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Zabat MA, Kim L, Varghese PP, O'Connell BK, Kim YH, Fischer CR. The Impact of Social Determinants of Health on Discharge Disposition Following One- and Two-Level Posterior Interbody Fusion. Cureus 2024; 16:e52939. [PMID: 38406160 PMCID: PMC10893980 DOI: 10.7759/cureus.52939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
Background Current research is limited in exploring the impact of social determinants of health (SDOH) on the discharge location within elective spine surgery. Further understanding of the influence of SDOH on disposition is necessary to improve outcomes. This study explores how SDOH influence discharge disposition for patients undergoing one- or two-level posterior interbody fusion (TLIF/PLIF). Methods This was a retrospective propensity-matched cohort study. Patients who underwent TLIF/PLIF between 2017 and 2020 at a single academic medical center were identified. The chart review gathered demographics, perioperative characteristics, intra/post-operative complications, discharge disposition, and 90-day outcomes. Discharge dispositions included subacute nursing facility (SNF), home with self-care (HSC), home with health services (HHS), and acute rehab facility (ARF). Demographic, perioperative, and disposition outcomes were analyzed by chi-square analysis and one-way ANOVA based on gender, race, and income quartiles. Results Propensity score matching for significant demographic factors isolated 326 patients. The rate of discharge to SNF was higher in females compared to males (25.00% vs 10.56%; p=0.001). Men were discharged to home at a higher rate than women (75.4% vs 61.95%; p=0.010). LatinX patients had the highest rate of home discharge, followed by Asians, Caucasians, and African Americans (83.33% vs 70.31% vs 66.45% vs 65.90%; p<0.001). The post hoc Tukey test demonstrated statistically significant differences between Asians and all other races in the context of age and BMI. Additionally, patients discharged to SNF showed the highest Charlson comorbidity index (CCI) score, followed by those at ARF, HHS, and HSC (4.36 vs 4.05 vs 2.87 vs 2.37; p<0.001). The estimated median income for the cohort ranged from $52,000 to $250,001, with no significant differences in income seen across comparisons. Conclusion Discharge disposition following one- or two-level TLIF/PLIF shows significant association with gender and race. No association was seen when comparing discharge rates among zip code-level median income quartiles.
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Affiliation(s)
- Michelle A Zabat
- Orthopaedic Surgery, New York University (NYU) Grossman School of Medicine, New York, USA
| | - Lindsay Kim
- Orthopaedic Surgery, State University of New York (SUNY) Downstate Health Sciences University, College of Medicine, Brooklyn, USA
| | - Priscilla P Varghese
- Orthopaedic Surgery, State University of New York (SUNY) Downstate Health Sciences University, College of Medicine, Brooklyn, USA
| | - Brooke K O'Connell
- Orthopaedic Surgery, New York University (NYU) Grossman School of Medicine, New York, USA
| | - Yong H Kim
- Orthopaedic Surgery, New York University (NYU) Grossman School of Medicine, New York, USA
| | - Charla R Fischer
- Orthopaedic Surgery, New York University (NYU) Grossman School of Medicine, New York, USA
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Issa TZ, Lee Y, Lambrechts MJ, Mazmudar AS, D'Antonio ND, Iofredda P, Endersby K, Kalra A, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Assessment of a Private Payer Bundled Payment Model for Lumbar Decompression Surgery. J Am Acad Orthop Surg 2023; 31:e984-e993. [PMID: 37467396 DOI: 10.5435/jaaos-d-23-00384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy. METHODS A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit. RESULTS Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (β: $2,398, P = 0.012) and surgery in a specialty hospital (β: $1,729, P = 0.096) or ambulatory surgery center (β: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit. CONCLUSIONS Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals.
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Affiliation(s)
- Tariq Z Issa
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Mo K, Ikwuezunma I, Mun F, Ortiz-Babilonia C, Wang KY, Suresh KV, Uppal A, Sethi I, Mesfin A, Jain A. Racial Disparities in Spine Surgery: A Systematic Review. Clin Spine Surg 2023; 36:243-252. [PMID: 35994052 DOI: 10.1097/bsd.0000000000001383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES To synthesize previous studies evaluating racial disparities in spine surgery. METHODS We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay. RESULTS A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications. CONCLUSIONS This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.
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Affiliation(s)
- Kevin Mo
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Ijezie Ikwuezunma
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Frederick Mun
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Kevin Y Wang
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Krishna V Suresh
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | | | | | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
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Agarwal MA, Dhaliwal JS, Yang EH, Aksoy O, Press M, Watson K, Ziaeian B, Fonarow GC, Moriarty JM, Saggar R, Channick R. Sex Differences in Outcomes of Percutaneous Pulmonary Artery Thrombectomy in Patients With Pulmonary Embolism. Chest 2023; 163:216-225. [PMID: 35926721 DOI: 10.1016/j.chest.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized. RESEARCH QUESTION What are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy? STUDY DESIGN AND METHODS This retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy. RESULTS Among 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9% vs 11.2%; P < .05), required more blood transfusions (11.9% vs 5.7%; P < .05), and experienced more vascular complications (5.0% vs 1.5%; P < .05). Women experienced higher in-hospital mortality (16.9% vs 9.3%; adjusted OR, 1.9; 95% CI, 1.2-3.0; P = .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9% vs 60.3%; adjusted OR, 0.7; 95% CI, 0.50-0.99; P = .04). INTERPRETATION In this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.
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Affiliation(s)
- Manyoo A Agarwal
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Jasmeet S Dhaliwal
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric H Yang
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Olcay Aksoy
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Marcella Press
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Karol Watson
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Gregg C Fonarow
- Division of Cardiovascular Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - John M Moriarty
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Borja AJ, Farooqi AS, Golubovsky JL, Glauser G, Strouz K, Burkhardt JK, McClintock SD, Malhotra NR. Simple and actionable preoperative prediction of postoperative healthcare needs of single-level lumbar fusion patients. J Neurosurg Spine 2022; 37:633-638. [PMID: 35901736 DOI: 10.3171/2022.5.spine22282] [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: 03/11/2022] [Accepted: 05/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative prediction of a patient's postoperative healthcare utilization is challenging, and limited guidance currently exists. The objective of the present study was to assess the capability of individual risk-related patient characteristics, which are available preoperatively, that may predict discharge disposition prior to lumbar fusion. METHODS In total, 1066 consecutive patients who underwent single-level, posterior-only lumbar fusion at a university health system were enrolled. Patients were prospectively asked 4 nondemographic questions from the Risk Assessment and Prediction Tool during preoperative office visits to evaluate key risk-related characteristics: baseline walking ability, use of a gait assistive device, reliance on community supports (e.g., Meals on Wheels), and availability of a postoperative home caretaker. The primary outcome was discharge disposition (home vs skilled nursing facility/acute rehabilitation). Logistic regression was performed to analyze the ability of each risk-related characteristic to predict likelihood of home discharge. RESULTS Regression analysis demonstrated that improved baseline walking ability (OR 3.17), ambulation without a gait assistive device (OR 3.13), and availability of a postoperative home caretaker (OR 1.99) each significantly predicted an increased likelihood of home discharge (all p < 0.0001). However, reliance on community supports did not significantly predict discharge disposition (p = 0.94). CONCLUSIONS Patient mobility and the availability of a postoperative caretaker, when determined preoperatively, strongly predict a patient's healthcare utilization in the setting of single-level, posterior lumbar fusion. These findings may help surgeons to streamline preoperative clinic workflow and support the patients at highest risk in a targeted fashion.
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Affiliation(s)
- Austin J Borja
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Ali S Farooqi
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Joshua L Golubovsky
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Gregory Glauser
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Krista Strouz
- 2McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia; and
| | - Jan-Karl Burkhardt
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Scott D McClintock
- 3The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Neil R Malhotra
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- 2McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia; and
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Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home. Ann Surg 2022; 276:e185-e191. [PMID: 35762618 DOI: 10.1097/sla.0000000000005544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether patients of Black race are at higher risk of losing the ability to live independently after surgery, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. SUMMARY BACKGROUND DATA It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. METHODS 368,360 adults undergoing surgery between 2007 and 2020 across two academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. RESULTS 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients lost the ability to live independently after surgery. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference [ARDadj] 1.9%;95%CI 1.6-2.2%;P<0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association (p-for-interaction<0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. CONCLUSIONS Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.
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7
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Farooqi AS, Borja AJ, Ajmera S, Glauser G, Strouz K, Ozturk AK, Petrov D, Chen HI, McClintock SD, Malhotra NR. Matched Analysis of the Risk Assessment and Prediction Tool (RAPT) for Discharge Planning Following Single-Level Posterior Lumbar Fusion. World Neurosurg 2022; 163:e113-e123. [DOI: 10.1016/j.wneu.2022.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
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Hung B, Pennington Z, Hersh AM, Schilling A, Ehresman J, Patel J, Antar A, Porras JL, Elsamadicy AA, Sciubba DM. Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases. J Neurosurg Spine 2021; 36:678-685. [PMID: 34740176 DOI: 10.3171/2021.7.spine21287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have suggested the possibility of racial disparities in surgical outcomes for patients undergoing spine surgery, although this has not been thoroughly investigated in those with spinal metastases. Given the increasing prevalence of spinal metastases requiring intervention, knowledge about potential discrepancies in outcomes would benefit overall patient care. The objective in the present study was to investigate whether race was an independent predictor of postoperative complications, nonroutine discharge, and prolonged length of stay (LOS) after surgery for spinal metastasis. METHODS The authors retrospectively examined patients at a single comprehensive cancer center who had undergone surgery for spinal metastasis between April 2013 and April 2020. Demographic information, primary pathology, preoperative clinical characteristics, and operative outcomes were collected. Factors achieving p values < 0.15 on univariate regression were entered into a stepwise multivariable logistic regression to generate predictive models. Nonroutine discharge was defined as a nonhome discharge destination and prolonged LOS was defined as LOS greater than the 75th percentile for the entire cohort. RESULTS Three hundred twenty-eight patients who had undergone 348 operations were included: 240 (69.0%) White and 108 (31.0%) Black. On univariable analysis, cohorts significantly differed in age (p = 0.02), marital status (p < 0.001), insurance status (p = 0.03), income quartile (p = 0.02), primary tumor type (p = 0.04), and preoperative Karnofsky Performance Scale (KPS) score (p < 0.001). On multivariable analysis, race was an independent predictor for nonroutine discharge: Black patients had significantly higher odds of nonroutine discharge than White patients (adjusted odds ratio [AOR] 2.24, 95% confidence interval [CI] 1.28-3.92, p = 0.005). Older age (AOR 1.06 per year, 95% CI 1.03-1.09, p < 0.001), preoperative KPS score ≤ 70 (AOR 3.30, 95% CI 1.93-5.65, p < 0.001), preoperative Frankel grade A-C (AOR 3.48, 95% CI 1.17-10.3, p = 0.02), insurance status (p = 0.005), being unmarried (AOR 0.58, 95% CI 0.35-0.97, p = 0.04), number of levels (AOR 1.17 per level, 95% CI 1.05-1.31, p = 0.004), and thoracic involvement (AOR 1.71, 95% CI 1.02-2.88, p = 0.04) were also predictive of nonroutine discharge. However, race was not independently predictive of postoperative complications or prolonged LOS. Higher Charlson Comorbidity Index (AOR 1.22 per point, 95% CI 1.04-1.43, p = 0.01), low preoperative KPS score (AOR 1.84, 95% CI 1.16-2.92, p = 0.01), and number of levels (AOR 1.15 per level, 95% CI 1.05-1.27, p = 0.004) were predictive of complications, while insurance status (p = 0.05), income quartile (p = 0.01), low preoperative KPS score (AOR 1.64, 95% CI 1.03-2.72, p = 0.05), and number of levels (AOR 1.16 per level, 95% CI 1.05-1.30, p = 0.004) were predictive of prolonged LOS. CONCLUSIONS Race, insurance status, age, baseline functional status, and marital status were all independently associated with nonroutine discharge. This suggests that a combination of socioeconomic factors and functional status, rather than medical comorbidities, may best predict postdischarge disposition in patients treated for spinal metastases. Further investigation in a prospective cohort is merited.
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Affiliation(s)
- Bethany Hung
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zach Pennington
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew M Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew Schilling
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,3Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Medical Center, Phoenix, Arizona
| | - Jaimin Patel
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Albert Antar
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose L Porras
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aladine A Elsamadicy
- 4Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut; and
| | - Daniel M Sciubba
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,5Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York
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Khan IS, Huang E, Maeder-York W, Yen RW, Simmons NE, Ball PA, Ryken TC. Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 157:e232-e244. [PMID: 34634504 DOI: 10.1016/j.wneu.2021.09.140] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.
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Affiliation(s)
- Imad S Khan
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
| | - Elijah Huang
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Walker Maeder-York
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Renata W Yen
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Nathan E Simmons
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Perry A Ball
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Timothy C Ryken
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Elsamadicy AA, Freedman IG, Koo AB, David W, Hengartner AC, Havlik J, Reeves BC, Hersh A, Pennington Z, Kolb L, Laurans M, Shin JH, Sciubba DM. Patient- and hospital-related risk factors for non-routine discharge after lumbar decompression and fusion for spondylolisthesis. Clin Neurol Neurosurg 2021; 209:106902. [PMID: 34481141 DOI: 10.1016/j.clineuro.2021.106902] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In various spinal surgeries, non-routine discharges have been associated with inferior outcomes. However, there exists a paucity of data regarding the relationship between non-routine discharge and quality of care among patients with spondylolisthesis. The aim of this study was to identify independent predictors for non-routine discharge following spinal decompression and fusion for lumbar spondylolisthesis. METHODS A retrospective cohort study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2016. Adult patients (≥18 years old) who underwent spinal decompression and fusion for lumbar spondylolisthesis were identified using ICD-9-CM diagnosis and CPT procedural coding systems. The study population was divided into two cohorts based on discharge disposition: routine (RD) and non-routine discharge (NRD). Patient demographics, comorbidities, adverse events, LOS, reoperation, and readmission were assessed. A multivariate logistic regression model was used to identify the independent predictors of non-home discharge and 30-day unplanned readmission. RESULTS A total of 5252 patients were identified, of which 4316 (82.2%) had a RD and 936 (18.8%) had a NRD. The NRD cohort tended to be older (p < 0.001) and have a higher BMI (p < 0.001). Patients who experienced a NRD had a longer LOS (NRD: 4.7 ± 3.7 days vs RD: 3.1 ± 2.0 days, p < 0.001), a higher proportion of adverse events (p < 0.001), higher rates of reoperation (p = 0.005) and unplanned 30-day readmission rates (p < 0.001). On multivariate regression analysis, age [OR: 1.08, 95% CI (1.06-1.10), p < 0.001], female sex [OR: 2.01, 95% (1.51-2.69), p < 0.001], non-Hispanic Black race/ethnicity [OR: 2.10, 95% CI (1.36-3.24), p = 0.001], BMI [OR: 1.03, 95% CI (1.01-1.05), p = 0.007], dependent functional status [OR: 3.33, 95% CI (1.59 - 6.99), p = 0.001], malnourishment [OR: 2.14, 95% CI (1.27-3.62), p = 0.005], and LOS [OR: 1.26, 95% CI (1.18-1.33), p < 0.001] were all independent predictors for NRD. However, NRD did not independently predict an unplanned 30-day readmission on multivariate analysis. CONCLUSION In our study we found that on univariate analysis NRD was associated with increased adverse events, length of stay and 30-day unplanned readmission. When controlling for patient- and hospital-related factors, we found that female sex, non-Hispanic Black race, BMI, dependent functional status, malnourishment and longer LOS were independently associated with NRD. However, NRD did not independently predict an unplanned 30-day readmission.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Wyatt David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew Hersh
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA
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11
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Washida K, Kato T, Ozasa N, Morimoto T, Yaku H, Inuzuka Y, Tamaki Y, Seko Y, Yamamoto E, Yoshikawa Y, Kitai T, Yamashita Y, Iguchi M, Nagao K, Kawase Y, Morinaga T, Toyofuku M, Furukawa Y, Ando K, Kadota K, Sato Y, Kuwahara K, Kimura T. Risk Factors and Clinical Outcomes of Nonhome Discharge in Patients With Acute Decompensated Heart Failure: An Observational Study. J Am Heart Assoc 2021; 10:e020292. [PMID: 34325523 PMCID: PMC8475677 DOI: 10.1161/jaha.120.020292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background No clinical studies have focused on the factors associated with discharge destination in patients with acute decompensated heart failure. Methods and Results Of 4056 consecutive patients hospitalized for acute decompensated heart failure in the KCHF (Kyoto Congestive Heart Failure) registry, we analyzed 3460 patients hospitalized from their homes and discharged alive. There were 3009 and 451 patients who were discharged to home and nonhome, respectively. We investigated the factors associated with nonhome discharge and compared the outcomes between home discharge and nonhome discharge. Factors independently and positively associated with nonhome discharge were age ≥80 years (odds ratio [OR],1.76; 95% CI,1.28–2.42), body mass index ≤22 kg/m2 (OR,1.49; 95% CI,1.12–1.97), poor medication adherence (OR, 2.08; 95% CI,1.49–2.88), worsening heart failure (OR, 2.02; 95% CI, 1.46–2.82), stroke during hospitalization (OR, 3.74; 95% CI, 1.75–8.00), functional decline (OR, 12.24; 95% CI, 8.74–17.14), and length of hospital stay >16 days (OR, 4.14; 95% CI, 3.01–5.69), while those negatively associated were diabetes mellitus (OR, 0.69; 95% CI, 0.51–0.94), cohabitants (OR, 0.62; 95% CI, 0.46–0.85), and ambulatory state before admission (OR, 0.25; 95% CI, 0.18–0.36). The cumulative 1‐year incidence of all‐cause death was significantly higher in the nonhome discharge group than in the home discharge group. The nonhome discharge group compared with the nonhome discharge group was associated with a higher adjusted risk for all‐cause death (hazard ratio, 1.66; P<0.001). Conclusions The discharge destination of patients with acute decompensated heart failure is influenced by factors such as prehospital social background, age, body mass index, low self‐care ability, events during hospitalization (worsening heart failure, stroke, etc), functional decline, and length of hospital stay; moreover, the prognosis of nonhome discharge patients is worse than that of home discharge patients. Registration Information clinicaltrials.gov. Identifier: NCT02334891.
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Affiliation(s)
- Koichi Washida
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Takao Kato
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Takeshi Morimoto
- Clinical Epidemiology Hyogo College of Medicine Nishinomiya Japan
| | - Hidenori Yaku
- Department of Cardiology Mitsubishi Kyoto Hospital Kyoto Japan
| | | | - Yodo Tamaki
- Division of Cardiology Tenri Hospital Nara Japan
| | - Yuta Seko
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Erika Yamamoto
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine Kobe City Medical Center General Hospital Hyogo Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Moritake Iguchi
- Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Kazuya Nagao
- Department of Cardiology Osaka Red Cross Hospital Osaka Japan
| | - Yuichi Kawase
- Department of Cardiology Kurashiki Central Hospital Okayama Japan
| | | | - Mamoru Toyofuku
- Department of Cardiology Japanese Red Cross Wakayama Medical Center Wakayama Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine Kobe City Medical Center General Hospital Hyogo Japan
| | - Kenji Ando
- Department of Cardiology Kokura Memorial Hospital Fukuoka Japan
| | - Kazushige Kadota
- Department of Cardiology Kurashiki Central Hospital Okayama Japan
| | - Yukihito Sato
- Department of Cardiology Hyogo Prefectural Amagasaki General Medical Center Hyogo Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine Shinshu University Graduate School of Medicine Nagano Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
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12
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Martini ML, Neifert SN, Oermann EK, Gilligan JT, Rothrock RJ, Yuk FJ, Gal JS, Nistal DA, Caridi JM. Application of Cooperative Game Theory Principles to Interpret Machine Learning Models of Nonhome Discharge Following Spine Surgery. Spine (Phila Pa 1976) 2021; 46:803-812. [PMID: 33394980 DOI: 10.1097/brs.0000000000003910] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively acquired data. OBJECTIVE The aim of this study was to identify interaction effects that modulate nonhome discharge (NHD) risk by applying coalitional game theory principles to interpret machine learning models and understand variable interaction effects underlying NHD risk. SUMMARY OF BACKGROUND DATA NHD may predispose patients to adverse outcomes during their care. Previous studies identified potential factors implicated in NHD; however, it is unclear how interaction effects between these factors contribute to overall NHD risk. METHODS Of the 11,150 reviewed cases involving procedures for degenerative spine conditions, 1764 cases (15.8%) involved NHD. Gradient boosting classifiers were used to construct predictive models for NHD for each patient. Shapley values, which assign a unique distribution of the total NHD risk to each model variable using an optimal cost-sharing rule, quantified feature importance and examined interaction effects between variables. RESULTS Models constructed from features identified by Shapley values were highly predictive of patient-level NHD risk (mean C-statistic = 0.91). Supervised clustering identified distinct patient subgroups with variable NHD risk and their shared characteristics. Focused interaction analysis of surgical invasiveness, age, and comorbidity burden suggested age as a worse risk factor than comorbidity burden due to stronger positive interaction effects. Additionally, negative interaction effects were found between age and low blood loss, indicating that intraoperative hemostasis may be critical for reducing NHD risk in the elderly. CONCLUSION This strategy provides novel insights into feature interactions that contribute to NHD risk after spine surgery. Patients with positively interacting risk factors may require special attention during their hospitalization to control NHD risk.Level of Evidence: 3.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey T Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Abstract
OBJECTIVE Spinal decompression with or without fusion is one of the most commonly performed procedures in spine surgery. However, there is limited evidence on the effect of discharge environment on outcomes after surgery. The purpose of this study is to identify the effects of discharge disposition setting on clinical outcomes after spine surgery. METHODS Patients who underwent lumbar decompression, lumbar decompression and fusion, or posterior cervical decompression and fusion surgery were retrospectively identified. All clinical and demographic data were obtained from electronic health records. Surgical outcomes included wound complications, revision surgery, "30-day" readmission (0-30 d), and "90-day" readmission (31-90 d). Discharge disposition was stratified into home/self-care, acute inpatient rehabilitation, and subacute rehabilitation. Patient-reported outcome measures including VAS Back, VAS Leg, VAS Neck, VAS Arm, PCS-12 and MCS-12, ODI, and NDI were compared between patient discharge disposition settings using the Mann-Whitney U test. Pearson's chi-square analysis was used to assess for differences in wound complications, revision surgery, 30-day readmission, or 90-day readmission rates. Multivariate logistic regression incorporating age, sex, body mass index (BMI), Charlson Comorbidity Index (CCI), and discharge disposition was used to determine independent predictors of wound complications. RESULTS A total of 637 patients were included in the study. A significant difference (P = 0.03) was found in wound complication based on discharge disposition, with subacute disposition having the highest proportion of wound complications (6.1%) and home disposition having the lowest (1.5%). There were no significant differences in the rates of revision surgery, 30-day readmission, or 90-day readmission between groups. Subacute rehabilitation (odds ratio: 3.67, P = 0.047) and CCI (odds ratio 1.49, P = 0.01) were independent predictors of wound complications. Significant improvement in PROMs was seen across all postacute discharge dispositions. Baseline (P = 0.02) and postoperative (P = 0.02) ODI were significantly higher among patients discharged to an acute facility (49.4 and 32.0, respectively) compared to home (42.2 and 20.0) or subacute (47.4 and 28.4) environments. CONCLUSION Subacute rehabilitation disposition and CCI are independent predictors of wound complications after spinal decompression surgery. Patients undergoing spine surgery have similar readmission and revision rates and experience similar clinical improvement across all postacute discharge dispositions.
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14
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Macki M, Fadel HA, Hamilton T, Lim S, Massie LW, Zakaria HM, Pawloski J, Chang V. The influence of sagittal spinopelvic alignment on patient discharge disposition following minimally invasive lumbar interbody fusion. JOURNAL OF SPINE SURGERY 2021; 7:8-18. [PMID: 33834123 DOI: 10.21037/jss-20-596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The aim of this study was to investigate the changes to spinopelvic sagittal alignment following minimally invasive (MIS) lumbar interbody fusion, and the influence of such changes on postoperative discharge disposition. Methods The Michigan Spine Surgery Improvement Collaborative was queried for all patients who underwent transforaminal lumbar interbody fusion (TLIF)or lateral lumbar interbody fusion (LLIF) procedures for degenerative spine disease. Several spinopelvic sagittal alignment parameters were measured, including sagittal vertical axis (SVA), lumbar lordosis, pelvic tilt, pelvic incidence, and pelvic incidence-lumbar lordosis mismatch. Primary outcome measure-discharge to a rehabilitation facility-was expressed as adjusted odds ratio (ORadj) following a multivariable logistical regression. Results Of the 83 patients in the study population, 11 (13.2%) were discharged to a rehabilitation facility. Preoperative SVA was equivalent. Postoperative SVA increased to 8.0 cm in the discharge-to-rehabilitation division versus a decrease to 3.6 cm in the discharge-to-home division (P<0.001). The odds of discharge to a rehabilitation facility increased by 25% for every 1-cm increase in postoperative sagittal balance (ORadj =1.27, P=0.014). The strongest predictor of discharge to rehabilitation was increasing decade of life (ORadj =3.13, P=0.201). Conclusions Correction of sagittal balance is associated with greater odds of discharge to home. These findings, coupled with the recognized implications of admission to a rehabilitation facility, will emphasize the importance of spine surgeons accounting for SVA into their surgical planning of MIS lumbar interbody fusions.
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Affiliation(s)
- Mohamed Macki
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Hassan A Fadel
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Travis Hamilton
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Seokchun Lim
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Lara W Massie
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Hesham Mostafa Zakaria
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Jacob Pawloski
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI, USA
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15
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Goh GS, Yue WM, Guo CM, Tan SB, Chen JLT. Comparative Demographics and Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Chinese, Malays, and Indians. Clin Spine Surg 2021; 34:66-72. [PMID: 33633059 DOI: 10.1097/bsd.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/29/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This study carried out a retrospective review of prospectively collected registry data. OBJECTIVE This study aimed to determine whether (1) utilization rates; (2) demographics and preoperative statuses; and (3) clinical outcomes differ among Chinese, Malays, and Indians undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). SUMMARY OF BACKGROUND DATA There is a marked racial disparity in spine surgery outcomes between white and African American patients. Comparative studies of ethnicity have mostly been carried out in American populations, with an underrepresentation of Asian ethnic groups. It is unclear whether these disparities exist among Chinese, Malays, and Indians. METHODS A prospectively maintained registry was reviewed for 753 patients who underwent primary MIS-TLIF for degenerative spondylolisthesis between 2006 and 2013. The cohort was stratified by race. Comparisons of demographics, functional outcomes, and patient satisfaction were performed preoperatively and 1 month, 3 months, 6 months, and 2 years postoperatively. RESULTS Compared with population statistics, there was an overrepresentation of Chinese (6.6%) and an underrepresentation of Malays (5.0%) and Indians (3.5%) who underwent MIS-TLIF. Malays and Indians were younger and had higher body mass index at the time of surgery compared with Chinese. After adjusting for age, sex, and body mass index, Malays had significantly worse back pain and Indians had poorer Short-Form 36 Physical Component Summary compared with Chinese preoperatively. Chinese also had a better preoperative Oswestry Disability Index compared with the other races. Although significant differences remained at 1 month, there was no difference in outcomes up to 2 years postoperatively, except for a lower Physical Component Summary in Indians compared with Chinese at 2 years. The rate of minimal clinically important difference attainment, satisfaction, and expectation fulfillment was also comparable. At 2 years, 87.0% of Chinese, 76.9% of Malays, and 91.7% of Indians were satisfied. CONCLUSION The variations in demographics, preoperative statuses, and postoperative outcomes between races should be considered when interpreting outcome studies of lumbar spine surgery in Asian populations. LEVEL OF EVIDENCE Level III-nonrandomized cohort study.
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Affiliation(s)
- Graham S Goh
- Department of Orthopedic Surgery, Singapore General Hospital
| | | | - Chang-Ming Guo
- Department of Orthopedic Surgery, Singapore General Hospital
| | - Seang-Beng Tan
- Orthopaedic and Spine Clinic, Mount Elizabeth Medical Centre, Singapore, Singapore
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Harada GK, Basques BA, Samartzis D, Goldberg EJ, Colman MW, An HS. Development and validation of a novel scoring tool for predicting facility discharge after elective posterior lumbar fusion. Spine J 2020; 20:1629-1637. [PMID: 32135302 DOI: 10.1016/j.spinee.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Discharge to acute/intermediate care facilities is a common occurrence after posterior lumbar fusion and can be associated with increased costs and complications after these procedures. This is particularly relevant with the growing popularity of bundled payment plans, creating a need to identify patients at greatest risk. PURPOSE To develop and validate a risk-stratification tool to identify patients at greatest risk for facility discharge after open posterior lumbar fusion. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Patients were queried using separate databases from the institution of study and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for all patients undergoing open lumbar fusion between 2011 and 2018. OUTCOME MEASURES Discharge to intermediate care and/or rehabilitation facilities. METHODS Using an 80:20 training and testing NSQIP data split, collected preoperative demographic and operative variables were used in a multivariate logistic regression to identify potential risk factors for postoperative facility discharge, retaining those with a p value <.05. A nomogram was generated to develop a scoring system from this model, with probability cutoffs determined for facility discharge. This model was subsequently validated within the NSQIP database, in addition to external validation at the institution of study. Overall model performance and calibration was assessed using the Brier score and calibration plots, respectively. RESULTS A total of 11,486 patients (10,453 NSQIP, 1,033 local cohort) were deemed eligible for study, of which 16.1% were discharged to facilities (16.7% NSQIP, 9.6% local cohort). Utilizing training data, age (p<.001), body mass index (p<.001), female sex (p<.001), diabetes (p=.043), peripheral vascular disease (p=.001), cancer (p=.010), revision surgery (p<.001), number of levels fused (p<.001), and spondylolisthesis (p=.049) were identified as significant risk factors for facility discharge. The area under the receiver operating characteristic curve (AUC) indicated a strong predictive model (AUC=0.750), with similar predictive ability in the testing (AUC=0.757) and local data sets (AUC=0.773). Using this tool, patients identified as low- and high-risk had a 7.94% and 33.28% incidence of facility discharge in the testing data set, while rates of 4.44% and 16.33% were observed at the institution of study. CONCLUSIONS Using preoperative variables as predictors, this scoring system demonstrated high efficiency in risk-stratifying patients with an approximate four to fivefold difference in rates of facility discharge after posterior lumbar fusion. This tool may help inform medical decision-making and guide reimbursement under bundled-care repayment plans.
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Affiliation(s)
- Garrett K Harada
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA.
| | - Bryce A Basques
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA
| | - Dino Samartzis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA
| | - Edward J Goldberg
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA
| | - Matthew W Colman
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA
| | - Howard S An
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA; International Spine Research and Innovation Initiative (ISRII), Rush University Medical Center, Chicago, IL, USA
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Machine Learning for Predictive Modeling of 90-day Readmission, Major Medical Complication, and Discharge to a Facility in Patients Undergoing Long Segment Posterior Lumbar Spine Fusion. Spine (Phila Pa 1976) 2020; 45:1151-1160. [PMID: 32706568 DOI: 10.1097/brs.0000000000003475] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case control study. OBJECTIVE To develop predictive models for postoperative outcomes after long segment lumbar posterior spine fusion (LSLPSF). SUMMARY OF BACKGROUND DATA Surgery for adult spinal deformity is effective for treating spine-related disability; however, it has high complication and readmission rates. METHODS Patients who underwent LSLPSF (three or more levels) were identified in State Inpatient Database. Data was queried for discharge-to-facility (DTF), 90-day readmission, and 90-day major medical complications, and demographic, comorbid, and surgical data. Data was partitioned into training and testing sets. Multivariate logistic regression, random forest, and elastic net regression were performed on the training set. Models were applied to the testing set to generate AUCs. AUCs between models were compared using the method by DeLong et al. RESULTS.: 37,852 patients were analyzed. The DTF, 90-day readmission, and 90-day major medical complication rates were 35.4%, 19.0%, and 13.0% respectively. For DTF, the logistic regression AUC was 0.77 versus 0.75 for random forest and 0.76 for elastic net (P < 0.05 for all comparisons). For 90-day readmission, the logistic regression AUC was 0.65, versus 0.63 for both random forest and elastic net (P < 0.05 for all comparisons). For 90-day major medical complications, the logistic regression AUC was 0.70, versus 0.69 for random forest and 0.68 for elastic net (P < 0.05 for all comparisons). CONCLUSION This study created comprehensive models to predict discharge to facility, 90-day readmissions, and 90-day major medical complications after LSLPSF. This information can be used to guide decision making between the surgeon and patient, as well as inform value-based payment models. LEVEL OF EVIDENCE 3.
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18
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Ogura Y, Gum JL, Steele P, Crawford CH, Djurasovic M, Owens RK, Laratta JL, Brown M, Daniels C, Dimar JR, Glassman SD, Carreon LY. Drivers for nonhome discharge in a consecutive series of 1502 patients undergoing 1- or 2-level lumbar fusion. J Neurosurg Spine 2020; 33:766-771. [PMID: 32736357 DOI: 10.3171/2020.5.spine20410] [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: 03/23/2020] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Unexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion. METHODS The electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors. RESULTS A total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001). CONCLUSIONS Increased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.
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Black Race as a Social Determinant of Health and Outcomes After Lumbar Spinal Fusion Surgery: A Multistate Analysis, 2007 to 2014. Spine (Phila Pa 1976) 2020; 45:701-711. [PMID: 31939767 DOI: 10.1097/brs.0000000000003367] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective analysis of patient hospitalization and discharge records. OBJECTIVE To examine the association between race and inpatient postoperative complications following lumbar spinal fusion surgery. SUMMARY OF BACKGROUND DATA Racial disparities in healthcare have been demonstrated across a range of surgical procedures. Previous research has identified race as a social determinant of health that impacts outcomes after lumbar spinal fusion surgery. However, these studies are limited in that they are outdated, contain data from a single institution, analyze small limited samples, and report limited outcomes. Our study aims to expand and update the literature examining the association between race and inpatient postoperative complications following lumbar spine surgery. METHODS We analyzed 267,976 patient discharge records for inpatient lumbar spine surgery using data from the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We used unadjusted bivariate analysis, adjusted multivariable, and stratified analysis to compare patient demographics, present-on-admission comorbidities, hospital characteristics, and complications by categories of race/ethnicity. RESULTS Black patients were 8% and 14% more likely than white patients to experience spine surgery specific complications (adjusted odds ratios [aOR]: 1.08, 95% confidence interval [CI]: 1.03-1.13) and general postoperative complications (aOR: 1.14, 95% CI: 1.07-1.20), respectively. Black patients, compared with white patients, also had increased adjusted odds of 30-day readmissions (aOR: 1.13, 95% CI: 1.07-1.20), 90-day readmissions (aOR: 1.07, 95% CI: 1.02-1.13), longer length of stay (LOS) (adjusted Incidence Rate Ratio: 1.15, 95% CI: 1.14-1.16), and higher total charges (adjusted Incidence Rate Ratio: 1.08, 95% CI: 1.07-1.09). CONCLUSION Our findings demonstrate that black patients, as compared with white patients, are more likely to have postoperative complications, longer postoperative lengths of stay, higher total hospital charges, and increased odds of 30- and 90-day readmissions following lumbar spinal fusion surgery. LEVEL OF EVIDENCE 4.
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20
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Beers K, Wen HH, Saha A, Chauhan K, Dave M, Coca S, Nadkarni G, Chan L. Racial and Ethnic Disparities in Pregnancy-Related Acute Kidney Injury. KIDNEY360 2020; 1:169-178. [PMID: 35368630 PMCID: PMC8809257 DOI: 10.34067/kid.0000102019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/28/2020] [Indexed: 04/28/2023]
Abstract
BACKGROUND Pregnancy-related AKI (PR-AKI) is increasing in the United States. PR-AKI is associated with adverse maternal outcomes. Disparities in racial/ethnic differences in PR-AKI by race have not been studied. METHODS This was a retrospective cohort study using the National Inpatient Sample (NIS) from 2005 to 2015. We identified patients who were admitted for a pregnancy-related diagnosis using the Neomat variable provided by the NIS database that indicates the presence of a maternal or neonatal diagnosis code or procedure code. PR-AKI was identified using ICD codes. Survey logistic regression was used for multivariable analysis adjusting for age, medical comorbidities, socioeconomic factors, and hospital/admission factors. RESULTS From 48,316,430 maternal hospitalizations, 34,001 (0.07%) were complicated by PR-AKI. Hospitalizations for PR-AKI increased from 3.5/10,000 hospitalizations in 2005 to 11.8/10,000 hospitalizations in 2015 with the largest increase seen in patients aged ≥35 and black patients. PR-AKI was associated with higher odds of miscarriage (adjusted odds ratio [aOR], 1.64; 95% CI, 1.34 to 2.07) and mortality (aOR, 1.53; 95% CI, 1.25 to 1.88). After adjustment for age, medical comorbidities, and socioeconomic factors, blacks were more likely than whites to develop PR-AKI (aOR, 1.17; 95% CI, 1.04 to 1.33). On subgroup analyses in hospitalizations of patients with PR-AKI, blacks and Hispanics were more likely to have preeclampsia/eclampsia compared with whites (aOR, 1.29; 95% CI, 1.01 to 1.65; and aOR, 1.69; 95% CI, 1.23 to 2.31, respectively). Increased odds of mortality in PR-AKI compared with whites were only seen in black patients (aOR, 1.61; 95% CI, 1.02 to 2.55). CONCLUSIONS The incidence of PR-AKI has increased and the largest increase was seen in older patients and black patients. PR-AKI is associated with miscarriages, adverse discharge from hospital, and mortality. Black and Hispanic patients with PR-AKI were more likely to have adverse outcomes than white patients. Further research is needed to identify factors contributing to these discrepancies.
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Affiliation(s)
- Kelly Beers
- Division of Nephrology, Departments of Medicine and
- Division of Nephrology and Hypertension, Albany Medical Center, Albany, New York
| | - Huei Hsun Wen
- Genetics and Genomics Sciences, The Charles Bronfman Institute for Personalized Medicine, and
| | - Aparna Saha
- Genetics and Genomics Sciences, The Charles Bronfman Institute for Personalized Medicine, and
| | | | - Mihir Dave
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Steven Coca
- Division of Nephrology, Departments of Medicine and
| | - Girish Nadkarni
- Division of Nephrology, Departments of Medicine and
- Genetics and Genomics Sciences, The Charles Bronfman Institute for Personalized Medicine, and
| | - Lili Chan
- Division of Nephrology, Departments of Medicine and
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Farrokhi F, Buchlak QD, Sikora M, Esmaili N, Marsans M, McLeod P, Mark J, Cox E, Bennett C, Carlson J. Investigating Risk Factors and Predicting Complications in Deep Brain Stimulation Surgery with Machine Learning Algorithms. World Neurosurg 2020; 134:e325-e338. [DOI: 10.1016/j.wneu.2019.10.063] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 01/07/2023]
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Karhade AV, Ogink PT, Thio QC, Cha TD, Hershman SH, Schoenfeld AJ, Bono CM, Schwab JH. Discharge Disposition After Anterior Cervical Discectomy and Fusion. World Neurosurg 2019; 132:e14-e20. [DOI: 10.1016/j.wneu.2019.09.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 12/23/2022]
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Glauser G, Piazza M, Berger I, Osiemo B, McClintock SD, Winter E, Chen HI, Ali ZS, Malhotra NR. The Risk Assessment and Prediction Tool (RAPT) for Discharge Planning in a Posterior Lumbar Fusion Population. Neurosurgery 2019; 86:E140-E146. [DOI: 10.1093/neuros/nyz419] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/10/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
As the use of bundled care payment models has become widespread in neurosurgery, there is a distinct need for improved preoperative predictive tools to identify patients who will not benefit from prolonged hospitalization, thus facilitating earlier discharge to rehabilitation or nursing facilities.
OBJECTIVE
To validate the use of Risk Assessment and Prediction Tool (RAPT) in patients undergoing posterior lumbar fusion for predicting discharge disposition.
METHODS
Patients undergoing elective posterior lumbar fusion from June 2016 to February 2017 were prospectively enrolled. RAPT scores and discharge outcomes were recorded for patients aged 50 yr or more (n = 432). Logistic regression analysis was used to assess the ability of RAPT score to predict discharge disposition. Multivariate regression was performed in a backwards stepwise logistic fashion to create a binomial model.
RESULTS
Escalating RAPT score predicts disposition to home (P < .0001). Every unit increase in RAPT score increases the chance of home disposition by 55.8% and 38.6% than rehab and skilled nursing facility, respectively. Further, RAPT score was significant in predicting length of stay (P = .0239), total surgical cost (P = .0007), and 30-d readmission (P < .0001). Amongst RAPT score subcomponents, walk, gait, and postoperative care availability were all predictive of disposition location (P < .0001) for both models. In a generalized multiple logistic regression model, the 3 top predictive factors for disposition were the RAPT score, length of stay, and age (P < .0001, P < .0001 and P = .0001, respectively).
CONCLUSION
Preoperative RAPT score is a highly predictive tool in lumbar fusion patients for discharge disposition.
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Affiliation(s)
- Gregory Glauser
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Piazza
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Berger
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Scott D McClintock
- The West Chester Statistical Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Eric Winter
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - H Isaac Chen
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina S Ali
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Stopa BM, Robertson FC, Karhade AV, Chua M, Broekman MLD, Schwab JH, Smith TR, Gormley WB. Predicting nonroutine discharge after elective spine surgery: external validation of machine learning algorithms. J Neurosurg Spine 2019; 31:742-747. [PMID: 31349223 DOI: 10.3171/2019.5.spine1987] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/13/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Nonroutine discharge after elective spine surgery increases healthcare costs, negatively impacts patient satisfaction, and exposes patients to additional hospital-acquired complications. Therefore, prediction of nonroutine discharge in this population may improve clinical management. The authors previously developed a machine learning algorithm from national data that predicts risk of nonhome discharge for patients undergoing surgery for lumbar disc disorders. In this paper the authors externally validate their algorithm in an independent institutional population of neurosurgical spine patients. METHODS Medical records from elective inpatient surgery for lumbar disc herniation or degeneration in the Transitional Care Program at Brigham and Women's Hospital (2013-2015) were retrospectively reviewed. Variables included age, sex, BMI, American Society of Anesthesiologists (ASA) class, preoperative functional status, number of fusion levels, comorbidities, preoperative laboratory values, and discharge disposition. Nonroutine discharge was defined as postoperative discharge to any setting other than home. The discrimination (c-statistic), calibration, and positive and negative predictive values (PPVs and NPVs) of the algorithm were assessed in the institutional sample. RESULTS Overall, 144 patients underwent elective inpatient surgery for lumbar disc disorders with a nonroutine discharge rate of 6.9% (n = 10). The median patient age was 50 years and 45.1% of patients were female. Most patients were ASA class II (66.0%), had 1 or 2 levels fused (80.6%), and had no diabetes (91.7%). The median hematocrit level was 41.2%. The neural network algorithm generalized well to the institutional data, with a c-statistic (area under the receiver operating characteristic curve) of 0.89, calibration slope of 1.09, and calibration intercept of -0.08. At a threshold of 0.25, the PPV was 0.50 and the NPV was 0.97. CONCLUSIONS This institutional external validation of a previously developed machine learning algorithm suggests a reliable method for identifying patients with lumbar disc disorder at risk for nonroutine discharge. Performance in the institutional cohort was comparable to performance in the derivation cohort and represents an improved predictive value over clinician intuition. This finding substantiates initial use of this algorithm in clinical practice. This tool may be used by multidisciplinary teams of case managers and spine surgeons to strategically invest additional time and resources into postoperative plans for this population.
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Affiliation(s)
- Brittany M Stopa
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Faith C Robertson
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aditya V Karhade
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Melissa Chua
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marike L D Broekman
- 2Department of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden, The Netherlands; and
| | - Joseph H Schwab
- 3Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Timothy R Smith
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - William B Gormley
- 1Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
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Yolcu Y, Wahood W, Alvi MA, Kerezoudis P, Habermann EB, Bydon M. Reporting Methodology of Neurosurgical Studies Utilizing the American College of Surgeons-National Surgical Quality Improvement Program Database: A Systematic Review and Critical Appraisal. Neurosurgery 2019; 86:46-60. [DOI: 10.1093/neuros/nyz180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/27/2019] [Indexed: 12/12/2022] Open
Abstract
AbstractBACKGROUNDUse of large databases such as the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has become increasingly common in neurosurgical research.OBJECTIVETo perform a critical appraisal and evaluation of the methodological reporting for studies in neurosurgical literature that utilize the ACS-NSQIP database.METHODSWe queried Ovid MEDLINE, EMBASE, and PubMed databases for all neurosurgical studies utilizing the ACS-NSQIP. We assessed each study according to number of criteria fulfilled with respect to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) Statement, and Journal of American Medical Association–Surgical Section (JAMA-Surgery) Checklist. A separate analysis was conducted among papers published in core and noncore journals in neurosurgery according to Bradford's law.RESULTSA total of 117 studies were included. Median (interquartile range [IQR]) scores for number of fulfilled criteria for STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist were 20 (IQR:19-21), 9 (IQR:8-9), and 6 (IQR:5-6), respectively. For STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist, item 9 (potential sources of bias), item 13 (supplemental information), and item 9 (missing data/sensitivity analysis) had the highest number of studies with no fulfillment among all studies (56, 68, 50%), respectively. When comparing core journals vs noncore journals, no significant difference was found (STROBE, P = .94; RECORD, P = .24; JAMA-Surgery checklist, P = .60).CONCLUSIONWhile we observed an overall satisfactory reporting of methodology, most studies lacked mention of potential sources of bias, data cleaning methods, supplemental information, and external validity. Given the pervasive role of national databases and registries for research and health care policy, the surgical community needs to ensure the credibility and quality of such studies that ultimately aim to improve the value of surgical care delivery to patients.
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Affiliation(s)
- Yagiz Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Waseem Wahood
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Panagiotis Kerezoudis
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Goyal A, Ngufor C, Kerezoudis P, McCutcheon B, Storlie C, Bydon M. Can machine learning algorithms accurately predict discharge to nonhome facility and early unplanned readmissions following spinal fusion? Analysis of a national surgical registry. J Neurosurg Spine 2019; 31:568-578. [PMID: 31174185 DOI: 10.3171/2019.3.spine181367] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonhome discharge and unplanned readmissions represent important cost drivers following spinal fusion. The authors sought to utilize different machine learning algorithms to predict discharge to rehabilitation and unplanned readmissions in patients receiving spinal fusion. METHODS The authors queried the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for patients undergoing cervical or lumbar spinal fusion. Outcomes assessed included discharge to nonhome facility and unplanned readmissions within 30 days after surgery. A total of 7 machine learning algorithms were evaluated. Predictive hierarchical clustering of procedure codes was used to increase model performance. Model performance was evaluated using overall accuracy and area under the receiver operating characteristic curve (AUC), as well as sensitivity, specificity, and positive and negative predictive values. These performance metrics were computed for both the imputed and unimputed (missing values dropped) datasets. RESULTS A total of 59,145 spinal fusion cases were analyzed. The incidence rates of discharge to nonhome facility and 30-day unplanned readmission were 12.6% and 4.5%, respectively. All classification algorithms showed excellent discrimination (AUC > 0.80, range 0.85-0.87) for predicting nonhome discharge. The generalized linear model showed comparable performance to other machine learning algorithms. By comparison, all models showed poorer predictive performance for unplanned readmission, with AUC ranging between 0.63 and 0.66. Better predictive performance was noted with models using imputed data. CONCLUSIONS In an analysis of patients undergoing spinal fusion, multiple machine learning algorithms were found to reliably predict nonhome discharge with modest performance noted for unplanned readmissions. These results provide early evidence regarding the feasibility of modern machine learning classifiers in predicting these outcomes and serve as possible clinical decision support tools to facilitate shared decision making.
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Affiliation(s)
- Anshit Goyal
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery, and
| | - Che Ngufor
- 3Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Curtis Storlie
- 3Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery, and
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Berger I, Piazza M, Sharma N, Glauser G, Osiemo B, McClintock SD, Lee JYK, Schuster JM, Ali Z, Malhotra NR. Evaluation of the Risk Assessment and Prediction Tool for Postoperative Disposition Needs After Cervical Spine Surgery. Neurosurgery 2019; 85:E902-E909. [DOI: 10.1093/neuros/nyz161] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/21/2019] [Indexed: 12/26/2022] Open
Abstract
AbstractBACKGROUNDBundled care payment models are becoming more prevalent in neurosurgery. Such systems place the cost of postsurgical facilities in the hands of the discharging health system. Opportunity exists to leverage prediction tools for discharge disposition by identifying patients who will not benefit from prolonged hospitalization and facilitating discharge to post-acute care facilities.OBJECTIVETo validate the use of the Risk Assessment and Predictive Tool (RAPT) along with other clinical variables to predict discharge disposition in a cervical spine surgery population.METHODSPatients undergoing cervical spine surgery at our institution from June 2016 to February 2017 and over 50 yr old had demographic, surgical, and RAPT variables collected. Multivariable regression analyzed each variable's ability to predict discharge disposition. Backward selection was used to create a binomial model to predict discharge disposition.RESULTSA total of 263 patients were included in the study. Lower RAPT score, RAPT walk subcomponent, older age, and a posterior approach predicted discharge to a post-acute care facility compared to home. Lower RAPT also predicted an increased risk of readmission. RAPT score combined with age increased the predictive capability of discharge disposition to home vs skilled nursing facility or acute rehabilitation compared to RAPT alone (P < .001).CONCLUSIONRAPT score combined with age is a useful tool in the cervical spine surgery population to predict postdischarge needs. This tool may be used to start early discharge planning in patients who are predicted to require post-acute care facilities. Such strategies may reduce postoperative utilization of inpatient resources.
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Affiliation(s)
- Ian Berger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Piazza
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil Sharma
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Glauser
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- Department of Mathematics, West Chester Statistical Institute, West Chester University, West Chester, Pennsylvania
| | - Scott D McClintock
- Department of Mathematics, West Chester Statistical Institute, West Chester University, West Chester, Pennsylvania
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina Ali
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Ogink PT, Karhade AV, Thio QCBS, Hershman SH, Cha TD, Bono CM, Schwab JH. Development of a machine learning algorithm predicting discharge placement after surgery for spondylolisthesis. 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; 28:1775-1782. [PMID: 30919114 DOI: 10.1007/s00586-019-05936-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE We aimed to develop a machine learning algorithm that can accurately predict discharge placement in patients undergoing elective surgery for degenerative spondylolisthesis. METHODS The National Surgical Quality Improvement Program (NSQIP) database was used to select patients that underwent surgical treatment for degenerative spondylolisthesis between 2009 and 2016. Our primary outcome measure was non-home discharge which was defined as any discharge not to home for which we grouped together all non-home discharge destinations including rehabilitation facility, skilled nursing facility, and unskilled nursing facility. We used Akaike information criterion to select the most appropriate model based on the outcomes of the stepwise backward logistic regression. Four machine learning algorithms were developed to predict discharge placement and were assessed by discrimination, calibration, and overall performance. RESULTS Nine thousand three hundred and thirty-eight patients were included. Median age was 63 (interquartile range [IQR] 54-71), and 63% (n = 5,887) were female. The non-home discharge rate was 18.6%. Our models included age, sex, diabetes, elective surgery, BMI, procedure, number of levels, ASA class, preoperative white blood cell count, and preoperative creatinine. The Bayes point machine was considered the best model based on discrimination (AUC = 0.753), calibration (slope = 1.111; intercept = - 0.002), and overall model performance (Brier score = 0.132). CONCLUSION This study has shown that it is possible to create a predictive machine learning algorithm with both good accuracy and calibration to predict discharge placement. Using our methodology, this type of model can be developed for many other conditions and (elective) treatments. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Paul T Ogink
- Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Aditya V Karhade
- Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA
| | - Quirina C B S Thio
- Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA
| | - Stuart H Hershman
- Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA
| | - Thomas D Cha
- Assistant Chief Orthopaedic Spine Center, Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, Boston, USA
| | - Christopher M Bono
- Executive Vice-Chair Department of Orthopaedic Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, USA
| | - Joseph H Schwab
- Orthopaedic Spine Service, Massachusetts General Hospital - Harvard Medical School, 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA
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Bortz CA, Passias PG, Segreto F, Horn SR, Lafage V, Smith JS, Line B, Mundis GM, Kebaish KM, Kelly MP, Protopsaltis T, Sciubba DM, Soroceanu A, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP. Indicators for Nonroutine Discharge Following Cervical Deformity-Corrective Surgery: Radiographic, Surgical, and Patient-Related Factors. Neurosurgery 2019; 85:E509-E519. [DOI: 10.1093/neuros/nyz016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 01/29/2019] [Indexed: 11/14/2022] Open
Abstract
AbstractBACKGROUNDNonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge.OBJECTIVETo identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm.METHODSA retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points.RESULTSOf 138 patients (61 yr, 63% female) undergoing surgery for CD (8 ± 5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P > .05) of index procedure. Despite no differences in BL EQ-5D (P = .946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P = .044).CONCLUSIONSevere preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.
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Affiliation(s)
- Cole A Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Frank Segreto
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Samantha R Horn
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- International Spine Study Group, Denver, Colorado
| | | | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, California
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, Colorado
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
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Kerezoudis P, Alvi MA, Spinner RJ, Meyer FB, Habermann EB, Bydon M. Predictors of Unplanned Returns to the Operating Room within 30 Days in Neurosurgery: Insights from a National Surgical Registry. World Neurosurg 2019; 123:e348-e370. [PMID: 30500576 DOI: 10.1016/j.wneu.2018.11.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/17/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the modern, increasingly pay-for-performance era, unplanned return to the operating room (ROR) is gaining attention as a surgical quality metric. However, large-scale data on the appropriateness and usefulness of this measure in neurosurgery are scarce. OBJECTIVE To provide a comprehensive description of all RORs after neurosurgical procedures in a national surgical registry and identify factors associated with ROR. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program multicenter database for patients undergoing neurosurgical procedures during 2012-2016. Multivariable logistic regression was conducted to identify factors associated with 30-day unplanned ROR after the 3 most common inpatient cranial and spinal operations: craniotomy for intra-axial neoplasm, convexity/falx meningioma, or skull base tumors; anterior cervical discectomy and fusion; and posterior lumbar decompression and posterior lumbar fusion. RESULTS A total of 193,459 cases were identified, of which 7067 (3.7%) had at least 1 unplanned ROR within 30 days after the index procedure (inpatient, 4.3%; outpatient, 1.5%). Overall, the most common reasons were wound complication/surgical site infection (0.7%), hematoma evacuation (0.6%), and repeat surgery (0.5%). On multivariable analysis, the relative amount of variation in reoperation risk was found to be 1%-24% for demographics, 1%-19% for comorbidities, 1%-6% for preoperative laboratory values, and 4%-58% for operative characteristics. CONCLUSIONS These findings may inform stakeholders on the optimal parameters that need to be taken into account when crafting, endorsing, and implementing quality metrics for neurosurgery that aim to assess surgical performance and reward or penalize hospitals and providers.
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Affiliation(s)
- Panagiotis Kerezoudis
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Surgical Outcomes Program, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.
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Sethi RK, Yanamadala V, Shah SA, Fletcher ND, Flynn J, Lafage V, Schwab F, Heffernan M, DeKleuver M, Mcleod L, Leveque JC, Vitale M. Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation. Spine Deform 2019; 7:228-235. [PMID: 30660216 DOI: 10.1016/j.jspd.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/02/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. METHODS We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. RESULTS This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. CONCLUSION Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.
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Affiliation(s)
- Rajiv K Sethi
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA.
| | - Vijay Yanamadala
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA; and Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Suken A Shah
- Dupont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA
| | | | - John Flynn
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Virginie Lafage
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | - Frank Schwab
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021
| | | | - Marinus DeKleuver
- Sint Maartenskliniek, Radboud University Medical Center, PO Box 9011, 6500 GM, Nijmegen, the Netherlands
| | - Lisa Mcleod
- University of Colorado Denver, 1201 Larimer St, Denver, CO 80204, USA
| | - Jean Christophe Leveque
- Virginia Mason Medical Center, University of Washington, 1100 9th Ave, Seattle, WA 98101, USA
| | - Michael Vitale
- Morgan Stanley Children's Hospital, Columbia University, 3959 Broadway, New York, NY 10032, USA
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Buchlak QD, Kowalczyk M, Leveque JC, Wright A, Farrokhi F. Risk stratification in deep brain stimulation surgery: Development of an algorithm to predict patient discharge disposition with 91.9% accuracy. J Clin Neurosci 2018; 57:26-32. [DOI: 10.1016/j.jocn.2018.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 08/12/2018] [Accepted: 08/21/2018] [Indexed: 01/25/2023]
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Karhade AV, Ogink P, Thio Q, Broekman M, Cha T, Gormley WB, Hershman S, Peul WC, Bono CM, Schwab JH. Development of machine learning algorithms for prediction of discharge disposition after elective inpatient surgery for lumbar degenerative disc disorders. Neurosurg Focus 2018; 45:E6. [DOI: 10.3171/2018.8.focus18340] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/02/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVEIf not anticipated and prearranged, hospital stay can be prolonged while the patient awaits placement in a rehabilitation unit or skilled nursing facility following elective spine surgery. Preoperative prediction of the likelihood of postoperative discharge to any setting other than home (i.e., nonroutine discharge) after elective inpatient spine surgery would be helpful in terms of decreasing hospital length of stay. The purpose of this study was to use machine learning algorithms to develop an open-access web application for preoperative prediction of nonroutine discharges in surgery for elective inpatient lumbar degenerative disc disorders.METHODSThe American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent elective inpatient spine surgery for lumbar disc herniation or lumbar disc degeneration between 2011 and 2016. Four machine learning algorithms were developed to predict nonroutine discharge and the best algorithm was incorporated into an open-access web application.RESULTSThe rate of nonroutine discharge for 26,364 patients who underwent elective inpatient surgery for lumbar degenerative disc disorders was 9.28%. Predictive factors selected by random forest algorithms were age, sex, body mass index, fusion, level, functional status, extent and severity of comorbid disease (American Society of Anesthesiologists classification), diabetes, and preoperative hematocrit level. On evaluation in the testing set (n = 5273), the neural network had a c-statistic of 0.823, calibration slope of 0.935, calibration intercept of 0.026, and Brier score of 0.0713. On decision curve analysis, the algorithm showed greater net benefit for changing management over all threshold probabilities than changing management on the basis of the American Society of Anesthesiologists classification alone or for all patients or for no patients. The model can be found here: https://sorg-apps.shinyapps.io/discdisposition/.CONCLUSIONSMachine learning algorithms show promising results on internal validation for preoperative prediction of nonroutine discharges. If found to be externally valid, widespread use of these algorithms via the open-access web application by healthcare professionals may help preoperative risk stratification of patients undergoing elective surgery for lumbar degenerative disc disorders.
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Affiliation(s)
- Aditya V. Karhade
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul Ogink
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quirina Thio
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike Broekman
- 2Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands; and
| | - Thomas Cha
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B. Gormley
- 3Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stuart Hershman
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wilco C. Peul
- 2Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands; and
| | - Christopher M. Bono
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H. Schwab
- 1Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Elsayed G, Erwood MS, Davis MC, Dupépé EC, McClugage SG, Szerlip P, Walters BC, Hadley MN. Association between preoperative activity level and functional outcome at 12 months following surgical decompression for lumbar spinal stenosis. J Neurosurg Spine 2018; 29:388-396. [PMID: 29979140 DOI: 10.3171/2018.2.spine171028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study defines the association of preoperative physical activity level with functional outcomes at 3 and 12 months following surgical decompression for lumbar spinal stenosis. METHODS Data were collected as a prospective observational registry at a single institution from 2012 through 2015, and then analyzed with a retrospective cohort design. Patients who were able to participate in activities outside the home preoperatively were compared to patients who did not participate in such activities, with respect to 3-month and 12-month functional outcomes postintervention, adjusted for relevant confounders. RESULTS Ninety-nine patients were included. At baseline, sedentary/inactive patients (n = 55) reported greater back pain, lower quality of life, and higher disability than similarly treated patients who were active preoperatively. Both cohorts experienced significant improvement from baseline in back pain, leg pain, disability, and quality of life at both 3 and 12 months after lumbar decompression surgery. At 3 months postintervention, sedentary/inactive patients reported more leg pain and worse disability than patients who performed activities outside the home preoperatively. However, at 12 months postintervention, there were no statistically significant differences between the two cohorts in back pain, leg pain, quality of life, or disability. Multivariate analysis revealed that sedentary/inactive patients had improved disability and higher quality of life after surgery compared to baseline. Active patients experienced greater overall improvement in disability compared to inactive patients. CONCLUSIONS Sedentary/inactive patients have a more protracted recovery after lumbar decompression surgery for spinal stenosis, but at 12 months postintervention can expect to reach similar long-term outcomes as patients who are active/perform activities outside the home preoperatively.
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Affiliation(s)
- Galal Elsayed
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Matthew S Erwood
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Matthew C Davis
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Esther C Dupépé
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Samuel G McClugage
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Paul Szerlip
- 2Department of Computer Science, University of Central Florida, Orlando, Florida
| | - Beverly C Walters
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
| | - Mark N Hadley
- 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and
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Piazza M, Sharma N, Osiemo B, McClintock S, Missimer E, Gardiner D, Maloney E, Callahan D, Smith JL, Welch W, Schuster J, Grady MS, Malhotra NR. Initial Assessment of the Risk Assessment and Prediction Tool in a Heterogeneous Neurosurgical Patient Population. Neurosurgery 2018; 85:50-57. [DOI: 10.1093/neuros/nyy197] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/13/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matthew Piazza
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Nikhil Sharma
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Benjamin Osiemo
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
- Department of Mathematics, Westchester University, Westchester, Pennsylvania
| | - Scott McClintock
- Department of Mathematics, Westchester University, Westchester, Pennsylvania
| | - Emily Missimer
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Diana Gardiner
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Eileen Maloney
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Danielle Callahan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - J Lachlan Smith
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - William Welch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - James Schuster
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - M Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
| | - Neil R Malhotra
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania
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