Preoperative factors affecting length of stay after elective anterior cervical discectomy and fusion with and without corpectomy: a multivariate analysis of an academic center cohort

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

Background

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

BACKGROUND

Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS.

METHODS

The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS.

RESULTS

Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062).

CONCLUSIONS

Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS.

LEVEL OF EVIDENCE: 3

Effect of Instrumented Spine Surgery on Length of Stay

INTRODUCTION

Total joint arthroplasty studies have identified that surgeries that take place later in the week have a longer length of stay compared with those earlier in the week. This has not been demonstrated in studies focused on anterior cervical diskectomy and fusions or minimally invasive lumbar laminectomies. All-inclusive instrumented spine surgeries, however, have not been analyzed. The purpose of this study was to determine whether day of surgery affects length of stay and whether there are predictive patient characteristics that affect length of stay in instrumented spine surgery.

METHODS

All instrumented spine surgeries in 2019 at a single academic tertiary center were retrospectively reviewed. Patients were categorized for surgical day and discharge disposition to home or a rehabilitation facility. Differences by patient characteristics in length of stay and discharge disposition were compared using Kruskal-Wallis and chi square tests along with multiple comparisons.

RESULTS

Seven hundred six patients were included in the analysis. Excluding Saturday, there were no differences in length of stay based on the day of surgery. Age older than 75 years, female, American Society of Anesthesiology (ASA) classification of 3 or 4, and an increased Charlson Comorbidity Index were all associated with a notable increase in length of stay. While most of the patients were discharged home, discharge to a rehabilitation facility stayed, on average, 4.7 days longer (6.8 days compared with 2.1 days, on average) and were associated with an age older than 66 years old, an ASA classification of 3 or 4, and a Charlson Comorbidity Index of 1 to 3.

CONCLUSIONS

Day of surgery does not affect length of stay in instrumented spine surgeries. Discharge to a rehabilitation facility, however, did increase the length of stay as did age older than 75 years, higher ASA classification, and increased Charlson Comorbidity Index classification.

Adherence to use of blood cultures according to current national guidelines and their impact in patients with community acquired pneumonia: A retrospective cohort

BACKGROUND

Community acquired pneumonia (CAP) is the most frequent cause of mortality secondary to infectious etiologies. Recommendations about the use of blood cultures in the diagnosis and treatment of CAP has been a contentious topic of debate and ever-changing recommendations.

METHODS

A cohort study was conducted in a community teaching hospital. All the patients that were admitted with a diagnosis of CAP, between January and December of 2019 were included. Sociodemographic and clinical characteristics were obtained. Blood cultures results were obtained, and it was evaluated if they were done in compliance with current recommendations by the Infectious Disease Society of America (IDSA).

RESULTS

721 patients were included in the study. Median age was 68 years and 50% of the patients were male (n = 293). Patients presented from home (84%) and the most common comorbidities were hypertension and diabetes (68% and 31%). 96 patients had positive blood culture and 34% (n = 247) of all the blood cultures were adequately ordered. 80 patients died or went to hospice and the median length of hospital stay in our cohort was 7 days. The multivariate model showed that mortality was associated with positive blood cultures (OR = 3.1 95%CI 1.63-5.87) and appropriateness of blood cultures (OR = 2.96 95% CI 1.2-5.7).

CONCLUSION

Adequate use of blood cultures in patients with CAP might have some association with the outcomes of this disease. However, a prospective study evaluating the utility of this test following current IDSA recommendations is needed to understand their impact in mortality and morbidity.

Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix

Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.

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

Background

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

Methods

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

Results

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

Conclusions

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

The Impact of Diabetes on Outcomes and Health Care Costs Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Anterior cervical discectomy and fusion (ACDF) is commonly used to treat an array of cervical spine pathology and is associated with good outcomes and low complication rates. Diabetes mellitus (DM) is a common comorbidity for patients undergoing ACDF, but the literature is equivocal about the impact it has on outcomes. Because DM is a highly prevalent comorbidity, it is crucial to determine if it is an associated risk factor for outcomes after ACDF procedures.

METHODS

Patients at a single institution from 2008 to 2016 undergoing ACDF were compared on the basis of having a prior diagnosis of DM versus no DM. The 2 cohorts were compared utilizing univariate tests and multivariate logistic and linear regressions.

RESULTS

Data for 2470 patients was analyzed. Diabetic patients had significantly higher Elixhauser scores (P < .0001). Univariate testing showed diabetic patients were more likely to suffer from sepsis (0.82% vs 0.10%, P = .03) and bleeding complications (3.0% vs 1.5%, P = .04). In multivariate analyses, diabetic patients had higher rates of non-home discharge (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.07-1.75, P = .013) and prolonged length of stay (OR = 1.95, 95% CI = 1.25-3.05, P = .003), but similar complication (OR = 1.46, 95% CI = 0.85-2.52, P = .17), reoperation (OR = 0.77, 95% CI = 0.33-1.81, P = .55), and 90-day readmission (OR = 1.53, 95% CI = 0.97-2.43) rates compared to nondiabetic patients. Direct cost was also shown to be similar between the cohorts after adjusting for patient, surgical, and hospital-related factors (estimate = -$30.25, 95% CI = -$515.69 to $455.18, P = .90).

CONCLUSIONS

Diabetic patients undergoing ACDF had similar complication, reoperation, and readmission rates, as well as similar cost of care compared to nondiabetic patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases

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.

A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion

INTRODUCTION

The movement toward reducing healthcare expenditures has led to an increased volume of outpatient anterior cervical diskectomy and fusions (ACDFs). Appropriateness for outpatient surgery can be gauged based on the duration of recovery each patient will likely need.

METHODS

Patients undergoing 1- or 2-level ACDFs were retrospectively identified at a single Level I spine surgery referral institution. Length of stay (LOS) was categorized binarily as either less than two midnights or two or more midnights. The data were split into training (80%) and test (20%) sets. Two multivariate regressions and three machine learning models were developed to predict a probability of LOS ≥ 2 based on preoperative patient characteristics. Using each model, coefficients were computed for each risk factor based on the training data set and used to create a calculatable ACDF Predictive Scoring System (APSS). Performance of each APSS was then evaluated on a subsample of the data set withheld from training. Decision curve analysis was done to evaluate benefit across probability thresholds for the best performing model.

RESULTS

In the final analysis, 1,516 patients had a LOS <2 and 643 had a LOS ≥2. Patient characteristics used for predictive modeling were American Society of Anesthesiologists score, age, body mass index, sex, procedure type, history of chronic pulmonary disease, depression, diabetes, hypertension, and hypothyroidism. The best performing APSS was modeled after a lasso regression. When applied to the withheld test data set, the APSS-lasso had an area under the curve from the receiver operating characteristic curve of 0.68, with a specificity of 0.78 and a sensitivity of 0.49. The calculated APSS scores ranged between 0 and 45 and corresponded to a probability of LOS ≥2 between 4% and 97%.

CONCLUSION

Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting.

Effect of Surgical Setting on Cost and Hospital Reported Outcomes for Single-Level Anterior Cervical Discectomy and Fusion

BACKGROUND

Hospitals seek to reduce costs and improve patient outcomes by decreasing length of stay (LOS), 30-day all-cause readmissions, and preventable complications. We evaluated hospital-reported outcome measures for elective single-level anterior cervical discectomy and fusions (ACDFs) between tertiary (TH) and community hospitals (CH) to determine location-based differences in complications, LOS, and overall costs.

METHODS

Patients undergoing elective single-level ACDF in a 1-year period were retrospectively reviewed from a physician-driven database from a single medical system consisting of 1 TH and 4 CHs. Adult patients who underwent elective single-level ACDF were included. Patients with trauma, tumor, prior cervical surgery, and infection were excluded. Outcomes measures included all-cause 30-day readmissions, preventable complications, LOS, and hospital costs.

RESULTS

A total of 301 patients (60 TH, 241 CH) were included. CHs had longer LOS (1.25 ± 0.50 versus 1.08 ± 0.28 days, P = .01). There were no differences in complication and readmission rates between hospital settings. CH, orthopaedic subspecialty, female sex, and myelopathy were predictors for longer LOS. Overall, costs at the TH were significantly higher than at CHs ($17 171 versus $11 737; Δ$ = 5434 ± 3996; P < .0001). For CHs, the total costs of drugs, rooms, supplies, and therapy were significantly higher than at the TH. TH status, orthopaedic subspecialty, and myelopathy were associated with higher costs.

CONCLUSION

Patients undergoing single-level ACDFs at CHs had longer LOS, but similar complications and readmission rates as those at the TH. However, cost of ACDF was 1.5 times greater in the TH. To improve patient outcomes, optimize value, and reduce hospital costs, modifiable factors for elective ACDFs should be evaluated.

LEVEL OF EVIDENCE

3.

Bilateral cervical plexus block for anterior cervical spine surgery: study protocol for a randomised placebo-controlled trial

Background

There has been increasing focus to improve the quality of recovery following anterior cervical spine surgery (ACSS). Postoperative pain and nausea are the most common reasons for prolonged hospital stay and readmission after ACSS. Superficial cervical plexus block (SCPB) provides site-specific analgesia with minimal side effects, thereby improving the quality of recovery. The aim of our study was to investigate the effect bilateral cervical plexus block has on postoperative recovery in patients undergoing ACSS.

Methods

The study is a pragmatic, multi-centre, blinded, parallel-group, randomised placebo-controlled trial. 136 eligible patients (68 in each group) undergoing ACSS will be included. Patients randomised to the intervention group will have a SCPB administered under ultrasound guidance with a local anaesthetic solution (0.2% ropivacaine, 15mL); patients randomised to the placebo group will be injected in an identical manner with a saline solution. The primary outcome is the 40-item quality of recovery questionnaire score at 24 h after surgery. In addition, comparisons between groups will be made for a 24-h opioid usage and length of hospital stay. Neck pain intensity will be quantified using the numeric rating scale at 1, 3, 6 and at 24 h postoperatively. Incidence of nausea, vomiting, dysphagia or hoarseness in the first 24 h after surgery will also be measured.

Discussion

By conducting a blinded placebo trial, we aim to control for the bias inherently associated with a tangible medical intervention and show the true treatment effect of SCPB in ACSS. A statistically significant result will indicate an overall improved quality of recovery for patients; alternatively, if no benefit is shown, this trial will provide evidence that this intervention is unnecessary.

Trial registration

ClinicalTrials.gov ACTRN12619000028101. Prospectively registered on 11 January 2019 with Australia New Zealand Clinical Trials Registry

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

US children of minority race are less likely to be admitted to the pediatric intensive care unit after traumatic injury, a retrospective analysis of a single pediatric trauma center

Background

The public health impact of pediatric trauma makes identifying opportunities to equalize health related disparities imperative. The influence of a child’s race on the likelihood of admission to the pediatric intensive care unit (PICU) is not well described. We hypothesized that traumatically injured children of minority race would have higher rates of PICU admission, compared to White children.

Methods

This was a retrospective review of a single institution’s trauma registry including children ≤18 years of age presenting to the emergency department (ED) whose injury necessitated pediatric trauma team activation at a Level 1 Pediatric Trauma Center from July 1, 2011 through June 30, 2016. Demographics, injury characteristics and hospital utilization data were collected. Race was categorized as White or racial minority, which included patients identifying as Black, Hispanic ethnicity, Native American or “other.” The primary outcome measure was admission to the PICU. Chi square or Mann Whitney rank sum tests were used, as appropriate, to compare differences in demographics and injury characteristics between those children who were and were not admitted to the PICU setting. Variables associated with PICU admission in univariate analyses were included in a multivariate analysis. Data are presented as median values and interquartile ranges, or numbers and percentages.

Results

The median age of the 654 included subjects was 8 [IQR 4–13] years; 55.2% were a racial minority. Nine (1.4%) children died in the ED and 576 (88.1%) were admitted to the hospital. Of the children requiring hospitalization, 195 (33.9%) were admitted to the PICU. Children admitted to the PICU were less likely to be from a racial minority group (26.1% vs 42.5%, p < 0.001). After adjusting for age and injury characteristics in a multivariable analysis, racial minority children had a lower odds of PICU admission compared to White children (OR 0.492 [95% C.I. 0.298–0.813, p = 0.006]).

Conclusions

In this retrospective analysis of traumatically injured children, minority race was associated with lower odds of PICU admission, suggesting that health care disparities based on race persist in pediatric trauma-related care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00309-x.

Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined.

OBJECTIVE

To review the medical literature on the safety of outpatient ACDF.

METHODS

We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups.

RESULTS

We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001).

CONCLUSION

Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.

Risk Factors of Extended Hospital Stay After One-Level Anterior Cervical Discectomy Fusion or Disc Replacement: Results from 1004 Patients in Food and Drug Administration Trials

BACKGROUND

Extended length of stay (LOS) after surgery is costly to the health care system and can be distressing to the patient and family. Previous studies have shown conflicting data on factors associated with increased LOS and are limited by using multiple different surgeries. Our study seeks to analyze factors that are associated with extended LOS.

OBJECTIVE

The objective of this study was to analyze data from 2 Food and Drug Administration trials of one-level cervical surgery to identify risk factors that are associated with extended LOS in the hospital.

METHODS

Extended LOS was defined to be >1 day. Patients with LOS ≤1 day were compared with those with LOS >1 day. Data from the BRYAN and Prestige ST Trial (n = 1004) were analyzed. Subjects with LOS ≤1 day were compared with those with LOS >1 day. Variables analyzed for their effect on LOS included demographic characteristics, patient-reported outcome measures, preoperative medical conditions, preoperative neurologic status, and intraoperative factors.

RESULTS

A total of 912 patients (90.84%) had an LOS ≤1 day and 92 patients (9.16%) had an extended LOS >1 day. Weak narcotic medication use (P = 0.021; odds ratio [OR], 1.72), Nurick gait (P = 0.019; OR, 1.796), and operative time (P < 0.0001; OR, 2.062) were found to significantly affect LOS.

CONCLUSIONS

Nurick gait, operative time, and history of weak narcotic use are associated with extended hospital stay. These data may be useful in preoperatively counseling patients, developing quality metrics for hospitals, and helping create financial models for cost/diagnosis-related group reimbursement for single-level anterior cervical surgery.

Gender differences in use of prolonged non-operative therapies prior to index ACDF surgery

Prior to anterior cervical discectomy and fusion (ACDF) surgery, patients suffering from cervical stenosis traditionally trial non-operative treatments for pain management. There is a paucity of data evaluating gender disparities in the prolonged utilization of conservative therapy prior to ACDF surgery. Therefore, the purpose of this study was to assess for gender-based differences in the utilization and cost of maximal non-operative therapy (MNT) for cervical stenosis prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing 1, 2, or 3-level index ACDF procedures between 2007 and 2016 were gathered from an insurance database consisting of 20.9 million covered lives. The utilization of MNTs within 5 years prior to index ACDF surgery was assessed. A total of 2254 patients (females: 53.1%) underwent an index ACDF surgery. There were a significantly greater percentage of female patients that utilized NSAIDs (p < 0.0001), opioids (p = 0.0019), muscle relaxants (p < 0.0001), cervical epidural steroid injections (p = 0.0428), and physical therapy/occupational therapy treatments (p < 0.0001). The total direct cost associated with all MNT prior to index ACDF was $4,833,384. On average, $2028.01 was spent per male patient while $2247.29 was spent per female patient. When normalized by number of pills billed per patient utilizing therapy, female patients utilized more NSAIDs (males: 591.8 pills, females: 669.3 pills), opioids (male: 1342.0 pills, female: 1650.1 pills), and muscle relaxants (males: 823.7 pills, females: 1211.1 pills). The results suggest that there may be gender differences in the utilization of non-operative therapies for symptomatic cervical stenosis prior to ACDF surgery.

Cost-effectiveness Applications of Patient-reported Outcome Measures (PROMs) in Spine Surgery

Because of the rising health care costs in the United States, there has been a focus on value-based care and improving the cost-effectiveness of surgical procedures. Patient-reported outcome measures (PROMs) can not only give physicians and health care providers immediate feedback on the well-being of the patients but also be used to assess health and determine outcomes for surgical research purposes. Recently, PROMs have become a prominent tool to assess the cost-effectiveness of spine surgery by calculating the improvement in quality-adjusted life years (QALY). The cost of a procedure per QALY gained is an essential metric to determine cost-effectiveness in universal health care systems. Common patient-reported outcome questionnaires to calculate QALY include the EuroQol-5 dimensions, the SF-36, and the SF-12. On the basis of the health-related quality of life outcomes, the cost-effectiveness of various spine surgeries can be determined, such as cervical fusions, lumbar fusions, microdiscectomies. As the United States attempts to reduce costs and emphasize value-based care, PROMs may serve a critical role in spine surgery moving forward. In addition, PROM-driven QALYs may be used to analyze novel spine surgical techniques for value-based improvements.

Factors Associated With Extended Length of Stay and 90-Day Readmission Rates Following ACDF

STUDY DESIGN

Retrospective.

OBJECTIVE

Identify patient risk factors for extended length of stay (LOS) and 90-day hospital readmissions following elective anterior cervical discectomy and fusion (ACDF).

METHODS

Included ACDF patients from 2013 to 2017 at a single institution. Eligible patients were subset into LOS <2 and LOS ≥2 days, and no 90-day hospital readmission and yes 90-day hospital readmission. Patient and surgical factors were compared between the LOS and readmission groups. Multivariable logistic regression analysis was utilized to determine the association of independent factors with LOS and 90-day readmission rates.

RESULTS

Our sample included 1896 patients; 265 (14%) had LOS ≥2 days, and 121 (6.4%) had a readmission within 90 days of surgery. Patient and surgical factors associated with LOS included patient age ≥65 years (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.15-2.56), marriage (OR 0.57, 95% CI 0.43-0.79), private health insurance (OR 0.28, 95% CI 0.15-0.50), American Society of Anesthesiologists (ASA) score (OR 1.52, 95% CI 1.12-1.86), African American race (OR 1.95, 95% CI 1.38-2.72), and harvesting iliac crest autograft (OR 4.94, 95% CI 2.31-10.8). Patient and surgical factors associated with 90-day hospital readmission included ASA score (OR 1.81, 95% CI 1.32-2.49), length of surgery (OR 1.002, 95% CI 1.001-1.004), and radiculopathy as indication for surgery (OR 0.60, 95% CI 0.39-0.96).

CONCLUSIONS

Extended LOS and 90-day hospital readmissions may lead to poorer patient outcomes and increased episode of care costs. Our study identified patient and surgical factors associated with extended LOS and 90-day readmission rates. In general, preoperative patient factors affected these outcomes more than surgical factors.

Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease

BACKGROUND

Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

OBJECTIVE

To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

METHODS

Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

RESULTS

The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

CONCLUSION

There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.

Predicting extended operative time and length of inpatient stay in cervical deformity corrective surgery

It's increasingly common for surgeons to operate on more challenging cases and higher risk patients, resulting in longer op-time and inpatient LOS. Factors predicting extended op-time and LOS for cervical deformity (CD) patients are understudied. This study identified predictors of extended op-time and length of stay (LOS) after CD-corrective surgery. CD patients with baseline (BL) radiographic data were included. Patients were stratified by extended LOS (ELOS; >75th percentile) and normal LOS (N-LOS; <75th percentile). Op-time analysis excluded staged cases, cases >12 h. A Conditional Variable Importance Table used non-replacement sampling set of Conditional Inference trees to identify influential factors. Mean comparison tests compared LOS and op-time for top factors. 142 surgical CD patients (61 yrs, 62%F, 8.2 levels fused). Op-time and LOS were 358 min and 7.2 days; 30% of patients experienced E-LOS (14 ± 13 days). Overlapping predictors of E-LOS and op-time included levels fused (>7 increased LOS 2.7 days; >5 increased op-time 96 min, P < 0.001), approach (anterior reduced LOS 3.0 days; combined increased op-time 69 min, P < 0.01), BMI (>38 kg/m² increased LOS 8.1 days; >39 kg/m² increased op-time 17 min), and osteotomy (LOS 2.0 days, op-time 62 min, P < 0.005). BL cervical parameters increased LOS and op-time: cSVA (>42 mm increased LOS; >50 mm increased op-time, P < 0.030), C0 slope (>@-0.9° increased LOS, >0.3° increased op-time, P < 0.003.) Additional op-time predictors: prior cervical surgery (p = 0.004) and comorbidities (P = 0.015). Other predictors of E-LOS: EBL (P < 0.001), change in mental status (P = 0.001). Baseline cervical malalignment, levels fused, and osteotomy predicted both increased op-time and LOS. These results can be used to better optimize patient care, hospital efficiency, and resource allocation.

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

Background

To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures.

Methods

A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for.

Results

Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts.

Conclusions

Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week.

Level of Evidence

3.

Preparing for Bundled Payments in Cervical Spine Surgery: Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay?

STUDY DESIGN

Retrospective, observational study.

OBJECTIVE

To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS).

SUMMARY OF BACKGROUND DATA

Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability.

METHODS

A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated.

RESULTS

In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05.

CONCLUSION

Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources.

LEVEL OF EVIDENCE

3.

The Effect of Preoperative Medications on Length of Stay, Inpatient Pain, and Narcotics Consumption After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To determine the association between preoperative medications and length of stay, inpatient pain, and narcotics consumption after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Previous studies have identified risk factors for increased length of hospital stay, inpatient pain, and narcotics consumption. However, little is known regarding the effects of preoperative medications on outcomes after spine surgery.

METHODS

A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Preoperative medications taken within 30 days before surgery were recorded for each patient and categorized by medication type. Poisson regression with robust error variance was used to determine the association between preoperative medications and length of stay, pain scores, and narcotics consumption. Multivariate analysis was performed using a backwards, stepwise regression to identify independent risk factors.

RESULTS

In total, 138 patients were included in this analysis. On bivariate analysis, benzodiazepines were associated with longer hospital stays [relative risk (RR)=2.03; P=0.031]. Benzodiazepines (RR=3.71; P<0.001) and preoperative narcotics (RR=2.60; P=0.012) were risk factors for pain ≥7 on postoperative day 0. On multivariate analysis, benzodiazepines were an independent risk factor for prolonged stay. Benzodiazepines, narcotics, and nonsteroidal anti-inflammatories were identified as independent risk factors for increased postoperative pain.

CONCLUSIONS

These results suggest that benzodiazepines are a risk factor for increased length of stay and postoperative pain after MIS TLIF. Preoperative narcotics and nonsteroidal anti-inflammatories were also identified as risk factors for postoperative pain though this did not lead to increases in narcotics consumption. Patients taking these medications should undergo more vigilant perioperative monitoring for adequate pain management. More work must be done to further elucidate the association between preoperative medications and postoperative outcomes after MIS TLIF.

Trends of postoperative length of stay in spine surgery over 10 years in Japan based on a prospective multicenter database

OBJECTIVES

To identify factors associated with prolonged length of stay (LOS) in spine surgery, with the goal of establishing details of LOS for multiple diseases and surgical procedures.

PATIENTS AND METHODS

The subjects were patients who underwent spine surgery at 10 facilities in the Nagoya Spine Group from January 2005 to December 2015. Data were collected for patient background, primary spinal pathology, anatomical location of the lesion, and surgical methods. The primary outcome was LOS, which was defined as the calendar days from surgery to hospital discharge.

RESULTS

A total of 10,829 patients (5953 males, 4876 females; age 5-93 years, mean 60.2 ± 28.8 years) were identified in the database. Average follow-up was 61 months (range: 13-120 months). Average LOS was 22.3 ± 21.3 days, and there was a gradual decrease in LOS over the study period. LOS was significantly correlated with age, and prolonged LOS was significantly associated with thoracic spine surgery and significantly longer after surgery with instrumentation. Average LOS was >30 days for intramedullary tumor resection and posterior cervical fusion, but only 10.2 days for microendoscopic discectomy. Reoperation was performed in 210 patients (1.9%) and these patients had a significantly higher average LOS of 43.1 days.

CONCLUSION

These results will assist quality improvement in spine surgery. The identified risk factors for prolonged LOS will also assist in planning of surgery, postoperative care, and discharge, with the goal of reducing health care costs.

Length of stay associated with posterior cervical fusion with intervertebral cages: experience from a device registry

Background

Using a multi-center medical device registry, we prospectively collected a set of perioperative and clinical outcomes among patients treated with tissue-sparing, posteriorly-placed intervertebral cage fusion used in the management of symptomatic, degenerative neural compressive disorders of the cervical spine.

Methods

Cervical fusion utilizing posteriorly-placed intervertebral cages offers a tissue-sparing alternative to traditional instrumentation for the treatment of symptomatic cervical radiculopathy. A registry was established to prospectively collect perioperative and clinical data in a real-world clinical practice setting for patients treated via this approach. This study evaluated length of stay as well as estimated blood loss and procedural time in 271 registry patients.

Results

The median length of stay was 1.1, 1.1 and 1.2 days for patients having a stand-alone arthrodesis, revision of a pseudoarthrosis, and circumferential fusion (360°), respectively, and was not related to number of levels treated. Historical comparison to published literature demonstrated that average lengths of stay associated with open, posterior lateral mass fixation were consistently ≥4 days. Average blood loss (range, 32-75 mL) and procedural time (range, 51-88 min) were also diminished in patients having tissue-sparing, cervical intervertebral cage fusion compared to open posterior lateral mass fixation.

Conclusions

Adoption of this tissue-sparing procedure may offer substantial cost-constraining benefits by reducing the length of post-operative hospitalization by, at least, 3 days compared to traditional lateral mass fixation.

Intersurgeon Cost Variability in Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective review of prospective patient outcomes and cost data.

OBJECTIVE

To analyze the contribution of surgeon-specific variability in cost and patient-reported outcomes (PROs) to overall variability in anterior cervical discectomy and fusion (ACDF), whereas adjusting for patient comorbidities.

SUMMARY OF BACKGROUND DATA

Cost reduction in surgical care has received increased attention. Patient factors contributing to cost variability in ACDF have been described; however, intersurgeon cost and outcome variability has received less attention in the literature.

METHODS

Adult patients undergoing elective primary ACDF by five different surgeons were analyzed from a prospective registry database. Direct and indirect 90-day costs were compared across each surgeon, along with PROs. Predicted costs were calculated based on patient co-morbidities, and an "observed versus expected" cost differential was measured for each surgeon; this O/E cost ratio was then compared with PROs.

RESULTS

A total of 431 patients were included in the analysis. There were no differences in comorbidities, age, smoking status, or narcotic use. There was significant variation between surgeons in total 90-day costs, as well as variation between each surgeon's observed versus expected cost ratio. Despite these surgeon-specific cost variations, there were no differences in PROs across the participating surgeons.

CONCLUSION

Intersurgeon cost variation in elective ACDF persists even after adjusting for patient comorbidities. There was no apparent correlation between increased surgeon-specific costs and 90-day PROs. These findings show there is opportunity for improvement in inter-surgeon cost variation without compromise in PROs.

LEVEL OF EVIDENCE

3.

Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database

BACKGROUND CONTEXT

With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population.

PURPOSE

The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF.

STUDY DESIGN/SETTING

This is a large-scale retrospective case control study.

PATIENT SAMPLE

The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery.

MATERIALS AND METHODS

A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF.

RESULTS

Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R²=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable.

CONCLUSIONS

Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.

Dependent functional status is associated with unplanned postoperative intubation after elective cervical spine surgery: a national registry analysis

PURPOSE

The impact of preoperative functional status on 30-day unplanned postoperative intubation and clinical outcomes among patients who underwent cervical spine surgery is not well-described. We hypothesized that functional dependence is associated with 30-day unplanned postoperative intubation and that among the reintubated cohort, functional dependence is associated with adverse postoperative clinical outcomes after cervical spine surgery.

METHODS

Utilizing the 2007-2016 American College of Surgeons National Surgical Quality Improvement Program database, we identified adult elective anterior and posterior cervical spine surgery patients by Current Procedural Terminology codes. We performed (1) a Cox Proportional Hazard analysis for the following outcomes: reintubation, prolonged ventilator use, and pneumonia and (2) an adjusted logistic regression analysis among patients that required postoperative reintubation to evaluate the association of functional status with adverse postoperative outcomes.

RESULTS

The sample size was 26,263, of which 550 (2.1%) were functionally dependent. The adjusted model suggested that when compared with functionally independent patients, dependent patients were at increased risk of unplanned 30-day intubation (HR 2.05, 95% CI 1.26-3.34; P = 0.003). The adjusted risk of 30-day postoperative pneumonia was significantly higher in patients with functional dependence (HR 1.61, 95% CI 1.02-2.54, P = 0.036). Among patients that required postoperative reintubation, the odds of 30-day mortality was significantly higher in patients with functional dependence (OR 5.82, 95% CI 1.59-23.4, P < 0.001).

CONCLUSION

Preoperative functional dependence is a good marker for estimating postoperative unplanned intubation following cervical spine surgery.

Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion

STUDY DESIGN

This is retrospective study of prospectively collected data.

OBJECTIVE

To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database.

SUMMARY OF BACKGROUND DATA

A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions.

RESULTS

A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2-5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032).

CONCLUSIONS

The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care.

LEVEL OF EVIDENCE

Level III.

Outpatient Anterior Cervical Discectomy and Fusion is Associated With Fewer Short-term Complications in One- and Two-level Cases: A Propensity-adjusted Analysis

STUDY DESIGN

Retrospective cohort study of prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) database.

OBJECTIVE

To determine the postoperative morbidity of one- and two-level outpatient anterior cervical discectomy and fusion (ACDF) relative to inpatient cases, and risk factors for postdischarge complications.

SUMMARY OF BACKGROUND DATA

ACDF is increasingly performed as an outpatient procedure, with evidence demonstrating outpatient one-level ACDF to be associated with fewer postoperative complications than inpatients. The postoperative morbidity and safety of outpatient two-level ACDF as a separate cohort is not well understood.

METHODS

ACDF cases from NSQIP 2011 to 2014 were identified. Differences in baseline characteristics between inpatient and outpatient cases were determined, and propensity score adjustment was used to account for selection bias. One- and two-level ACDF cohorts were analyzed separately. Unadjusted and propensity-adjusted multivariable logistic regressions were performed to determine the risk of postoperative complications in outpatient cases relative to inpatient cases, and predictors of postdischarge complications.

RESULTS

A total of 22,006 ACDF cases were included, of which 4759 were outpatient procedures. Propensity-adjusted differences in preoperative characteristics were all P > 0.5, indicating successful adjustment of selection bias. Among 6890 two-level cases, of which 1429 (20.7%) were outpatient, the overall unadjusted rate of complications was 1.47% for outpatients and 3.94% for inpatients, P < 0.001. Propensity-adjusted multivariable regression showed a lower rate of postoperative complications in the outpatient cohort (odds ratio 0.48, 95% confidence interval 0.30-0.75). Greater comorbidity burden as measured by Charlson Comorbidity Index, higher American Society of Anesthesiologists class, chronic steroid use, hypertension, and male sex were independent risk factors for postdischarge complications.

CONCLUSION

After adjusting for selection bias and patient risk factors, outpatient two-level ACDF was not associated with increased postoperative morbidity relative to inpatients, and may be considered in appropriately indicated patients.

LEVEL OF EVIDENCE

3.

Factors Affecting Length of Stay Following Elective Anterior and Posterior Cervical Spine Surgery

Background

Disease of the cervical spine is widely prevalent, most commonly secondary to degenerative disc changes and spondylosis.

Objective

The goal of the paper was to identify a possible discrepancy regarding the length of stay (LOS) between the anterior and posterior approaches to elective cervical spine surgery and identify contributing factors.

Methods

A retrospective study was performed on 587 patients (341 anterior, 246 posterior) that underwent elective cervical spinal surgery between October 2001 and March 2014. Pre- and intraoperative data were analyzed. Statistical analysis was performed using GraphPad Prism 5 (GraphPad Software, Inc., La Jolla, CA) and the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY).

Results

Average LOS was 3.21 ± 0.32 days for patients that benefited from the anterior approach cervical spinal surgery and 5.28 ± 0.37 days for patients that benefited from the posterior approach surgery, P-value < 0.0001. Anterior patients had lower American Society of Anesthesiologists scores (2.43 ± 0.036 vs. 2.70 ± 0.044). Anterior patients also had fewer intervertebral levels operated upon (2.18 ± 0.056 vs. 4.11 ± 0.13), shorter incisions (5.49 ± 0.093 cm vs. 9.25 ± 0.16 cm), lower estimated blood loss (EBL) (183.8 ± 9.0 cc vs. 340.0 ± 8.7 cc), and shorter procedure times (4.12 ± 0.09 hours vs. 4.47 ± 0.10 hours). Chi-squared tests for hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and asthma showed no significant difference between groups.

Conclusions:

Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher EBL, longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach. Future studies should include multiple surgeons. The goal would be to create a model that could accurately predict the postoperative length of stay based on patient and operative factors.

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.].

Outpatient Anterior Cervical Discectomy and Fusion: An Analysis of Readmissions from the New Jersey State Ambulatory Services Database

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) performed as an outpatient has become increasingly common for treating cervical spine pathology. Few reports have attempted to assess readmissions following outpatient ACDF. This study was performed to address this issue using population-based databases.

METHODS

The State Ambulatory Services Database (SASD) for New Jersey (NJ) from 2003-2012 was used for analysis. Patients receiving ACDF (defined as anterior cervical fusion (ICD-0 code=81.02) + excision of intervertebral disc (80.51)) were extracted; those with three or more levels fused (ICD-9 codes 81.63-81.64), cancer (ICD-9 codes 140-239), or trauma (ICD-9 codes=805.0-806.9) were excluded. A series of perioperative complications including durotomy, red blood cell transfusion, acute posthemorrhagic anemia, paraplegia (weakness), and mortality were examined. Propensity score matching (PSM) was used to adjust the analysis for patient age, race, sex, primary payer for care, and number of diagnoses. The NJ SASD defined readmission as admission to the same facility within seven days of initial discharge.

RESULTS

Two thousand sixteen (2,016) patients were found, 1,528 of whom had readmission data. Of these 1,528 patients, 83 (5.4%) required readmission. PSM was performed prior to comparing readmission versus non-readmission. While there was no difference in perioperative complications between the two groups, the small sample size of the readmission cohort prevented this analysis from having sufficient power. No patient requiring readmission had an initial length of stay greater than one day.

CONCLUSION

Based on a 10-year outpatient analysis, fewer than 6% of outpatient 1-2 level ACDFs require readmission. Future studies involving outpatients from several states will be necessary to determine whether these results of outpatient ACDF are applicable nationwide.

Effect of obesity on cost per quality-adjusted life years gained following anterior cervical discectomy and fusion in elective degenerative pathology

BACKGROUND

Obese patients have greater comorbidities along with higher risk of complications and greater costs after spine surgery, which may result in increased cost and lower quality of life compared with their non-obese counterparts.

PURPOSE

The aim of the present study was to determine cost-utility following anterior cervical discectomy and fusion (ACDF) in obese patients.

STUDY DESIGN

This study analyzed prospectively collected data.

PATIENT SAMPLE

Patients undergoing elective ACDF for degenerative cervical pathology at a single academic institution were included in the study.

OUTCOME MEASURES

Cost and quality-adjusted life years (QALYs) were the outcome measures.

METHODS

One- and two-year medical resource utilization, missed work, and health state values (QALYs) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Total cost (direct+indirect) was used to compute cost per QALY gained. Patients were defined as obese for body mass index (BMI) ≥35 based on the WHO definition of class II obesity. A subgroup analysis was conducted in morbidly obese patients (BMI≥40).

RESULTS

There were significant improvements in pain (neck pain or arm pain), disability (Neck Disability Index), and quality of life (EuroQol-5D and Short Form-12) at 2 years after surgery (p<.001). There was no significant difference in post-discharge health-care resource utilization, direct cost, indirect cost, and total cost between obese and non-obese patients at postoperative 1-year and 2-year follow-up. Mean 2-year direct cost for obese patients was $19,225±$8,065 and $17,635±$6,413 for non-obese patients (p=.14). There was no significant difference in the mean total 2-year cost between obese ($23,144±$9,216) and non-obese ($22,183±$10,564) patients (p=.48). Obese patients had a lower mean cumulative gain in QALYs versus non-obese patients at 2-years (0.34 vs. 0.42, p=.32). Two-year cost-utility in obese ($68,070/QALY) versus non-obese patients ($52,816/QALY) was not significantly different (p=.11). Morbidly obese patients had lower QALYs gained (0.17) and higher cost per QALYs gained ($138,094/QALY) at 2 years.

CONCLUSIONS

Anterior cervical discectomy and fusion provided a significant gain in health state utility in obese patients, with a mean 2-year cost-utility of $68,070 per QALYs gained, which can be considered moderately cost-effective. Morbidly obese patients had lower cost-effectiveness; however, surgery does provide a significant improvement in outcomes. Obesity, and specifically morbid obesity, should to be taken into consideration as physician and hospital reimbursements move toward a bundled model.

Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

The aim of this study was to characterize spinal fractures in patients with ankylosing spondylitis.

SUMMARY OF BACKGROUND DATA

Patients with ankylosing spondylitis are susceptible to fractures of the spinal column, even from minor trauma. However, the literature describing patients with ankylosing spondylitis and spinal fractures consists largely of case reports and small case series. The purpose of this study is to better characterize fractures of the ankylosed spine, including the patient population, locations of fracture, and outcomes in a large, nationally representative sample.

METHODS

All patients with diagnoses of both fracture of the spinal column and ankylosing spondylitis admitted between 2005 and 2011 were identified in the National Inpatient Sample (NIS). Patient demographics, fracture regions, and complications were characterized with descriptive statistics. The associations between injury characteristics and outcomes were assessed using Poisson regression.

RESULTS

A total of 939 patients with ankylosing spondylitis admitted with a spinal fracture were identified in NIS. The average age was 68.4 ± 14.7 years, and 85% of patients were male. Cervical fractures were the most common (53.0%), followed by thoracic (41.9%), lumbar (18.2%), and sacral (1.5%). Spinal cord injury was present in 27.5% of cervical fractures, 16.0% of thoracic fractures, and 21.1% of cases overall. Fractures involving more than 1 region of the spine occurred in 13.1% of patients. Patients were treated with fusion in 49.9% of cases. In-hospital adverse events occurred in 29.4% of patients, and 6.6% of patients died during their admission.

CONCLUSION

More than 10% of patients had fractures in more than 1 region of the spine. There is a high risk of adverse events in this population, and 6.6% of patients died during their inpatient stay. These results provide clinicians with a better understanding of the distribution and the high morbidity and mortality of fractures in the ankylosed spine.

LEVEL OF EVIDENCE

3.

Preoperative predictors of increased hospital costs in elective anterior cervical fusions: a single-institution analysis of 1,082 patients

BACKGROUND CONTEXT

The frequency of anterior cervical fusion (ACF) surgery and total hospital costs in spine surgery have substantially increased in the last several years.

PURPOSE

To determine which patient comorbidities are associated with increased total hospital costs after elective one- or two-level ACFs.

STUDY DESIGN/SETTING

Retrospective cohort analysis.

PATIENT SAMPLE

Individuals who have undergone elective one- or two-level ACFs at our single institution. The total number of patients amounted to 1,082.

OUTCOME MEASURES

Total hospital costs during single admission.

METHODS

Multivariate linear regression models were used to analyze independent effects of preoperative patient characteristics on total hospital costs. Univariate analysis was used to examine association of these characteristics on operative time, length of hospital stay (LOS), and complications.

RESULTS

Age, obesity, and diabetes were independently associated with increased average hospital costs of $1,404 (95% confidence interval [CI], $857-$1,951; p<.001), $681 (95% CI, $285-$1,076; p=.001), and $1,877 (95% CI, $726-$3,072; p=.001), respectively. Age was associated with increased LOS (p<.001) and complications (p<.001) but not operative time (p=.431). Diabetes was associated with increased LOS (p<.001) and complications (p=.042) but not operative time (p=.234). Obesity was not associated with increased LOS (p=.164), complications (p=.890), or operative time (p=.067).

CONCLUSIONS

This study highlights the patient comorbidities associated with increased hospital costs after one- or two-level ACFs and the potential drivers of these costs.