Glaucoma Surgery SOS: Emergency Department Utilization Greater Among Younger and First-Time Surgical Glaucoma Patients

PURPOSE

To describe the frequency, findings, and interventions of patients' emergency department visits after all types of glaucoma surgery DESIGN: Retrospective cohort study SUBJECTS: All surgical glaucoma patients between 2013 and 2021 METHODS: This single institution study collected demographics, surgery type, and surgical parameters for each patient. Subsequently, for those visiting the emergency department within 50 days of surgery, data was collected on reason for visit, findings, and ophthalmic intervention. Logistic regression models were used to determine the odds of ED visits based on multiple risk factors.

MAIN OUTCOME

Postoperative presentation to ED RESULTS: Among 9155 surgeries in 5505 patients, 5.7% had ED visits within 50 days, with 46.3% having ocular complaints. Patients with ocular diagnoses presented earlier than those without (p < 0.001). Patients who presented to the ED with an ocular diagnosis were found to be significantly younger than those who did not present (62.2 ± 18.6 vs 65.4 ± 18.0 years old, p < 0.028). Furthermore, white patients were more likely than black patients to present with an ocular diagnosis compared to a non-ocular diagnosis (OR 2.64, 95% CI 1.67-4.18, p<0.001). Patients undergoing their first glaucoma surgery had a much higher chance of presenting to the ED compared to patients who had undergone more than one surgery (OR: 3.75, 95%CI 2.74 - 5.14, p < 0.001). Those who underwent traditional surgeries were more likely than patients with trabecular meshwork bypass stent (TMBS) to present to the ED with an ocular diagnosis (OR: 3.02, 95% CI 1.29 - 7.08, p = 0.011). Filtering surgeries and glaucoma drainage device (GDD) revisions exhibited more vision-threatening conditions than glaucoma drainage devices (p = 0.037 and p = 0.010 respectively). Ophthalmology consultation was sought for 88.0% of ocular diagnoses. Most received medical therapy (71.0%), primarily IOP-lowering drops.

CONCLUSION

ED visits after glaucoma surgery are infrequent, yet more often seen in younger patients or those undergoing their first glaucoma surgery. TMBS, but not trabecular meshwork excision and/or Schlemm's canal dilation (TME/SCD), were less likely to present to the ED than traditional surgeries. Filtering surgeries and tube revisions presented more often with visual threatening conditions.

90-Day Emergency Department Utilization and Readmission Rate After Full-Endoscopic Spine Surgery: A Multicenter, Retrospective Analysis of 821 Patients

BACKGROUND AND OBJECTIVES

Emergency department (ED) utilization and readmission rates after spine surgery are common quality of care measures. Limited data exist on the evaluation of quality indicators after full-endoscopic spine surgery (FESS). The objective of this study was to detect rates, causes, and risk factors for unplanned postoperative clinic utilization after FESS.

METHODS

This retrospective multicenter analysis assessed ED utilization and clinic readmission rates after FESS performed between 01/2014 and 04/2023 for degenerative spinal pathologies. Outcome measures were ED utilizations, hospital readmissions, and revision surgeries within 90 days postsurgery.

RESULTS

Our cohort includes 821 patients averaging 59 years of age, who underwent FESS. Most procedures targeted the lumbar or sacral spine (85.75%) while a small fraction involved the cervical spine (10.11%). The most common procedures were lumbar unilateral laminotomies for bilateral decompression (40.56%) and lumbar transforaminal discectomies (25.58%). Within 90 days postsurgery, 8.0% of patients revisited the ED for surgical complications. A total of 2.2% of patients were readmitted to a hospital of which 1.9% required revision surgery. Primary reasons for ED visits and clinic readmissions were postoperative pain exacerbation, transient neurogenic bladder dysfunction, and recurrent disk herniations. Our multivariate regression analysis revealed that female patients had a significantly higher likelihood of using the ED (P = .046; odds ratio: 1.77, 95% CI 1.01-3.1 5.69% vs 10.33%). Factors such as age, American Society of Anesthesiologists class, body mass index, comorbidities, and spanned spinal levels did not significantly predict postoperative ED utilization.

CONCLUSION

This analysis demonstrates the safety of FESS, as evidenced by acceptable rates of ED utilization, clinic readmission, and revision surgery. Future studies are needed to further elucidate the safety profile of FESS in comparison with traditional spinal procedures.

Emergency department visits within 90 days of lumbar discectomy

BACKGROUND CONTEXT

Lumbar discectomy is a common procedure following which emergency department (ED) visits may occur. Although many quality improvement initiatives target reemissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to health-care resource utilization and costs.

PURPOSE

To analyze the timing and risk factors predicting ED utilization following lumbar discectomy and thereby facilitate better-targeted risk reduction.

STUDY DESIGN/SETTING

Retrospective database review of the 2010 to April 30th, 2021, M157Ortho PearlDiver dataset.

PATIENT SAMPLE

Single-level lumbar laminotomy/discectomy between 2010 and April 30th, 2021, in the PearlDiver M157Ortho dataset.

OUTCOME MEASURES

Functional measures-ED utilization in the 90 days following lumbar discectomy, patient-level predictors for ED utilization, and number and type of reoperations performed in the 90 days following lumbar discectomy.

METHODS

Lumbar laminotomies/discectomies were identified. Patients were excluded if additional procedures were performed or if there was not 90-day follow-up in the dataset. Patient factors were extracted, including age, sex, Elixhauser comorbidity index (ECI), region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of lumbar discectomy were then determined. Cohort average weekly ED utilization at 1-year postoperatively was calculated as a baseline for reference. Patient factors predictive of postoperative ED utilization were then determined with univariate and multivariate analyses. Primary diagnoses for ED visits were also categorized. Patients who underwent reoperation for complications related to lumbar discectomy following ED visits were determined, and types of reoperation procedures were characterized.

RESULTS

Of 281,103 lumbar discectomy patients identified, ED visits within 90 days of surgery were identified for 28,632 (10.2%). Of note, 40.4% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following lumbar discectomy, including: younger age (odds ratio [OR] 1.21 per decade decrease), female sex (OR 1.12 relative to male), higher ECI (OR 1.42 per 2-point increase), having surgery performed in the Northeast, Midwest, or West United States (OR 1.05, 1.17, and 1.13, respectively, relative to South), and Medicaid coverage (OR 1.89 relative to Medicare). Forty-three percent of ED visits were surgical site related, of which surgical site pain predominated at 34.2% of overall reasons. Of patients who visited the ED, 943 (3.3%) underwent reoperation in the subsequent 2 weeks. Laminectomy with nerve root decompression was the most performed reoperation (30.9%), followed by incision and drainage (22.5%), posterior nonsegmental instrumentation (10.3%), laminectomy facetectomy and foraminotomy (9.97%), repair of dural/CSF leak or pseudomeningocele with laminectomy (9.3%), repair of dural/CSF leak not requiring laminectomy (8.9%), arthrodesis (4.3%), and posterior segmental instrumentation (3.9%).

CONCLUSIONS

Following lumbar discectomy, over 1 in 10 patients were found to visit the ED in the 90 days following their surgery, most commonly in the first 2 postoperative weeks. Specific patient characteristics were associated with such ED visits, with the most common primary diagnoses among ED visitors being surgical site pain. About 3.3% of patients who visited the ED underwent reoperation in the subsequent 2 weeks. Through identification of the timing, risk factors, primary reasons for, and risk of reoperation following ED utilization in the 90-day period after lumbar discectomy, care pathways can be modified to improve patient satisfaction, outcomes, and reduce excess health-care expenditures.

Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis

BACKGROUND

In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at > 20%, despite focused interventions to enhance perioperative support.

AIM

To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada.

METHODS

Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits.

RESULTS

A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally.

CONCLUSIONS

Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.

Previous Emergency Department Admission Is Associated With Increased 90-Day Readmission Following Cervical Spine Surgery: Evidenced Using Propensity Score Matching

STUDY DESIGN

This was a retrospective case-control study.

OBJECTIVE

The objective of this study was to evaluate whether prior emergency department admission was associated with an increased risk for 90-day readmission following elective cervical spinal fusion.

SUMMARY OF BACKGROUND DATA

The incidence of cervical spine fusion reoperations has increased, necessitating the improvement of patient outcomes following surgery. Currently, there are no studies assessing the impact of emergency department visits before surgery on the risk of 90-day readmission following elective cervical spine surgery. This study aimed to fill this gap and identify a novel risk factor for readmission following elective cervical fusion.

METHODS

The 2016-2018 Nationwide Readmissions Database was queried for patients aged 18 years and older who underwent an elective cervical fusion. Prior emergency admissions were defined using the variable HCUP_ED in the Nationwide Readmissions Database database. Univariate analysis of patient demographic details, comorbidities, discharge disposition, and perioperative complication was evaluated using a χ 2 test followed by multivariate logistic regression.

RESULTS

In all, 2766 patients fit the inclusion criteria, and 18.62% of patients were readmitted within 90 days. Intraoperative complications, gastrointestinal complications, valvular, uncomplicated hypertension, peripheral vascular disorders, chronic obstructive pulmonary disease, cancer, and experiencing less than 3 Charlson comorbidities were identified as independent predictors of 90-day readmission. Patients with greater than 3 Charlson comorbidities (OR=0.04, 95% CI 0.01-0.12, P <0.001) and neurological complications (OR=0.29, 95% CI 0.10-0.86, P =0.026) had decreased odds for 90-day readmission. Importantly, previous emergency department visits within the calendar year before surgery were a new independent predictor of 90-day readmission (OR=9.74, 95% CI 6.86-13.83, P <0.001).

CONCLUSIONS

A positive association exists between emergency department admission history and 90-day readmission following elective cervical fusion. Screening cervical fusion patients for this history and optimizing outcomes in those patients may reduce 90-day readmission rates.

Outcomes With a Mobile Digital Health Platform for Patients Undergoing Spine Surgery: Retrospective Analysis

BACKGROUND

Digital health solutions have been shown to enhance outcomes for individuals with chronic medical illnesses, but few have been validated for surgical patients. The digital health platform ManageMySurgery (MMS) has been validated for spine surgery as a feasible method for patients along their surgical journey through in-app education and completion of patient-reported outcomes surveys.

OBJECTIVE

The aim of this study is to determine the rates of 90-day emergency room (ER) visits, readmissions, and complications in patients undergoing spine surgery using MMS compared to patients using traditional perioperative care alone.

METHODS

Patients undergoing spine surgery at a US-based academic hospital were invited to use MMS perioperatively between December 2017 and September 2021. All patients received standard perioperative care and were classified as MMS users if they logged into the app. Demographic information and 90-day outcomes were acquired via electronic health record review. The odds ratios of having 90-day ER visits, readmissions, mild complications, and severe complications between the MMS and non-MMS groups were estimated using logistic regression models.

RESULTS

A total of 1015 patients were invited, with 679 using MMS. MMS users and nonusers had similar demographics: the average ages were 57.9 (SD 12.5) years and 61.5 (SD 12.7) years, 54.1% (367/679) and 47.3% (159/336) were male, and 90.1% (612/679) and 88.7% (298/336) had commercial or Medicare insurance, respectively. Cervical fusions (559/1015, 55.07%) and single-approach lumbar fusions (231/1015, 22.76%) were the most common procedures for all patients. MMS users had a lower 90-day readmission rate (55/679, 8.1%) than did nonusers (30/336, 8.9%). Mild complications (MMS: 56/679, 8.3%; non-MMS: 32/336, 9.5%) and severe complications (MMS: 66/679, 9.7%; non-MMS: 43/336, 12.8%) were also lower in MMS users. MMS users had a lower 90-day ER visit rate (MMS: 62/679, 9.1%; non-MMS: 45/336, 13.4%). After adjustments were made for age and sex, the odds of having 90-day ER visits for MMS users were 32% lower than those for nonusers, but this difference was not statistically significant (odds ratio 0.68, 95% CI 0.45-1.02; P=.06).

CONCLUSIONS

This is one of the first studies to show differences in acute outcomes for people undergoing spine surgery who use a digital health app. This study found a correlation between MMS use and fewer postsurgical ER visits in a large group of spine surgery patients. A planned randomized controlled trial will provide additional evidence of whether this digital health tool can be used as an intervention to improve patient outcomes.

Emergency Department Visits After Outpatient Spine Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs).

SUMMARY OF BACKGROUND DATA

Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established.

METHODS

This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed.

RESULTS

In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P <0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits.

CONCLUSIONS

Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion

Background

Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use.

Methods

Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression.

Results

Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001).

Conclusions

More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Quantifying the Economic Impact of Depression for Spine Patients in the United States

STUDY DESIGN

This was a retrospective cross-sectional analysis.

OBJECTIVE

The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden.

SUMMARY OF BACKGROUND DATA

Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery.

MATERIALS AND METHODS

Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index.

RESULTS

A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort.

CONCLUSIONS

Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.

Effect of Perioperative Opioid Use on Patients Undergoing Hip Arthroscopy

Background

Opioids are commonly used to treat postoperative pain; however, guidelines vary regarding safe opioid use after hip arthroscopy.

Purpose/Hypothesis

The purposes were to (1) identify risk factors for persistent opioid use, (2) assess the effect of opioid use on outcomes, and (3) describe common opioid prescribing patterns after hip arthroscopy. It was hypothesized that preoperative opioid use would affect complication rates and result in greater postoperative opioid use.

Study Design

Case-control study; Level of evidence 3.

Methods

The Utah State All Payer Claims Database was queried for patients who underwent hip arthroscopy between January 2013 and December 2017. Included were patients ≥14 years of age at index surgery with continuous insurance. Patients were separated into acute (<3 months) and chronic (≥3 months) postoperative opioid use groups. Primary outcomes included revision surgery, complications (infection, pulmonary embolism/deep venous thrombosis, death), emergency department (ED) visits, and hospital admissions. Multivariate logistic regression was utilized to identify factors associated with the outcomes.

Results

Included were 2835 patients (mean age, 47 years; range, 14-64 years), of whom 2544 were in the acute opioid use and 291 were in the chronic opioid use group. Notably, 91% of the patients in the chronic group took opioid medications preoperatively, and they were more than twice as likely to carry a mental health diagnosis (P < .01). Patients in the acute group had a significantly shorter initial prescription duration, took fewer opioid pills, and had fewer refills than those in the chronic group (P < .01 for all). Patients in the chronic group had a significantly higher risk of postoperative ED visits (odds ratio [OR], 2.76; P = .008), hospital admission (OR, 3.02; P = .002), and additional surgery (P = .003), as well as infection (OR, 2.55; P < .001) and hematoma (OR, 2.43; P = .030). Patients who had used opioids before hip arthroscopy were more likely to need more refills (P < .01). A formal opioid use disorder diagnosis correlated significantly with postoperative hospital admissions (OR, 3.83; P = .044) and revision hip arthroscopy (OR, 4.72; P = .003).

Conclusion

Mental health and substance use disorders were more common in patients with chronic postoperative opioid use, and chronic postoperative opioid use was associated with greater likelihood of postoperative complications. Preoperative opioid use was significantly correlated with chronic postoperative opioid use and with increased refill requests after index arthroscopy.

Reasons and Risk Factors for Emergency Department Visits After Primary Total Knee Arthroplasty: An Analysis of 1.3 Million Patients

BACKGROUND

Well-powered studies investigating the relationship of emergency department (ED) visits and total knee arthroplasty (TKA) are limited. Therefore, the specific aims of this study were to: 1) compare patient demographics of patients who did and did not have an ED visit; and for the visits, identified: 2) leading reasons; and 3) risk factors for ED visits (prearthroplasty/postarthroplasty).

METHODS

Patients undergoing primary TKA who had an ED visit within 90 days after their index procedure were identified from a nationwide database. The query yielded 1,364,655 patients who did (n = 5689) and did not have (n = 1,358,966) an ED visit. Baseline demographics such as age, sex, and comorbidity prevalence between the two cohorts; reasons for ED visits; and prearthroplasty and postarthroplasty risk factors were analyzed. Odds ratios (ORs) of ED visits were assessed using multivariate binomial logistic regression analyses. A P-value less than 0.001 was considered statistically significant.

RESULTS

Patients who did and did not have ED visits differed with respect to age (P < .0001) and mean Elixhauser Comorbidity Index scores (9 vs 6, P < .0001). Musculoskeletal etiologies were the most common reason for ED visits. Hypertension was the greatest contributor to ED visits prearthroplasty and postarthroplasty. Comorbid conditions associated with ED visits postarthroplasty included peripheral vascular disease (OR: 1.61, P < .0001), coagulopathy (OR: 1.58, P < .0001), and rheumatoid arthritis (OR: 1.56, P < .0001).

CONCLUSION

By identifying demographic patterns of patients, reasons, and risk factors, the information found from this study can help identify targets for quality improvement to potentially reduce the incidence of ED visits after primary TKA.

Patient-specific prediction model for clinical and quality-of-life outcomes after lumbar spine surgery

OBJECTIVE

Patient demographics, comorbidities, and baseline quality of life (QOL) are major contributors to postoperative outcomes. The frequency and cost of lumbar spine surgery has been increasing, with controversy revolving around optimal management strategies and outcome predictors. The goal of this study was to generate predictive nomograms and a clinical calculator for postoperative clinical and QOL outcomes following lumbar spine surgery for degenerative disease.

METHODS

Patients undergoing lumbar spine surgery for degenerative disease at a single tertiary care institution between June 2009 and December 2012 were retrospectively reviewed. Nomograms and an online calculator were modeled based on patient demographics, comorbidities, presenting symptoms and duration of symptoms, indication for surgery, type and levels of surgery, and baseline preoperative QOL scores. Outcomes included postoperative emergency department (ED) visit or readmission within 30 days, reoperation within 90 days, and 1-year changes in the EuroQOL-5D (EQ-5D) score. Bootstrapping was used for internal validation.

RESULTS

A total of 2996 lumbar surgeries were identified. Thirty-day ED visits were seen in 7%, 30-day readmission in 12%, 90-day reoperation in 3%, and improvement in EQ-5D at 1 year that exceeded the minimum clinically important difference in 56%. Concordance indices for the models predicting ED visits, readmission, reoperation, and dichotomous 1-year improvement in EQ-5D were 0.63, 0.66, 0.73, and 0.84, respectively. Important predictors of clinical outcomes included age, body mass index, Charlson Comorbidity Index, indication for surgery, preoperative duration of symptoms, and the type (and number of levels) of surgery. A web-based calculator was created, which can be accessed here: https://riskcalc.org/PatientsEligibleForLumbarSpineSurgery/.

CONCLUSIONS

The prediction tools derived from this study constitute important adjuncts to clinical decision-making that can offer patients undergoing lumbar spine surgery realistic and personalized expectations of postoperative outcome. They may also aid physicians in surgical planning, referrals, and counseling to ultimately lead to improved patient experience and outcomes.

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology

STUDY DESIGN

Retrospective review of an administrative database.

OBJECTIVES

The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.

METHODS

Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.

RESULTS

In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001.

CONCLUSION

Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.

COVID-19 and Neurosurgery Consultation Call Volume at a Single Large Tertiary Center With a Propensity-Adjusted Analysis

BACKGROUND

The COVID-19 pandemic has significantly affected patient care across specialties. Ramifications for neurosurgery include substantial disruptions to surgical training and changes in nonurgent patient presentations to the emergency department. This study quantifies the effects of the COVID-19 pandemic on the number of emergency department patients who were referred to the neurosurgery department for further consultation and treatment and identifies and describes trends in the characteristics of these visits.

METHODS

A retrospective review was performed of neurosurgical consultations at a single high-volume institution for 28 call-day periods before and after the official announcement of the pandemic. Primary outcomes included consultations per call-day, patient presentation category, and patient admission.

RESULTS

The neurosurgical service was consulted regarding 629 patients (367 male patients) during the study period, with 471 (75%) and 158 (25%) patients presenting before and after the announcement of the COVID-19 pandemic, respectively. The mean number of neurosurgical consultations per call-day was significantly lower in the COVID-19 period (5.6 consultations) compared with the pre-COVID-19 period (16.8 consultations) (P < 0.001). After adjusting for patient demographics, the rate of presentation for general nonurgent concerns, such as back pain, headaches, and other general weaknesses, significantly decreased (odds ratio [95% confidence interval], 0.60 [0.47-0.77], P < 0.001).

CONCLUSIONS

Neurosurgical consultations significantly decreased after the onset of the COVID-19 pandemic, with a substantially lower overall number of consultations necessitating operative interventions. Furthermore, the relative number of patients with nonemergent neurological conditions significantly decreased during the pandemic.

Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I

BACKGROUND

Postoperative emergency department (ED) visits following suboccipital decompression in Chiari malformation type I (CM-1) patients are not well described. We sought to evaluate the magnitude, etiology, and significance of postoperative ED service utilization in adult CM-1 patients at a tertiary referral center.

METHODS

A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS).

RESULTS

In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a postoperative ED visit (P = 0.023). The occurrence of a postoperative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted odds ratio of CCOS ≥13 = 0.35, P = 0.021; adjusted odds ratio of CCOS ≥14 = 0.38, P = 0.016).

CONCLUSIONS

Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of postoperative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of postoperative ED service utilization are warranted.

Emergency Department Visits After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

The incidence of emergency department (ED) visits after posterior spinal fusion (PSF) in adolescent idiopathic scoliosis (AIS) patients is not well known. We hypothesize that the majority of ED visits are related to constipation and pain issues, and are not for serious complications.

METHODS

Using a private insurance claims database, we identified AIS patients aged 10 to 21 years who underwent PSF from 2010 to 2015. Patients were excluded for diagnoses of neuromuscular or syndromic scoliosis. ED visits that occurred within the 6-month postoperative period were identified. The diagnoses present at these visits were pooled and analyzed, in addition to insurance payments associated with these visits. Significance was set at P=0.05.

RESULTS

A total of 5934 patients met inclusion criteria. Mean age was 14.4±2.2 years, and 75% of the patients were girls. A total of 577 (9.7%) patients had at least 1 ED visit in the 6-month postoperative period, whereas 92 (1.6%) had 2 ED visits and 19 (0.3%) had 3 or more ED visits. The median time to ED visits was 33 days after surgery. Independent risk factors for ED visits were: older age, and greater levels fused (P<0.05). The top 5 most common reasons for ED visits were: pain/back or musculoskeletal, constipation/GI issues, asthma/ respiratory issues, upper respiratory infection, and dehydration. Rates of ED visits were similar among the US geographic regions. Patients who had an ED visit had significantly higher total 6-month health care payments than those who did not (P<0.001).

CONCLUSIONS

Approximately 10% of the patients had ≥1 ED visit in the 6-month period after PSF for AIS. A majority of the diagnoses at these ED visits were outpatient medical issues.

LEVEL OF EVIDENCE

Level III.