .001) and minor (36.8% vs 10.5%; P < .001) complication rates as compared with nondialysis-dependent patients. Dialysis-dependent patients had substantially increased mean lengths of stay (9.8 days compared with 2.0 days; P < .001) and total hospital charges ($141 790 compared with $46 562; P < .001). CONCLUSION Dialysis-dependence is associated with drastically increased complication rates, risk of mortality, and represent a significant financial and psychosocial burden to patients undergoing elective cervical spine surgery. Both surgeons and patients should be aware of these risks while planning elective surgeries.
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Affiliation(s)
| | - Anthony M. White
- University of Arizona, Phoenix, AZ,Anthony M. White, Department of Orthopedic Surgery, University of Arizona, 1320 North 10th Street, Suite A, Phoenix, AZ 85006, USA.
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10
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Risk Factors of Extended Hospital Stay After One-Level Anterior Cervical Discectomy Fusion or Disc Replacement: Results from 1004 Patients in Food and Drug Administration Trials. World Neurosurg 2020; 145:e7-e13. [PMID: 32810632 DOI: 10.1016/j.wneu.2020.08.039] [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: 01/18/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Extended length of stay (LOS) after surgery is costly to the health care system and can be distressing to the patient and family. Previous studies have shown conflicting data on factors associated with increased LOS and are limited by using multiple different surgeries. Our study seeks to analyze factors that are associated with extended LOS. OBJECTIVE The objective of this study was to analyze data from 2 Food and Drug Administration trials of one-level cervical surgery to identify risk factors that are associated with extended LOS in the hospital. METHODS Extended LOS was defined to be >1 day. Patients with LOS ≤1 day were compared with those with LOS >1 day. Data from the BRYAN and Prestige ST Trial (n = 1004) were analyzed. Subjects with LOS ≤1 day were compared with those with LOS >1 day. Variables analyzed for their effect on LOS included demographic characteristics, patient-reported outcome measures, preoperative medical conditions, preoperative neurologic status, and intraoperative factors. RESULTS A total of 912 patients (90.84%) had an LOS ≤1 day and 92 patients (9.16%) had an extended LOS >1 day. Weak narcotic medication use (P = 0.021; odds ratio [OR], 1.72), Nurick gait (P = 0.019; OR, 1.796), and operative time (P < 0.0001; OR, 2.062) were found to significantly affect LOS. CONCLUSIONS Nurick gait, operative time, and history of weak narcotic use are associated with extended hospital stay. These data may be useful in preoperatively counseling patients, developing quality metrics for hospitals, and helping create financial models for cost/diagnosis-related group reimbursement for single-level anterior cervical surgery.
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Yerneni K, Nichols N, Abecassis ZA, Karras CL, Tan LA. Preoperative Opioid Use and Clinical Outcomes in Spine Surgery: A Systematic Review. Neurosurgery 2020; 86:E490-E507. [DOI: 10.1093/neuros/nyaa050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 01/11/2020] [Indexed: 01/09/2023] Open
Abstract
AbstractBACKGROUNDPrescription opioid use and opioid-related deaths have become an epidemic in the United States, leading to devastating economic and health ramifications. Opioids are the most commonly prescribed drug class to treat low back pain, despite the limited body of evidence supporting their efficacy. Furthermore, preoperative opioid use prior to spine surgery has been reported to range from 20% to over 70%, with nearly 20% of this population being opioid dependent.OBJECTIVETo review the medical literature on the effect of preoperative opioid use in outcomes in spine surgery.METHODSWe reviewed manuscripts published prior to February 1, 2019, exploring the effect of preoperative opioid use on outcomes in spine surgery. We identified 45 articles that analyzed independently the effect of preoperative opioid use on outcomes (n = 32 lumbar surgery, n = 19 cervical surgery, n = 7 spinal deformity, n = 5 “other”).RESULTSPreoperative opioid use is overwhelmingly associated with negative surgical and functional outcomes, including postoperative opioid use, hospitalization duration, healthcare costs, risk of surgical revision, and several other negative outcomes.CONCLUSIONThere is an urgent and unmet need to find and apply extensive perioperative solutions to combat opioid use, particularly in patients undergoing spine surgery. Further investigations are necessary to determine the optimal method to treat such patients and to develop opioid-combative strategies in patients undergoing spine surgery.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noah Nichols
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
| | - Zachary A Abecassis
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Constantine L Karras
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, California
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Non-medical factors significantly influence the length of hospital stay after surgery for degenerative spine disorders. 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 2019; 29:203-212. [PMID: 31734806 DOI: 10.1007/s00586-019-06209-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unnecessarily long hospital stays are costly and inefficient. Studies have shown that the length of hospital stay (LOS) for spine surgical procedures is influenced by various disease-related or medical factors, but few have examined the role of socio-demographic/socio-economic (SDE) factors. METHODS This was a retrospective analysis of data from 10,770 patients (5056 men, 5714 women; 62 ± 15 years) with degenerative spinal disorders, collected prospectively in an in-house database within the framework of EUROSPINE's Spine Tango Registry. Surgeons completed the Tango surgery form (clinical history, demographics, surgical measures, complications), and patients, a baseline Core Outcome Measures Index. Stepwise linear regression analyses examined SDE predictors of LOS, controlling for potential medical/biological factors. RESULTS The mean LOS was 7.9 ± 5.2 days. The final model accounted for 42% of variance in LOS, with SDE variables explaining 13% variance and medical/surgical predictors, 29%. In the final model, the SDE factors age and being female were significant independent predictors of LOS, whereas others were either non-significant (insurance status, being of Swiss nationality, being a smoker) or reached only borderline significance (p < 0.1) (BMI). Controlling for all other SDE and medical/surgical confounders, being female was associated with 1.11-day longer LOS (95% CI 0.96-1.27; p < 0.0001). CONCLUSIONS Patients of advanced age and female gender are at increased risk of longer hospital stay after surgery for degenerative spinal disorders. Further studies should seek to understand the reasoning behind the gender disparity, in order to minimise potentially unnecessary costs of prolonged LOS. Targeted preoperative discharge planning may improve the utilisation of hospital resources. These slides can be retrieved under Electronic Supplementary Material.
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Zhan H, Guo R, Xu H, Liu X, Yu X, Xu Q, Chen H, Dai M, Zhang B. Hospital length of stay following first-time elective open posterior lumbar fusion in elderly patients: a retrospective analysis of the associated clinical factors. Medicine (Baltimore) 2019; 98:e17740. [PMID: 31689822 PMCID: PMC6946405 DOI: 10.1097/md.0000000000017740] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To identify independent factors associated with prolonged hospital length of stay (LOS) in elderly patients undergoing first-time elective open posterior lumbar fusion surgery.We retrospectively analyzed the data of 303 elderly patients (age range: 60-86 years) who underwent first-time elective open lumbar posterior fusion surgery at our center from December 2012 to December 2017. Preoperative and perioperative variables were extracted and analyzed for all patients, and multivariate stepwise regression analysis was used to determine the variables affecting the LOS and important predictors of LOS prolongation (P < .001).The mean age of the patients was 67.0 ± 5.5 years, and the mean LOS was 18.5 ± 11.8 days, ranging from 7 to 103 days. Of the total, 166 patients (54.8%) were men and 83 patients (27.4%) had extended LOS. Multiple linear regression analysis determined that age (P < .001), preoperative waiting time ≥7 days (P < .001), pulmonary comorbidities (P = .010), and diabetes (P = .010) were preoperative factors associated with LOS prolongation. Major complications (P = .002), infectious complications (P = .001), multiple surgeries (P < .001), and surgical bleeding (P = .018) were perioperative factors associated with LOS prolongation. Age (P < .001), preoperative waiting time ≥7 days (P < .001), infectious complications (P < .001), and multiple surgeries (P < .001) were important predictors of LOS prolongation.Extended LOS after first-time elective open posterior lumbar fusion surgery in elderly patients is associated with factors including age, preoperative waiting time, infectious complications, and multiple surgeries. Surgeons should recognize and note these relevant factors while taking appropriate precautions to optimize the modifiable factors, thereby reducing the LOS as well as hospitalization costs.
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Kobayashi K, Ando K, Kato F, Kanemura T, Sato K, Hachiya Y, Matsubara Y, Kamiya M, Sakai Y, Yagi H, Shinjo R, Ishiguro N, Imagama S. Trends of postoperative length of stay in spine surgery over 10 years in Japan based on a prospective multicenter database. Clin Neurol Neurosurg 2018; 177:97-100. [PMID: 30640049 DOI: 10.1016/j.clineuro.2018.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/22/2018] [Accepted: 12/28/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To identify factors associated with prolonged length of stay (LOS) in spine surgery, with the goal of establishing details of LOS for multiple diseases and surgical procedures. PATIENTS AND METHODS The subjects were patients who underwent spine surgery at 10 facilities in the Nagoya Spine Group from January 2005 to December 2015. Data were collected for patient background, primary spinal pathology, anatomical location of the lesion, and surgical methods. The primary outcome was LOS, which was defined as the calendar days from surgery to hospital discharge. RESULTS A total of 10,829 patients (5953 males, 4876 females; age 5-93 years, mean 60.2 ± 28.8 years) were identified in the database. Average follow-up was 61 months (range: 13-120 months). Average LOS was 22.3 ± 21.3 days, and there was a gradual decrease in LOS over the study period. LOS was significantly correlated with age, and prolonged LOS was significantly associated with thoracic spine surgery and significantly longer after surgery with instrumentation. Average LOS was >30 days for intramedullary tumor resection and posterior cervical fusion, but only 10.2 days for microendoscopic discectomy. Reoperation was performed in 210 patients (1.9%) and these patients had a significantly higher average LOS of 43.1 days. CONCLUSION These results will assist quality improvement in spine surgery. The identified risk factors for prolonged LOS will also assist in planning of surgery, postoperative care, and discharge, with the goal of reducing health care costs.
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Affiliation(s)
- Kazuyoshi Kobayashi
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Fumihiko Kato
- Department of Orthopaedic Surgery, Chubu Rosai Hospital, 1-10-6, Komei, Minato-ku, Nagoya, 455-8530, Japan
| | - Tokumi Kanemura
- Department of Orthopaedic Surgery, Konan Kosei Hospital, 137, Omatsubara, Takaya-cho, Konan, Aichi, 483-8704, Japan
| | - Koji Sato
- Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daini Hospital, 2-9, Myoken-cho, Showa-ku, Nagoya, 466-8650, Japan
| | - Yudo Hachiya
- Department of Orthopaedic Surgery, Hachiya Orthopaedic Hospital, 2-4, Suemoridori, Chikusa-ku, Nagoya, 464-0821, Japan
| | - Yuji Matsubara
- Department of Orthopaedic Surgery, Kariya Toyota General Hospital, 15, Sumiyoshi-cho5, Kariyashi, Aichi, 448-8505, Japan
| | - Mitsuhiro Kamiya
- Department of Orthopaedic Surgery, Aichi Medical University, 1-1, Iwasaku, Nagakute, Aichi, 480-1195, Japan
| | - Yoshihito Sakai
- Department of Orthopaedic Surgery, National Center for Geriatrics and Gerontology, 7-430, Morioka-cho, Obu, Aichi, 474-8511, Japan
| | - Hideki Yagi
- Department of Orthopaedic Surgery, Japanese Red Cross Nagoya Daiichi Hospital, 3-35, Michishita-cho, Nakamura-ku, Nagoya, 453-8511, Japan
| | - Ryuichi Shinjo
- Department of Orthopaedic Surgery, Anjo Kosei Hospital, 28, Higashi-Kohan, Anjo-cho, Anjo, Aichi, 446-8602, Japan
| | - Naoki Ishiguro
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, 466-8560, Japan.
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Surgeon Reimbursement Relative to Hospital Payments for Spinal Fusion: Trends From 10-year Medicare Analysis. Spine (Phila Pa 1976) 2018; 43:720-731. [PMID: 28885293 DOI: 10.1097/brs.0000000000002405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, economic analysis. OBJECTIVE The aim of this study was to analyze the trend in hospital charge and payment adjusted to corresponding surgeon charge and payment for cervical and lumbar fusions in a Medicare sample population from 2005 to 2014. SUMMARY OF BACKGROUND DATA Previous studies have reported trends and variation in hospital charges and payments for spinal fusion, but none have incorporated surgeon data in analysis. Knowledge of the fiscal relationship between hospitals and surgeons over time will be important for stakeholders as we move toward bundled payments. METHODS A 5% Medicare sample was used to capture hospital and surgeon charges and payments related to cervical and lumbar fusion for degenerative disease between 2005 and 2014. We defined hospital charge multiplier (CM) as the ratio of hospital/surgeon charge. Similarly, the hospital/surgeon payment ratio was defined as hospital payment multiplier (PM). The year-wise and regional trend in patient profile, length of stay, discharge disposition, CM, and PM were studied for all fusion approaches separately. RESULTS A total of 40,965 patients, stratified as 15,854 cervical and 25,111 lumbar fusions, were included. The hospital had successively higher charges and payments relative to the surgeon from 2005 to 2014 for all fusions with an inverse relation to hospital length of stay. Increasing complexity of fusion such as for anterior-posterior cervical fusion had higher hospital reimbursements per dollar earned by the surgeon. There was regional variation in how much the hospital charged and received per surgeon dollar. CONCLUSION Hospital charge and payment relative to surgeon had an increasing trend despite a decreasing length of stay for all fusions. Although the hospital can receive higher payments for higher-risk patients, this risk is not reflected proportionally in surgeon payments. The shift toward value-based care with shared responsibility for outcomes and cost will likely rely on better aligning incentives between hospital and providers. LEVEL OF EVIDENCE 3.
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Distribution and Determinants of 90-Day Payments for Multilevel Posterior Lumbar Fusion: A Medicare Analysis. Clin Spine Surg 2018; 31:E197-E203. [PMID: 29369155 DOI: 10.1097/bsd.0000000000000612] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN A retrospective, economic analysis. OBJECTIVE The objective of this article is to analyze the distribution of 90-day payments, sources of variation, and reimbursement for complications and readmissions for primary ≥3-level posterior lumbar fusion (PLF) from Medicare data. A secondary objective was to identify risk factors for complications. SUMMARY OF BACKGROUND DATA Bundled payments represent a single payment system to cover all costs associated with a single episode of care, typically over 90 days. The dollar amount spent on different health service providers and the variation in payments for ≥3-level PLF have not been analyzed from a bundled perspective. MATERIALS AND METHODS Administrative claims data were used to study 90-day Medicare (2005-2012) reimbursements for primary ≥3-level PLF for deformity and degenerative conditions of the lumbar spine. Distribution of payments, sources of variation, and reimbursements for managing complications were studied using linear regression models. Risk factors for complications were studied by stepwise multiple-variable logistic regression analysis. RESULTS Hospital payments comprised 73.8% share of total 90-day payment. Adjusted analysis identified several factors for variation in index hospital payments. The average 90-day Medicare payment for all multilevel PLFs without complications was $35,878 per patient. The additional average cost of treating complications with/without revision surgery within 90 days period ranged from $17,284 to $68,963. A 90-day bundle for ≥3-level PLF with readmission ranges from $88,648 (3 levels) to $117,215 (8+ levels). Rates and risk factors for complications were also identified. CONCLUSIONS The average 90-day payment per patient from Medicare was $35,878 with several factors such as levels of surgery, comorbidities, and development of complications influencing the cost. The study also identifies the risks and costs associated with complications and readmissions and emphasize the significant effect these would have on bundled payments (additional burden of up to 192% the cost of an average uncomplicated procedure over 90 days). LEVEL OF EVIDENCE Level 3.
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Abstract
Episode-based bundling may become the major form of reimbursement for many elective spine procedures. As the amount for a 90-day episode of care is not known for a lumbar discectomy, we analyzed the previous reimbursements from Commercial payers (2007-Q2 2015), Medicare Advantage (2007-Q2 2015), and Medicare (2005-2012) for a primary single-level lumbar discectomy/decompression. Distribution of payments among various service providers was studied and a 90-day bundle was simulated. Depending on the payer type, the average facility costs constituted 59.7% to 73.6% of total payments, followed by surgeon's fees, which accounted for 13.7% to 18.5%. Postacute services made up 8.8% to 15.8% of the total reimbursement. Surgeries performed in the inpatient setting were significantly more expensive as compared with surgeries performed in the outpatient setting (P<0.01). The average 90-day bundle amount was estimated at $11,091, $6571, and $6239 for Commercial payers, Medicare Advantage, and Medicare, respectively. Overall, service providers in the Southern region were reimbursed the lowest from Commercial payers and Medicare, compared with other regions. Postacute services are not as major cost drivers after discectomy as after total joint arthroplasty or hip fracture repair.
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Abstract
STUDY DESIGN Retrospective study of prospectively collected data. OBJECTIVE To analyze the incidence and risk factors for readmissions following anterior lumbar interbody fusion. SUMMARY OF BACKGROUND DATA No study has yet reported readmission rates for a specific lumbar surgical approach. There is evidence to indicate differences in perioperative complication rates between anterior versus posterior lumbar interbody fusion techniques, which may translate into differences in readmission rates. METHODS The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent anterior lumbar interbody fusion. Patients were separated into groups of those with and without 30-day readmissions. Univariate analysis and multivariate logistic regression were used to analyze the effect of different risk factors on 30-day readmissions. RESULTS Multivariate analysis showed that morbid obesity (odds ratio 15.6, P = 0.002) and alcohol use (odds ratio 16.9, P = 0.004) independently predicted unplanned 30-day readmission. Sex, pulmonary comorbidity, cardiac comorbidity, and steroid use were not found to be significant independent predictors of unplanned 30-day readmission in anterior lumbar interbody fusion. CONCLUSION Adult patients undergoing anterior lumbar interbody fusion who were morbidly obese and had history of alcohol use are at increased risk for 30-day readmissions. Future studies should look to directly compare readmission rates and risk factors between alternative lumbar interbody surgical approaches with longer follow-up and more clinical and radiological parameters investigated. LEVEL OF EVIDENCE 3.
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Ninety-Day Reimbursements for Primary Single-Level Posterior Lumbar Interbody Fusion From Commercial and Medicare Data. Spine (Phila Pa 1976) 2018; 43:193-200. [PMID: 29252824 DOI: 10.1097/brs.0000000000002283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, economic analysis. OBJECTIVE To analyze the distribution of 90-day payments for a primary single-level posterior lumbar interbody fusion from Commercial payers and Medicare. SUMMARY OF BACKGROUND DATA Episode-based bundled payments aim to align incentives of all health care providers toward the common goal of high quality and economic health care. Understanding the evolving reimbursement models for spine surgery will require knowledge on existing payments, distribution, and variation. Also, it will help identify areas for cost reduction. This is currently not known for a primary single-level posterior lumbar interbody fusion. METHODS Administrative claims data were used to study reimbursements from Commercial payers (2007-Q3 2015), Medicare Advantage (2007-Q3 2015), and Medicare (2005-2012) for a primary single-level posterior lumbar interbody fusion. Distribution of payments among various service providers was studied. In addition to descriptive analysis, variation between regions and payers was studied by a one-way analysis of variance and post hoc Tukey test. RESULTS Average hospital costs comprise 74.2% to 77% of the total payments, followed by surgeon's fees which accounted for 12.8% to 13.7%. Overall burden of readmissions/revisions was 2.1% to 2.7%, but for the readmitted patient it constitutes 25% to 54% of the 90-day payment. Inpatient surgery had significantly higher facility costs than outpatient surgery (P = 0.02). The average 90-day payment amount was $51,465, $26,234, and $25,501 for Commercial payers, Medicare Advantage, and Medicare, respectively. There was some regional variation, however not consistent among different payers. CONCLUSION Hospital costs constitute the majority share of 90-day payments, which can be reduced by performing surgery in the outpatient setting. Reducing hospital costs and readmissions can lower the financial burden associated with this common spine procedure. LEVEL OF EVIDENCE 3.
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Inpatient Outcomes in Dialysis-dependent Patients Undergoing Elective Lumbar Surgery for Degenerative Lumbar Disease. Spine (Phila Pa 1976) 2017; 42:1494-1501. [PMID: 28198782 DOI: 10.1097/brs.0000000000002122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate hospital outcomes in dialysis-dependent patients undergoing elective lumbar surgeries. SUMMARY OF BACKGROUND DATA Because of their overall poor health status and concomitant comorbidity burden, spinal surgery in dialysis-dependent patients represents a significant challenge to spine surgeons. Large studies evaluating their immediate postoperative outcomes in elective lumbar surgery are lacking. METHODS Utilizing the National Inpatient Sample, an estimated 1834 dialysis-dependent patients undergoing elective lumbar spine surgery for degenerative lumbar conditions were compared to an estimated 2,522,594 non-dialysis-dependent patients undergoing the same procedures between 2002 and 2012. Our primary outcomes measures included postoperative complication rates, hospital length of stay, and total hospital costs. RESULTS Mean age of dialysis-dependent patients was 64.2 years compared to 59.9 in the non-dialysis-dependent cohort (P < 0.001). Dialysis-dependent patients had substantially higher inpatient mortality rates (1.8% vs 0.1%; P < 0.001), major complication rates (8.1% vs 1.1%; P < 0.001), and an increased need for blood transfusion (18.3% vs 12.5%; P < 0.001). Multivariate analysis revealed that dialysis dependence independently increased odds of in-hospital mortality (odds ratio = 8.30; 95% confidence interval 5.78-11.93; P < 0.001) and odds of a major postoperative complication (odds ratio = 3.63; 95% confidence interval 3.49-3.89; P < 0.001). Dialysis dependence was associated with an increased mean length of stay of 3.3 days (P < 0.001) and a significant increase in hospital costs when stratified by procedure type. CONCLUSION Dialysis dependence is associated with poorer immediate postoperative outcomes and increased hospital costs when compared to non-dialysis-dependent patients. In addition, an increased need for postoperative transfusion should be anticipated in this patient population. Further studies are warranted to confirm these findings. LEVEL OF EVIDENCE 3.
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Preoperative Depression, Smoking, and Employment Status are Significant Factors in Patient Satisfaction After Lumbar Spine Surgery. Clin Spine Surg 2017. [PMID: 28632560 DOI: 10.1097/bsd.0000000000000331] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To determine whether comorbidities and demographics, identified preoperatively, can impact patient outcomes and satisfaction after lumbar spine surgery. SUMMARY OF BACKGROUND DATA The surgical treatment of lower back pain does not always eliminate a patient's pain and symptoms. Revision surgeries are costly and expose the patient to additional risk. We aim to identify patient characteristics that may suggest a greater or lesser likelihood of postsurgical success by examining patient-reported measures and outcomes after surgery. METHODS Preoperative smoking status, self-reported depression, prevalence of diabetes, obesity, level of education, and employment status were assessed in the context of patient outcome and satisfaction after lumbar spine surgery. Patients were contacted before surgery, and at 3 and 12 months postoperatively, and responded to Oswestry Disability Index (ODI) and EuroQol-5 Dimensions (EQ-5D) self-assessment examinations, as well as a satisfaction measure. RESULTS A total of 166 patients who underwent lumbar spine surgeries at Iowa Spine and Brain Institute, a department of Covenant Medical Center, and were included in the National Neurosurgery Quality and Outcomes Database were assessed preoperatively, and at 3 and 12 months postoperatively using self-assessment tools. Depression, smoking, and employment status were found to be significant factors in patient satisfaction. Depressed patients, smokers, and patients on disability at the time of surgery have worse ODI and EQ-5D scores at all of the timepoints (baseline, 3 months, and 12 months postsurgery). CONCLUSIONS Depression, smoking, and employment status, specifically whether a patient is on disability at the time of surgery, are all significant factors in patient satisfaction after lumbar spine surgery. These factors are also shown in impact ODI and EQ-5D scores. Surgeons should consider these particular characteristics when developing a lower back pain treatment plan involving surgery.
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Chotai S, Sivaganesan A, Sielatycki JA, Archer KR, Call R, McGirt MJ, Devin CJ. Surgeon-Level Variability in Outcomes, Cost, and Comorbidity Adjusted-Cost for Elective Lumbar Decompression and Fusion. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx243] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
BACKGROUND
The costs and outcomes following degenerative spine surgery may vary from surgeon to surgeon. Patient factors such as comorbidities may increase the health care cost. These variations are not well studied.
OBJECTIVE
To understand the variation in outcomes, costs, and comorbidity-adjusted cost for surgeons performing lumbar laminectomy and fusions surgery.
METHODS
A total of 752 patients undergoing laminectomy and fusion, performed by 7 surgeons, were analyzed. Patient-reported outcomes and 90-d cost were analyzed. Multivariate regression model was built for high-cost surgery. A separate linear regression model was built to derive comorbidity-adjusted 90-d costs.
RESULTS
No significant differences in improvement were found across all the patient-reported outcomes, complications, and readmission among the surgeons. In multivariable model, surgeons #4 (P < .0001) and #6 (P = .002) had higher odds of performing high-cost fusion surgery. The comorbidity-adjusted costs were higher than the actual 90-d costs for surgeons #1 (P = .08), #3 (P = .002), #5 (P < .0001), and #7 (P < .0001), whereas they were lower than the actual costs for surgeons #2 (P = .128), #4 (P < .0001), and #6 (P = .44).
CONCLUSION
Our study provides valuable insight into variations in 90-d costs among the surgeons performing elective lumbar laminectomy and fusion at a single institution. Specific surgeons were found to have greater odds of performing high-cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patients’ preoperative comorbidities must be accounted for when crafting value-based payment models. Furthermore, designing intervention targeting “modifiable” factors tied to the way the surgeons practice may increase the overall value of spine care.
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Affiliation(s)
- Silky Chotai
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Spine Outcomes Research Lab, Vanderbilt Spine Center, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Spine Outcomes Research Lab, Vanderbilt Spine Center, Nashville, Tennessee
| | - John A Sielatycki
- Department Or-thopaedic Surgery, Vanderbilt Spine Cen-ter, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristin R Archer
- Department Or-thopaedic Surgery, Vanderbilt Spine Cen-ter, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard Call
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Spine Outcomes Research Lab, Vanderbilt Spine Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neuro-surgery and Spine Associates, Charlotte, North Carolina
| | - Clinton J Devin
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Orthopaedic Surgery and Department of Neurological Surgery, Spine Outcomes Research Lab, Vanderbilt Spine Center, Nashville, Tennessee
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Factors Affecting Length of Stay and Complications After Elective Anterior Cervical Discectomy and Fusion: A Study of 2164 Patients From The American College of Surgeons National Surgical Quality Improvement Project Database (ACS NSQIP). Clin Spine Surg 2016; 29:E34-42. [PMID: 24525748 DOI: 10.1097/bsd.0000000000000080] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective review of the prospective American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database with 30-day follow-up of 2164 patients undergoing elective anterior cervical discectomy and fusion (ACDF). OBJECTIVE To determine factors independently associated with increased length of stay (LOS) and complications after ACDF to facilitate preoperative planning and setting of realistic expectations for patients and providers. SUMMARY OF BACKGROUND DATA The effect of individual preoperative factors on LOS and complications has been evaluated in small-scale studies. Large database analysis with multivariate analysis of these variables has not been reported. METHODS The ACS NSQIP database from 2005 to 2010 was queried for patients undergoing ACDF procedures. Preoperative and perioperative variables were collected. Multivariate regression determined significant predictors (P<0.05) of extended LOS and complications. RESULTS Average LOS was 2.0±4.0 days (mean±SD) with a range of 0-103 days. By multivariate analysis, age 65 years and above, functional status, transfer from facility, preoperative anemia, and diabetes were the preoperative factors predictive of extended LOS. Major complications, minor complications, and extended surgery time were the perioperative factors associated with increased LOS. The elongating effect of these variables was determined, and ranged from 0.5 to 5.0 days. Seventy-one patients (3.3%) had a total of 92 major complications, including return to operating room (40), venous thrombotic events (13), respiratory (21), cardiac (6), mortality (5), sepsis (4), and organ space infection (3). Multivariate analysis determined ASA score ≥3, preoperative anemia, age 65 years and above, extended surgery time, and male sex to be predictive of major complications (odds ratios ranging between 1.756 and 2.609). No association was found between levels fused and LOS or complications. CONCLUSION Extended LOS after ACDF is associated with factors including age, anemia, and diabetes, as well as the development of postoperative complications. One in 33 patients develops a major complication postoperatively, which are associated with an increased LOS of 5 days.
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[Influencing factors on the length of stay in lumbar spine surgery : analysis of the German spine registry]. DER ORTHOPADE 2015; 43:1043-51. [PMID: 25371016 DOI: 10.1007/s00132-014-3033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Spinal disc herniation, lumbar spinal stenosis and spondylolisthesis are known to be leading causes of lumbar back pain. The cost of low back pain management and related operations are continuously increasing in the healthcare sector. There are many studies regarding complications after spine surgery but little is known about the factors predicting the length of stay in hospital. The purpose of this study was to identify these factors in lumbar spine surgery in order to adapt the postoperative treatment. MATERIAL AND METHODS The current study was carried out as a post hoc analysis on the basis of the German spine registry. Patients who underwent lumbar spine surgery by posterior surgical access and with posterior fusion and/or rigid stabilization, whereby procedures with dynamic stabilization were excluded. Patient characteristics were tested for association with length of stay (LOS) using bivariate and multivariate analyses. RESULTS A total of 356 patients met the inclusion criteria. The average age of all patients was 64.6 years and the mean LOS was 11.9 ± 6.0 days with a range of 2-44 days. Independent factors that were influencing LOS were increased age at the time of surgery, higher body mass index, male gender, blood transfusion of 1-2 erythrocyte concentrates and the presence of surgical complications. CONCLUSION Identification of predictive factors for prolonged LOS may allow for estimation of patient hospitalization time and for optimization of postoperative care. In individual cases this may result of a reduction in the LOS.
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Gruskay JA, Fu M, Bohl DD, Webb ML, Grauer JN. Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis. Spine J 2015; 15:1188-95. [PMID: 24184639 DOI: 10.1016/j.spinee.2013.10.022] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 06/12/2013] [Accepted: 10/17/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Elective posterior lumbar fusion is a common surgical procedure, but reported length of hospital stay is variable (usually 3-7 days). The effect of a limited number of factors on length of stay (LOS) has previously been evaluated. However, multivariate analysis using LOS as a dependent variable to separate potentially confounding variables has not been performed. PURPOSE To facilitate setting of realistic expectations and considering the significant costs of hospitalization, it would be ideal to have a clear understanding of the variables affecting LOS for this surgery. STUDY DESIGN/SETTING This is a retrospective case series at a tertiary care center. PATIENT SAMPLE One hundred three patients undergoing elective, open, one- to three-level posterior lumbar instrumented fusion (with or without decompression) by the orthopedic spine service at our institution between January 2010 and June 2012 were included in the study. OUTCOME MEASURES LOS was determined from the date of surgery to the date of discharge. METHODS Preoperative factors (patient demographics, previous surgery, levels instrumented, American Society of Anesthesiologists [ASA] score, and major medical comorbidities including diabetes, hypertension, malignancy, pulmonary disease, or heart disease), intraoperative factors (complications, drain placement, estimated blood loss, blood transfusion, fluids administered, operating room time, and surgery time), and postoperative factors (drain removal, blood transfusion, complications, and discharge destination) were collected and analyzed with multivariate stepwise regression to determine predictors of LOS. "Postoperative complications" were excluded as an independent variable from the regression analysis because of its close relationship with LOS. No funding was received for the completion of this study, and there are no potential conflicts of interests. RESULTS Our sample included 70 one-level, 26 two-level, and 7 three-level operations. Average LOS was 3.6±1.8 days (mean±SD) with the range 0 to 12 days. Of this cohort, 79% (81 of 103) had a stay of 4 days or less. The only preoperative variables associated with LOS in the multivariate model were age (p=.038) and ASA score (p=.001). History of heart disease (p=.005) was significantly associated with a decreased hospital stay. Intraoperative complications included six dural tears and one pedicle fracture. No intraoperative factors were found to be associated with a longer LOS. Postoperative complications occurred in 32% of patients (33 of 103). Common complications included anemia requiring transfusion (11), altered mental status (8), pneumonia (4), hardware complications requiring reoperation (3). Only one serious complication, renal failure, occurred. Average LOS for patients with a postoperative complication was 5.1±2.3 vs. 2.9±0.9 days for patients with no complication (p<.001). Discharge to a subacute or nursing facility (p<.001) was significantly associated with increased LOS. Levels fused were not predictive of LOS, possibly due to the skew toward one-level cases in our sample. CONCLUSION Patients who are older and have widespread systemic disease tend to stay in the hospital longer after surgery. Contrary to our expectations, no single comorbidity was predictive of longer hospital stays. Heart disease was associated with a shorter LOS, but this may have been due to a more extensive preoperative workup and closer medical management. Intraoperative events did not affect LOS; however, postoperative events did. These data should prove useful for counseling patients and setting expectations of patients and the health care team.
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Affiliation(s)
- Jordan A Gruskay
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave., New Haven, CT 06510, USA
| | - Michael Fu
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave., New Haven, CT 06510, USA
| | - Daniel D Bohl
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave., New Haven, CT 06510, USA
| | - Matthew L Webb
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave., New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, 800 Howard Ave., New Haven, CT 06510, USA.
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Kanaan SF, Waitman RL, Yeh HW, Arnold PM, Burton DC, Sharma NK. Structural equation model analysis of the length-of-hospital stay after lumbar spine surgery. Spine J 2015; 15:612-21. [PMID: 25463975 PMCID: PMC4502957 DOI: 10.1016/j.spinee.2014.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 10/22/2014] [Accepted: 11/05/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Length-of-hospital stay (LOS) after lumbar spine surgery (LSS) can be affected by many factors. However, few studies have evaluated predictors of LOS, and all have used limited number of variables as predictors. PURPOSE The purpose of the study was to identify presurgical, surgical, and postsurgical predictors of LOS after LSS. STUDY DESIGN/SETTING Retrospective review of consecutive patients who had LSS at the University of Kansas Hospital from October 2008 to April, 2012. PATIENT SAMPLE Five hundred ninety-three patients underwent LSS consisting of laminotomy, laminectomy, or arthrodesis. DEPENDENT VARIABLE LOS. Multiple presurgical, surgical, and postsurgical variables were extracted from the patients' medical records and considered as possible predictors (independent variables) of LOS. METHODS Potential predictors that were significantly correlated with LOS were used as indicators to construct three latent factors presurgical, surgical, and postsurgical, which were in turn used to predict LOS in a structural equation model. RESULTS The average LOS was 4.01±2.73 days. The presurgical factor was indicated by age (61.97±14.49 years), previous level of function (60.5% were totally independent), previous hemoglobin level (13.70±1.36 mg/dL), and use of assistive devices (60% were assistive device users). The surgical factor was indicated by severity of illness (50.2% had minor disease severity), presence of complications (1.9%), and stay in an intensive care unit (4.0%). The postsurgical factor was indicated by postsurgical walking distance (166.43±175.75 ft), level of assistance during walking (5.18±0.81 out of 7 points), balance scores (6.18±1.82 out of 10 points), and bed mobility and transfer dependency scores (9.81±1.99 out of 14 points). These three latent factors explained 47% of variation in LOS. CONCLUSIONS Postsurgical factors predicted the highest variation in LOS in comparison with presurgical and surgical factors and should be taken into consideration for discharge planning. Postsurgical factors are related to the patient's function, modifiable with rehabilitation, and can be improved to shorten LOS. Inclusion of more reliable and standardized presurgical variables could improve the predictability of the model.
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Affiliation(s)
- Saddam F Kanaan
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center
| | | | - Hung-Wen Yeh
- Department of Biostatistics, University of Kansas Medical Center
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center
| | - Neena K Sharma
- Department of Rehabilitation Sciences, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan.
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Davis DE, Paxton ES, Maltenfort M, Abboud J. Factors affecting hospital charges after total shoulder arthroplasty: an evaluation of the National Inpatient Sample database. J Shoulder Elbow Surg 2014; 23:1860-1866. [PMID: 25156958 DOI: 10.1016/j.jse.2014.04.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 04/05/2014] [Accepted: 04/08/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of total shoulder arthroplasties (TSA) performed in the United States increases yearly. At the same time, cost containment in health care continues to be a major concern. Therefore, it is imperative to identify specific variables that affect the cost of shoulder arthroplasty. METHODS The U.S. National Inpatient Sample database was queried (1993-2010) to evaluate total hospital charges for shoulder arthroplasty. Etiology of arthritis, multiple medical comorbidities, and patient and hospital demographics were evaluated for their effect on total inpatient hospital charges by a multivariate analysis. RESULTS Hospital charges for TSA increased from 1993 to 2010. Gender, race, and obesity were not associated with these differences in hospital charges. Post-traumatic and rheumatoid arthritis resulted in increased hospital charges; however, osteoarthritis resulted in decreased charges from the baseline. Multiple comorbidities (diabetes, lung disease, heart disease, and kidney disease) resulted in increased hospital charges after TSA. Regionally, the western and southern United States had the highest total charges above baseline. Larger hospitals and private urban hospitals also showed charges above baseline. CONCLUSIONS The factors related to increased hospital charges after TSA are multifactorial and include medical comorbidities, patient demographics, and regionalization. As the future of health care continues to evolve, it is important for practitioners, legislators, insurance administrators, and hospitals to recognize factors that increase costs.
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Affiliation(s)
- Daniel E Davis
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - E Scott Paxton
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mitchell Maltenfort
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joseph Abboud
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Preoperative factors affecting length of stay after elective anterior cervical discectomy and fusion with and without corpectomy: a multivariate analysis of an academic center cohort. Spine (Phila Pa 1976) 2014; 39:939-46. [PMID: 24718069 PMCID: PMC4024365 DOI: 10.1097/brs.0000000000000307] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of 183 patients who underwent elective anterior cervical discectomy and fusion (ACDF) at a single institution during a 2-year period. OBJECTIVE To determine which preoperative factors were independently associated with a prolonged hospital length of stay (LOS) after ACDF. SUMMARY OF BACKGROUND DATA ACDF has become the most common treatment modality for addressing cervical spine pathology. Extended LOS after ACDF is associated with increased costs and complications. There is a lack of conclusive data for factors affecting LOS after ACDF. This study aims to create a multivariate model to determine the association of various patient and operative characteristics with LOS after ACDF. METHODS Patients who underwent elective ACDF at a single academic institution between January 2011 and February 2013 were identified using billing records. Their charts were reviewed to collect variables available preoperatively such as patient demographics, comorbidities, and surgery planned. Patients were categorized as normal or extended LOS, with extended LOS defined as LOS more than the 75th percentile. A multivariate logistic regression was used to determine which factors were independently associated with extended LOS. RESULTS A total of 183 patients with ACDF were identified. The average LOS for this cohort was 2.0 ± 2.5 days (mean ± standard deviation). Extended LOS was defined as 3 days or more. Multivariate analysis revealed that preoperative factors independently associated with extended LOS were history of nonspinal malignancy (odds ratio [OR] = 4.9), history of pulmonary disease (OR = 4.0), and procedures that included corpectomy (OR = 4.5). CONCLUSION Patients with a history of nonspinal malignancy or pulmonary disease, as well as patients who underwent corpectomy, were more likely to have an extended LOS (ORs, 4.0-4.9). Of significant note, other factors that one might expect to be associated with extended LOS did not independently predict extended LOS in this analysis. LEVEL OF EVIDENCE 3.
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Using the ACS-NSQIP to identify factors affecting hospital length of stay after elective posterior lumbar fusion. Spine (Phila Pa 1976) 2014; 39:497-502. [PMID: 24384669 PMCID: PMC3961012 DOI: 10.1097/brs.0000000000000184] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010 that included 1861 patients who had undergone elective posterior lumbar fusion. OBJECTIVE To characterize factors that were independently associated with increased hospital length of stay (LOS) in patients who had undergone elective posterior lumbar fusion. SUMMARY OF BACKGROUND DATA Posterior lumbar spine fusion is a common surgical procedure used to treat lumbar spine pathology. LOS is an important clinical variable and a major determinant of inpatient hospital costs. There is lack of studies in the literature using multivariate analysis to examine specifically the predictors of LOS after elective posterior lumbar fusion. METHODS Patients who underwent elective posterior lumbar fusion from 2005 to 2010 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Preoperative and intraoperative variables were extracted for each case and a multivariate linear regression was performed to assess the contribution of each variable to LOS. RESULTS A total of 1861 patients who had undergone elective posterior lumbar fusion were identified. The average age for patients in this cohort was 60.6 ± 13.9 years (mean ± standard deviation) with a body mass index of 30.3 ± 6.2 kg/m. Of the total patients, 44.7% of patients were male. LOS was in the range from 0 days to 51 days. Multivariate linear regression identified age (P < 0.001), morbid obesity (body mass index ≥ 40 kg/m, P < 0.001), American Society of Anesthesiologists class (P = 0.001), operative time (P < 0.001), multilevel procedure (P = 0.001), and intraoperative transfusion (P < 0.001) as significant predictors of extended LOS. CONCLUSION The identified preoperative and intraoperative variables associated with extended LOS after elective posterior lumbar fusion may be helpful to clinicians for patient counseling and postoperative planning. LEVEL OF EVIDENCE 3.
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Post-traumatic stress symptoms after elective lumbar arthrodesis are associated with reduced clinical benefit. Spine (Phila Pa 1976) 2013; 38:1508-15. [PMID: 23324934 DOI: 10.1097/brs.0b013e318285f05a] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To assess the impact of postoperative post-traumatic stress disorder (PTSD) symptoms on clinical outcomes after lumbar arthrodesis. SUMMARY OF BACKGROUND DATA Postoperative PTSD symptoms occur among many patients who underwent elective lumbar fusion. Although adverse impact of preoperative depression and psychiatric distress has been described, no reports have assessed the impact of postoperative PTSD symptoms on clinical outcomes after lumbar arthrodesis. METHODS Seventy-three patients undergoing elective lumbar spinal arthrodesis completed the PTSD Checklist-Civilian Version (PCL-C) at 3, 6, 9, and 12 months postoperatively. Short-Form 36 and the Oswestry Disability Index (ODI) were completed preoperatively and at 1 year postoperatively. Impact of postoperative PTSD symptoms, preoperative psychiatric diagnoses, and mental composite scores on clinical outcome scores and likelihood of reaching minimal clinically important difference for ODI and physical composite score (PCS) was evaluated. RESULTS PTSD symptoms were reported in 22% of the cohort, with significantly reduced surgical benefit as measured by final (P < 0.0001 and P = 0.003) and total change (P = 0.013 and P = 0.032) in ODI and PCS scores, respectively. Likelihood of reaching minimal clinically important difference for both ODI and PCS was also reduced for patients reporting PTSD symptoms (P = 0.009 and P = 0.001, respectively). A preoperative psychiatric diagnosis correlated only with final ODI score (P = 0.008). Preoperative mental composite scores were significantly correlated with final ODI and PCS scores, as well as final change from preoperative and likelihood of reaching minimal clinically important difference for PCS, but not for ODI scores. CONCLUSION Postoperative psychological distress was strongly correlated with reduced clinical benefit among patients who underwent elective lumbar arthrodesis, and seemed to be a stronger predictor of reduced clinical benefit than either major psychiatric diagnosis or preoperative mental composite scores. Efforts to reduce postoperative psychological distress may offer an opportunity to enhance patient reported clinical outcomes from elective spine surgery. LEVEL OF EVIDENCE 2.
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Parker SL, Shau DN, Mendenhall SK, McGirt MJ. Factors influencing 2-year health care costs in patients undergoing revision lumbar fusion procedures. J Neurosurg Spine 2012; 16:323-8. [DOI: 10.3171/2011.12.spine11750] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Object
Revision lumbar fusion procedures are technically challenging and can be associated with tremendous health care resource utilization and cost. There is a paucity of data regarding specific factors that significantly contribute to increased cost of care. In light of this, the authors set out to identify independent risk factors predictive of increasing 2-year direct health care costs after revision lumbar fusion.
Methods
One hundred fifty patients undergoing revision instrument-assisted fusion for adjacent-segment disease (50 cases), pseudarthrosis (47 cases), or same-level stenosis (53 cases) were included in this study. Patient demographics, comorbidities, preoperative health states as assessed by patient-reported outcome questionnaires and perioperative complications were collected and analyzed. Two-year back-related medical resource utilization and direct health care costs were assessed. The independent association of all variables to increasing cost was assessed using multivariate linear regression analysis.
Results
There was a wide range ($24,935–$63,769) in overall 2-year direct costs for patients undergoing revision lumbar fusion (mean $32,915 ± $8344 [± SD]). Preoperative variables independently associated with 2-year direct health care costs included diagnosis of congestive heart failure, more severe leg pain (visual analog scale), greater back-related disability (Oswestry Disability Index), and worse mental health (12-Item Short Form Health Survey Mental Component Summary score). There was a 1.1- to 1.2-fold increase in cost for patients in the greatest quartiles compared with those in the lowest quartiles for these variables. Surgical site infection, return to the operating room, and spine-related hospital readmission during the 90-day global health period were postoperative variables independently associated with 2-year cost. Patients in the greatest versus lowest quartiles had a 1.7- to 1.9-fold increase in cost for these variables.
Conclusions
Revision lumbar fusion can be associated with considerable 2-year health care costs. These costs can also vary widely among patients, as evidenced by the 2.6-fold overall cost range in this series. Although comorbidities and preoperative severity of disease states contribute to cost of care, the primary drivers of increased cost include perioperative complications such as surgical site infection, return to the operating room, and readmission during the global health period. Measures focused on health service improvement will be most successful in reducing the cost of care for patients undergoing revision lumbar fusion.
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