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Hebert KJ, Matta R, Horns JJ, Paudel N, Das R, McCormick BJ, Myers JB, Hotaling JM. Prior COVID-19 infection associated with increased risk of newly diagnosed erectile dysfunction. Int J Impot Res 2024; 36:521-525. [PMID: 36922696 PMCID: PMC10015534 DOI: 10.1038/s41443-023-00687-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 02/17/2023] [Accepted: 02/28/2023] [Indexed: 03/17/2023]
Abstract
We sought to assess if COVID-19 infection recovery is associated with increased rates of newly diagnosed erectile dysfunction. Using IBM MarketScan, a commercial claims database, men with prior COVID-19 infection were identified using ICD-10 diagnosis codes. Using this cohort along with an age-matched cohort of men without prior COVID-19 infection, we assessed the incidence of newly diagnosed erectile dysfunction. Covariates were assessed using a multivariable model to determine association of prior COVID-19 infection with newly diagnosed erectile dysfunction. 42,406 men experienced a COVID-19 infection between January 2020 and January 2021 of which 601 (1.42%) developed new onset erectile dysfunction within 6.5 months follow up. On multivariable analysis while controlling for diabetes, cardiovascular disease, smoking, obesity, hypogonadism, thromboembolism, and malignancy, prior COVID-19 infection was associated with increased risk of new onset erectile dysfunction (HR 1.27; 95% CI 1.1-1.5; P = 0.002). Prior to the widespread implementation of the COVID-19 vaccine, the incidence of newly diagnosed erectile dysfunction is higher in men with prior COVID-19 infection compared to age-matched controls. Prior COVID-19 infection was associated with a 27% increased likelihood of developing new-onset erectile dysfunction when compared to those without prior infection.
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Affiliation(s)
- Kevin J Hebert
- Division of Urology, University of Utah, Salt Lake City, UT, USA.
| | - Rano Matta
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - Joshua J Horns
- Surgical Population Analysis Research Core, University of Utah, Salt Lake City, UT, USA
| | - Niraj Paudel
- Surgical Population Analysis Research Core, University of Utah, Salt Lake City, UT, USA
| | - Rupam Das
- Surgical Population Analysis Research Core, University of Utah, Salt Lake City, UT, USA
| | | | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, University of Utah, Salt Lake City, UT, USA
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Boissiere L, Haleem S, Liquois F, Aunoble S, Cursolle JC, Régnault de la Mothe G, Petit M, Pellet N, Bourghli A, Larrieu D, Obeid I. Prospective same day discharge instrumented lumbar spine surgery - a forty patient consecutive series. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024:10.1007/s00586-024-08365-9. [PMID: 38918227 DOI: 10.1007/s00586-024-08365-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE Outpatient lumbar decompression surgeries have been successfully performed in France for over twenty years, earning acceptance. However, outpatient instrumented lumbar spine procedures and arthroplasties are less documented. This study aimed to evaluate the feasibility, efficiency, and safety of outpatient lumbar instrumented surgery. METHODS A prospective single-center study involving three experienced surgeons was conducted from September 2020 to September 2021, with a minimum six-month postoperative follow-up. Inclusion criteria comprised patients aged 18 to 75 eligible for same-day discharge, undergoing single-level lumbar spinal fusion or arthroplasty via anterior or posterior Wiltse approach. The primary endpoint was assessing the percentage of successful outpatient discharges (within twelve hours), with secondary endpoints including perioperative/postoperative complications and discharge pain prescriptions in terms of frequency and severity. RESULTS Forty patients (mean age: 44 years; 16/24 male/female ratio) underwent surgery, including 18 lumbar arthroplasties, twelve ALIF, and ten TLIF procedures. The majority of surgeries were performed at L4-L5 (18 procedures) and L5-S1 levels (22 procedures). 95% (38/40) of patients were successfully discharged within twelve hours, with only two patients discharged the following day. No postoperative hematomas, serious adverse events, or revision surgeries were noted. CONCLUSION 95% of patients were discharged successfully within twelve hours following outpatient lumbar fusion surgery, with a 100% patient satisfaction rate. Specific technical solutions were not necessary, and oral pain relief sufficed. Patient selection and education, including early pain management, played crucial roles in complication avoidance. This study underscores the safety of outpatient instrumented lumbar spine procedures, leading to cost reduction and expedited recovery.
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Affiliation(s)
- Louis Boissiere
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France.
| | - Shahnawaz Haleem
- Royal Orthopaedic Hospital, Spinal House, The Woodlands, Bristol Road South, Birmingham, B31 2AP, UK
| | - Frédéric Liquois
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
| | - Stéphane Aunoble
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
| | | | | | - Marion Petit
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
| | - Nicolas Pellet
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Daniel Larrieu
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
| | - Ibrahim Obeid
- ELSAN, Polyclinique Jean Villar, 53 avenue Maryse Bastié, Bruges, 33520, France
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Spears CA, Hodges SE, Liu B, Venkatraman V, Edwards RM, Than KD, Abd-El-Barr MM, Parente B, Lee HJ, Lad SP. Nationwide Analysis of Risk Factors Related to Opioid Weaning Following Lumbar Decompression Surgery - A Retrospective Database Study. World Neurosurg 2024; 186:e20-e34. [PMID: 38519019 DOI: 10.1016/j.wneu.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 03/24/2024]
Abstract
BACKGROUND Opioids are often prescribed for patients who eventually undergo lumbar decompression. Given the potential for opioid-related morbidity and mortality, postoperative weaning is often a goal of surgery. The purpose of this study was to examine the relationship between preoperative opioid use and postoperative complete opioid weaning among lumbar decompression patients. METHODS We surveyed the IBM Marketscan Databases for patients who underwent lumbar decompression during 2008-2017, had >30 days of opioid use in the year preceding surgery, and consumed a daily average of >0 morphine milligram equivalents in the 3 months preceding surgery. We used multivariable logistic regression and marginal standardization to examine the association between preoperative opioid use duration, average daily dose, and their interactions with complete opioid weaning in the 10-12 months after surgery. RESULTS Of the 11,114 patients who met inclusion criteria, most (54.7%, n = 6083) had a preoperative average daily dose of 1-20 morphine milligram equivalents. Postoperatively, 6144 patients (55.3%) remained on opioids. For patients with >180 days of preoperative use, the adjusted probability of weaning increased as the preoperative dose decreased. Obesity increased the likelihood of weaning, whereas older age, several comorbidities, female sex, and Medicaid decreased the odds of weaning. CONCLUSIONS Patients who used opioids for longer preoperatively were less likely to completely wean following surgery. Among patients with >180 days of preoperative use, those with lower preoperative doses were more likely to wean. Weaning was also associated with several clinical and demographic factors. These findings may help shape expectations regarding opioid use following lumbar decompression.
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Affiliation(s)
- Charis A Spears
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah E Hodges
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vishal Venkatraman
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ryan M Edwards
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Khoi D Than
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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Mani K, Kleinbart E, Goldman SN, Golding R, Gelfand Y, Murthy S, Eleswarapu A, Yassari R, Fourman MS, Krystal J. Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202405000-00011. [PMID: 38743853 PMCID: PMC11095963 DOI: 10.5435/jaaosglobal-d-24-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. METHODS Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. RESULTS Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). CONCLUSIONS The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Emily Kleinbart
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Samuel N. Goldman
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Regina Golding
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Yaroslav Gelfand
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Saikiran Murthy
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Ananth Eleswarapu
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Reza Yassari
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Mitchell S. Fourman
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
| | - Jonathan Krystal
- From the Albert Einstein College of Medicine, Bronx, NY (Mr. Mani, Ms. Kleinbart, Mr. Goldman, Ms. Golding); the Department of Neurological Surgery (Dr. Gelfand, Dr. Murthy, Dr. Yassari) and the Department of Orthopaedic Surgery (Dr. Eleswarapu, Dr. Fourman, Dr. Krystal), Montefiore Einstein, Bronx, NY
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Schönnagel L, Tani S, Vu-Han TL, Zhu J, Camino-Willhuber G, Dodo Y, Caffard T, Chiapparelli E, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Hughes AP, Sama AA. Predicting conversion of ambulatory ACDF patients to inpatient: a machine learning approach. Spine J 2024; 24:563-571. [PMID: 37980960 DOI: 10.1016/j.spinee.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/29/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND CONTEXT Machine learning is a powerful tool that has become increasingly important in the orthopedic field. Recently, several studies have reported that predictive models could provide new insights into patient risk factors and outcomes. Anterior cervical discectomy and fusion (ACDF) is a common operation that is performed as an outpatient procedure. However, some patients are required to convert to inpatient status and prolonged hospitalization due to their condition. Appropriate patient selection and identification of risk factors for conversion could provide benefits to patients and the use of medical resources. PURPOSE This study aimed to develop a machine-learning algorithm to identify risk factors associated with unplanned conversion from outpatient to inpatient status for ACDF patients. STUDY DESIGN/SETTING This is a machine-learning-based analysis using retrospectively collected data. PATIENT SAMPLE Patients who underwent one- or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021. OUTCOME MEASURES Length of stay, conversion rates from ambulatory setting to inpatient. METHODS Patients were divided into two groups based on length of stay: (1) Ambulatory (discharge within 24 hours) or Extended Stay (greater than 24 hours but fewer than 48 hours), and (2) Inpatient (greater than 48 hours). Factors included in the model were based on literature review and clinical expertise. Patient demographics, comorbidities, and intraoperative factors, such as surgery duration and time, were included. We compared the performance of different machine learning algorithms: Logistic Regression, Random Forest (RF), Support Vector Machine (SVM), and Extreme Gradient Boosting (XGBoost). We split the patient data into a training and validation dataset using a 70/30 split. The different models were trained in the training dataset using cross-validation. The performance was then tested in the unseen validation set. This step is important to detect overfitting. The performance was evaluated using the area under the curve (AUC) of the receiver operating characteristics analysis (ROC) as the primary outcome. An AUC of 0.7 was considered fair, 0.8 good, and 0.9 excellent, according to established cut-offs. RESULTS A total of 581 patients (59% female) were available for analysis. Of those, 140 (24.1%) were converted to inpatient status. The median age was 51 (IQR 44-59), and the median BMI was 28 kg/m2 (IQR 24-32). The XGBoost model showed the best performance with an AUC of 0.79. The most important features were the length of the operation, followed by sex (based on biological attributes), age, and operation start time. The logistic regression model and the SVM showed worse results, with an AUC of 0.71 each. CONCLUSIONS This study demonstrated a novel approach to predicting conversion to inpatient status in eligible patients for ambulatory surgery. The XGBoost model showed good predictive capabilities, superior to the older machine learning approaches. This model also revealed the importance of surgical duration time, BMI, and age as risk factors for patient conversion. A developing field of study is using machine learning in clinical decision-making. Our findings contribute to this field by demonstrating the feasibility and accuracy of such methods in predicting outcomes and identifying risk factors, although external and multi-center validation studies are needed.
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Affiliation(s)
- Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Soji Tani
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Tu-Lan Vu-Han
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jiaqi Zhu
- Biostatistics Core, Hospital for Special Surgery, 541 E. 71st Street, New York, NY 10021, USA
| | - Gaston Camino-Willhuber
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Department of Orthopedic Surgery, University of Ulm, Oberer Eselsberg 45, 89081 Ulm, Germany
| | - Erika Chiapparelli
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - William D Zelenty
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Federico P Girardi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alexander P Hughes
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Kirsch EP, Yang LZ, Lee HJ, Parente B, Lad SP. Healthcare resource utilization for chronic low back pain among high-utilizers. Spine J 2024; 24:601-616. [PMID: 38081464 DOI: 10.1016/j.spinee.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/26/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Chronic low back pain is a leading cause of morbidity and is among the largest cost drivers for the healthcare system. Research on healthcare resource utilization of patients with low back pain who are not surgical candidates is limited, and few studies follow individuals who generate high healthcare costs over time. PURPOSE This claims study aimed to identify patients with high-impact mechanical, chronic low back pain (CLBP), quantify their low back pain-related health resource utilization, and explore associated patient characteristics. We hypothesize that patients in the top quartile of healthcare resource utilization in the second year after initial diagnosis will continue to generate considerable back pain-related costs in subsequent years. STUDY DESIGN/SETTING IBM MarketScan Research Databases from 2009-2019 were retrospectively analyzed. PATIENT SAMPLE Adults in the United States with an initial diagnosis of low back pain between 2010 and 2014 who did not have cancer, spine surgery, recent pregnancy, or inflammatory spine conditions, were identified using the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. To ensure patients had chronic low back pain, it was required that individuals had additional claims with a low back pain diagnosis 6 to 12 and 12 to 24 months after initial diagnosis. OUTCOME MEASURES Cost and utilization of inpatient visits, outpatient visits, emergency room visits, pharmacologic and nonpharmacologic treatment options and imaging for chronic low back pain. METHODS Annual back pain-related costs and the use of pharmacologic and nonpharmacologic treatments for 5 years were analyzed. Logistic regression was utilized to identify factors associated with persistent high spending. RESULTS Of 16,917 individuals who met the criteria for chronic low back pain, 4,229 met the criteria for having high healthcare utilization, defined as being in the top quartile of back pain-related costs in the 12 to 24 months after their initial diagnosis. The mean and median back pain-related cost in the first year after an initial diagnosis was $7,112 (SD $9,670) and $4,405 (Q1 $2,147, Q3 $8,461). Mean and median back pain related costs in the second year were $11,989 (SD $20,316) and $5,935 (Q1 $3,892, Q3 $10,678). Costs continued to be incurred in years 3 to 5 at a reduced rate. The cumulative mean cost for back pain over the 5 years following the initial diagnosis was $31,459 (SD $39,545). The majority of costs were from outpatient services. Almost a quarter of the high utilizers remained in the top quartile of back pain-related costs during years 3 to 5 after the initial diagnosis, and another 19% remained in the top quartile for 2 of the 3 subsequent years. For these two groups combined (42%), the 5-year cumulative mean cost for back pain was $43,818 (SD $48,270). Patient characteristics associated with a higher likelihood of remaining as high utilizers were diabetes, having a greater number of outpatient visits and pharmacologic prescriptions, and lower utilization of imaging services. CONCLUSION This is one of the first studies to use an administrative claims database to identify high healthcare resource utilizers among a population of United States individuals with nonsurgical, chronic low back pain and follow their utilization over time. There was a population of individuals who continued to experience high costs 5 years beyond their initial diagnosis, and the majority of individuals continued to seek outpatient services. Further longitudinal claims research that incorporates symptom severity is needed to understand the economic implications of this condition.
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Affiliation(s)
- Elayna P Kirsch
- Department of Neurosurgery, Duke University Medical Center, 200 Trent Drive, Blue Zone Durham, NC 27710, USA
| | - Lexie Z Yang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, Suite 1102, Hock Plaza Box 2721, Durham, NC 27710, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, Suite 1102, Hock Plaza Box 2721, Durham, NC 27710, USA
| | - Beth Parente
- Department of Neurosurgery, Duke University Medical Center, 200 Trent Drive, Blue Zone Durham, NC 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, 200 Trent Drive, Blue Zone Durham, NC 27710, USA.
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Schwenk ES, Ferd P, Torjman MC, Li CJ, Charlton AR, Yan VZ, McCurdy MA, Kepler CK, Schroeder GD, Fleischman AN, Issa T. Intravenous versus oral acetaminophen for pain and quality of recovery after ambulatory spine surgery: a randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105386. [PMID: 38499358 DOI: 10.1136/rapm-2024-105386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/07/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION As ambulatory spine surgery increases, efficient recovery and discharge become essential. Multimodal analgesia is superior to opioids alone. Acetaminophen is a central component of multimodal protocols and both intravenous and oral forms are used. While some advantages for intravenous acetaminophen have been touted, prospective studies with patient-centered outcomes are lacking in ambulatory spine surgery. A substantial cost difference exists. We hypothesized that intravenous acetaminophen would be associated with fewer opioids and better recovery. METHODS Patients undergoing ambulatory spine surgery were randomized to preoperative oral placebo and intraoperative intravenous acetaminophen or preoperative oral acetaminophen. All patients received general anesthesia and multimodal analgesia. The primary outcome was 24-hour opioid use in intravenous morphine milligram equivalents (MMEs), beginning with arrival to the postanesthesia care unit (PACU). Secondary outcomes included pain, Quality of Recovery (QoR)-15 scores, postoperative nausea and vomiting, recovery time, and correlations between pain catastrophizing, QoR-15, and pain. RESULTS A total of 82 patients were included in final analyses. Demographics were similar between groups. For the primary outcome, the median 24-hour MMEs did not differ between groups (12.6 (4.0, 27.1) vs 12.0 (4.0, 29.5) mg, p=0.893). Postoperative pain ratings, PACU MMEs, QoR-15 scores, and recovery time showed no differences. Spearman's correlation showed a moderate negative correlation between postoperative opioid use and QoR-15. CONCLUSION Intravenous acetaminophen was not superior to the oral form in ambulatory spine surgery patients. This does not support routine use of the more expensive intravenous form to improve recovery and accelerate discharge. TRIAL REGISTRATION NUMBER NCT04574778.
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Affiliation(s)
- Eric S Schwenk
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Polina Ferd
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Marc C Torjman
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Chris J Li
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alex R Charlton
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vivian Z Yan
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael A McCurdy
- Orthopaedic Surgery, Rothman Orthopaedics, Philadelphia, Pennsylvania, USA
| | | | | | - Andrew N Fleischman
- Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tariq Issa
- Orthopaedic Surgery, Rothman Orthopaedics, Philadelphia, Pennsylvania, USA
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Subramanian T, Akosman I, Amen TB, Pajak A, Kumar N, Kaidi A, Araghi K, Shahi P, Asada T, Qureshi SA, Iyer S. Comparison of the Safety of Inpatient Versus Outpatient Lumbar Fusion : A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2024; 49:269-277. [PMID: 37767789 DOI: 10.1097/brs.0000000000004838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The objective of this study is to synthesize the early data regarding and analyze the safety profile of outpatient lumbar fusion. SUMMARY OF BACKGROUND DATA Performing lumbar fusion in an outpatient or ambulatory setting is becoming an increasingly employed strategy to provide effective value-based care. As this is an emerging option for surgeons to employ in their practices, the data is still in its infancy. METHODS This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that described outcomes of inpatient and outpatient lumbar fusion cohorts were searched from PubMed, Medline, The Cochrane Library, and Embase. Rates of individual medical and surgical complications, readmission, and reoperation were collected when applicable. Patient-reported outcomes (PROMs) were additionally collected if reported. Individual pooled comparative meta-analysis was performed for outcomes of medical complications, surgical complications, readmission, and reoperation. PROMs were reviewed and qualitatively reported. RESULTS The search yielded 14 publications that compared outpatient and inpatient cohorts with a total of 75,627 patients. Odds of readmission demonstrated no significant difference between outpatient and inpatient cohorts [OR=0.94 (0.81-1.11)]. Revision surgery similarly was no different between the cohorts [OR=0.81 (0.57-1.15)]. Pooled medical and surgical complications demonstrated significantly decreased odds for outpatient cohorts compared with inpatient cohorts [OR=0.58 (0.34-0.50), OR=0.41 (0.50-0.68), respectively]. PROM measures were largely the same between the cohorts when reported, with few studies showing better ODI and VAS Leg outcomes among outpatient cohorts compared with inpatient cohorts. CONCLUSION Preliminary data regarding the safety of outpatient lumbar fusion demonstrates a favorable safety profile in appropriately selected patients, with PROMs remaining comparable in this setting. There is no data in the form of prospective and randomized trials which is necessary to definitively change practice.
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Affiliation(s)
- Tejas Subramanian
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Izzet Akosman
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Troy B Amen
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Anthony Pajak
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Austin Kaidi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kasra Araghi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Pratyush Shahi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Tomoyuki Asada
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz A Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Sravisht Iyer
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
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Amen TB, Song J, Mai E, Rudisill SS, Bovonratwet P, Subramanian T, Kaidi AK, Maayan O, Qureshi SA, Iyer S. Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors. Spine J 2023; 23:1848-1857. [PMID: 37716549 DOI: 10.1016/j.spinee.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND CONTEXT Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern. PURPOSE This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database. OUTCOME MEASURES Hospital readmission within 30 postoperative days. METHODS Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission. RESULTS A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all). CONCLUSION This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA.
| | - Junho Song
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Eric Mai
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Samuel S Rudisill
- Rush Medical College, Rush University Medical Center, Chicago, IL, USA
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Tejas Subramanian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Austin K Kaidi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Omri Maayan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sheeraz A Qureshi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
| | - Sravisht Iyer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th St, New York, NY, USA
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Issa TZ, Lee Y, Lambrechts MJ, Mazmudar AS, D'Antonio ND, Iofredda P, Endersby K, Kalra A, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Assessment of a Private Payer Bundled Payment Model for Lumbar Decompression Surgery. J Am Acad Orthop Surg 2023; 31:e984-e993. [PMID: 37467396 DOI: 10.5435/jaaos-d-23-00384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy. METHODS A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit. RESULTS Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (β: $2,398, P = 0.012) and surgery in a specialty hospital (β: $1,729, P = 0.096) or ambulatory surgery center (β: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit. CONCLUSIONS Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals.
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Affiliation(s)
- Tariq Z Issa
- From the Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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11
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Tani S, Okano I, Dodo Y, Camino-Willhuber G, Caffard T, Schönnagel L, Chiapparelli E, Amoroso K, Tripathi V, Arzani A, Oezel L, Shue J, Zelenty WD, Lebl DR, Cammisa FP, Girardi FP, Hughes AP, Sokunbi G, Sama AA. Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients. Spine (Phila Pa 1976) 2023; 48:1427-1435. [PMID: 37389987 DOI: 10.1097/brs.0000000000004767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
STUDY DESIGN/SETTING A retrospective observational study. OBJECTIVE The aim of this study was to investigate the factors associated with the conversion of patient status from ambulatory anterior cervical discectomy and fusion (ACDF) to inpatient. SUMMARY OF BACKGROUND DATA Surgeries are increasingly performed in an ambulatory setting in an era of rising healthcare costs and pressure to improve patient satisfaction. ACDF is a common ambulatory cervical spine surgery, however, there are certain patients who are unexpectedly converted from an outpatient procedure to inpatient admission and little is known about the risk factors for conversion. MATERIALS AND METHODS Patients who underwent one-level or two-level ACDF in an ambulatory setting at a single specialized orthopedic hospital between February 2016 to December 2021 were included. Baseline demographics, surgical information, complications, and conversion reasons were compared between patients with ambulatory surgery or observational stay (stay <48 h) and inpatient (stay >48 h). RESULTS In total, 662 patients underwent one-level or two-level ACDF (median age, 52 yr; 59.5% were male), 494 (74.6%) patients were discharged within 48 hours and 168 (25.4%) patients converted to inpatient. Multivariable logistic regression analysis demonstrated that females, low body mass index <25, American Society of Anesthesiologists classification (ASA) ≥3, long operation, high estimated blood loss, upper-level surgery, two-level fusion, late operation start time, and high postoperative pain score were considered independent risk factors for conversion to inpatient. Pain management was the most common reason for the conversion (80.0%). Ten patients (1.5%) needed reintubation or remained intubated for airway management. CONCLUSIONS Several independent risk factors for prolonged hospital stay after ambulatory ACDF surgery were identified. Although some factors are unmodifiable, other factors, such as procedure duration, operation start time, and blood loss could be potential targets for intervention. Surgeons should be aware of the potential for life-threatening airway complications in ambulatory-scheduled ACDF.
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Affiliation(s)
- Soji Tani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Ichiro Okano
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Dodo
- Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | | | - Thomas Caffard
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, University of Ulm, Ulm, Germany
| | - Lukas Schönnagel
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Krizia Amoroso
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Vidushi Tripathi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Artine Arzani
- Spine Care Institute, Hospital for Special Surgery, New York, NY
- Weill Cornell Medicine, New York, NY
| | - Lisa Oezel
- Department of Orthopedic Surgery and Traumatology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Jennifer Shue
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | - Darren R Lebl
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | | | | | - Gbolabo Sokunbi
- Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Spine Care Institute, Hospital for Special Surgery, New York, NY
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12
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Schultz E, Zhuang T, Shapiro LM, Hu SS, Kamal RN. Is outpatient spine surgery associated with new, persistent opioid use in opioid-naïve patients? A retrospective national claims database analysis. Spine J 2023; 23:1451-1460. [PMID: 37355048 PMCID: PMC10538426 DOI: 10.1016/j.spinee.2023.06.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND CONTEXT Although spine procedures have historically been performed inpatient, there has been a recent shift to the outpatient setting for selected cases due to increased patient satisfaction and reduced cost. Effective postoperative pain management while limiting over-prescribing of opioids, which may lead to persistent opioid use, is critical to performing spine surgery in the outpatient setting. PURPOSE To assess if there is an increased risk for new, persistent opioid use between inpatient and outpatient spine procedures. STUDY DESIGN Retrospective analysis using national administrative claims database. PATIENT SAMPLE A total of 390,049 opioid-naïve patients with a perioperative opioid prescription who underwent an inpatient or outpatient spine surgery. OUTCOME MEASURES Patients with perioperative opioid prescriptions who filled ≥ 1 opioid prescription between 90- and 180-days following surgery were defined as new, persistent opioid users. METHODS We utilized a claims database to identify opioid-naïve patients who underwent lumbar or cervical fusion, total disc arthroplasty, or decompression procedures. We constructed a multivariable logistic regression to evaluate the association between inpatient versus outpatient surgery and the development of new, persistent opioid use while adjusting for several patient factors. RESULTS A total of 19,205 (11.7%) inpatient and 18,546 (8.2%) outpatient patients developed new, persistent opioid use. Outpatient lumbar and cervical spine surgery patients were significantly less likely to develop new, persistent opioid use following surgery compared to inpatient spine surgery patients (OR = 0.71 [95% confidence interval {CI}: 0.69, 0.73], p < .001). Average morphine milligram equivalents (MMEs) (inpatient = 1,476 MME +/- 22.7, outpatient = 1,072 MME +/- 18.5, p < .001) and average MMEs per day (inpatient = 91.6 MME +/- 0.32, outpatient = 77.7 MME +/- 0.28, p < .001) were lower in the outpatient cohort compared to the inpatient. CONCLUSION Our results support the shift from inpatient to outpatient spine procedures, as outpatient procedures were not associated with an increased risk for new, persistent opioid use. As more patients become candidates for outpatient spine surgery, predictors of new, persistent opioid use should be considered during risk stratification. LEVEL OF EVIDENCE Level III Prognostic Study. MINI ABSTRACT We utilized a national administrative claims database to identify opioid-naïve patients who underwent common spine procedures. Outpatient lumbar and cervical spine surgery patients were significantly less likely to be new, persistent opioid users following surgery compared to inpatient spine surgery patients. Our results support the shift to outpatient spine procedures.
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Affiliation(s)
- Emily Schultz
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California San Francisco
| | - Serena S Hu
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University.
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13
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Monk SH, Hani U, Pfortmiller D, Adamson TE, Bohl MA, Branch BC, Kim PK, Smith MD, Holland CM, McGirt MJ. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis. Neurosurgery 2023; 93:867-874. [PMID: 37067954 DOI: 10.1227/neu.0000000000002483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/09/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series. OBJECTIVE To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting. METHODS A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed. RESULTS There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery. CONCLUSION In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Ummey Hani
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Michael A Bohl
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
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14
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Amen TB, Chatterjee A, Dekhne M, Rudisill SS, Subramanian T, Song J, Kazarian GS, Morse KW, Iyer S, Qureshi S. Improving Racial and Ethnic Disparities in Outpatient Anterior Cervical Discectomy and Fusion Driven by Increasing Utilization of Ambulatory Surgical Centers in New York State. Spine (Phila Pa 1976) 2023; 48:1282-1288. [PMID: 37249380 DOI: 10.1097/brs.0000000000004736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/12/2023] [Indexed: 05/31/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The purpose of this study was to assess trends in disparities in utilization of hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for outpatient ACDF (OP-ACDF) between White, Black, Hispanic, and Asian/Pacific Islander patients from 2015 to 2018 in New York State. SUMMARY OF BACKGROUND DATA Racial and ethnic disparities within the field of spine surgery have been thoroughly documented. To date, it remains unknown how these disparities have evolved in the outpatient setting alongside the rapid emergence of ASCs and whether restrictive patterns of access to these outpatient centers exist by race and ethnicity. MATERIALS AND METHODS We conducted a retrospective review from 2015 to 2018 using the Healthcare Cost and Utilization Project (HCUP) New York State Ambulatory Database. Differences in utilization rates for OP-ACDF were assessed and trended over time by race and ethnicity for both HOPDs and freestanding ASCs. Poisson regression was used to evaluate the association between utilization rates for OP-ACDF and race/ethnicity. RESULTS Between 2015 and 2018, Black, Hispanic, and Asian patients were less likely to undergo OP-ACDF compared with White patients in New York State. However, the magnitude of these disparities lessened over time, as Black, Hispanic, and Asian patients had greater relative increases in utilization of HOPDs and ASCs for ACDF when compared with White patients ( Ptrend <0.001). The magnitude of the increase in freestanding ASC utilization was such that minority patients had higher ACDF utilization rates in freestanding ASCs by 2018 ( P <0.001). CONCLUSIONS We found evidence of improving racial disparities in the relative utilization of outpatient ACDF in New York State. The increase in access to outpatient ACDF appeared to be driven by an increasing number of patients undergoing ACDF in freestanding ASCs in large metropolitan areas. These improving disparities are encouraging and contrast previously documented inequalities in inpatient spine surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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15
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Monk SH, Hani U, Pfortmiller D, Dyer EH, Smith MD, Kim PK, Bohl MA, Coric D, Adamson TE, Holland CM, McGirt MJ. Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis. Neurosurgery 2023; 93:628-635. [PMID: 36995083 DOI: 10.1227/neu.0000000000002464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/26/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking. OBJECTIVE To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up. METHODS A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility. CONCLUSION Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Ummey Hani
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - E Hunter Dyer
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Michael A Bohl
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Domagoj Coric
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte , North Carolina , USA
- SpineFirst, Atrium Health, Charlotte , North Carolina , USA
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Canseco JA, Karamian BA, Lambrechts MJ, Issa TZ, Conaway W, Minetos PD, Bowles D, Alexander T, Sherman M, Schroeder GD, Hilibrand AS, Vaccaro AR, Kepler CK. Risk stratification of patients undergoing outpatient lumbar decompression surgery. Spine J 2023; 23:675-684. [PMID: 36642254 DOI: 10.1016/j.spinee.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND CONTEXT Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSE To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTING Retrospective single-institution cohort. PATIENT SAMPLE A total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURES Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODS Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTS A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.
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Affiliation(s)
- Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Brian A Karamian
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - William Conaway
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Paul D Minetos
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Daniel Bowles
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Tyler Alexander
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Monk SH, Zeitouni D, Cowan D, Rossi VJ, Parish JM, Dyer EH, Smith MD, Kim PK, Adamson TE. Feasibility and Safety of Microendoscopic Posterior Cervical Foraminotomy in an Ambulatory Surgery Center: A Longitudinal Experience with 1000 Cases. World Neurosurg 2023; 173:e228-e233. [PMID: 36787856 DOI: 10.1016/j.wneu.2023.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/14/2023]
Abstract
OBJECTIVE Ambulatory surgery centers (ASCs) have become an increasingly attractive setting for spine surgery in recent decades. Although posterior cervical foraminotomy (PCF) is widely performed in ASCs, there are no studies supporting the safety of this practice. We aimed to demonstrate the feasibility and safety of microendoscopic (MED)-PCF in a large cohort of patients at a freestanding ASC. METHODS Consecutive patients undergoing MED-PCF for unilateral cervical radiculopathy at a single freestanding ASC from January 2013 to December 2020 were queried. Standard demographic and perioperative data were collected. Outcomes included need for inpatient transfer, perioperative complications, 30-day readmission, 30-day reoperation, and clinical improvement according to the Odom criteria. RESULTS A total of 1106 patients underwent MED-PCF during the study period. Mean age was 53.3 ± 10.3 years. Most patients underwent decompression at C5-6 (31.4%) or C6-7 (51.9%). Approximately 10% underwent surgery at multiple levels. Mean operative time was 40.0 ± 16.4 minutes. There were no intraoperative or immediate postoperative complications. All patients were discharged home within a few hours of surgery. The rates of 30-day readmission (0.81%) and reoperation (0.36%) were exceedingly low. Nearly 3 quarters of patients (73.7%) achieved a good or excellent clinical outcome (73.7%) according to the Odom criteria. CONCLUSIONS MED-PCF can be performed in a freestanding ASC with exceedingly low rates of perioperative complications and short-term readmission or reoperation. Our findings support the ongoing migration of PCF from the hospital to the ambulatory setting. Future studies assessing patient-reported outcomes and long-term reoperation rates are necessary.
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Affiliation(s)
- Steve H Monk
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA.
| | - Daniel Zeitouni
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - David Cowan
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Vincent J Rossi
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Jonathan M Parish
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - E Hunter Dyer
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Mark D Smith
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Paul K Kim
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Atrium Health Neurological Surgery, Charlotte, North Carolina, USA; Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
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Jones J, Malik AT, Khan SN, Yu E, Kim J. Is Outpatient Anterior Lumbar Fusion (ALIF) Safe? An Analysis of 30-day Outcomes. Clin Spine Surg 2023; 36:E114-E117. [PMID: 36210499 DOI: 10.1097/bsd.0000000000001402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 08/24/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Review of publicly available database. OBJECTIVE To compare 30-day outcomes of single-level ALIF procedures performed in outpatient and inpatient settings. SUMMARY OF BACKGROUND DATA Despite a growing interest in performing standalone anterior lumbar interbody fusions (ALIFs) as an outpatient procedure, no study has evaluated the safety or efficacy of this procedure outside an inpatient setting. METHODS The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was queried using CPT code 22558 to identify patients undergoing a single-level ALIF. Patients receiving concurrent posterior lumbar surgery/fusion/instrumentation, pelvic fixation, or surgery due to tumor, trauma and/or deformity were excluded to capture an isolated cohort of patients receiving single-level standalone ALIFs. A total of 3728 single-level standalone ALIFs were included in the study. Multivariate regression analyses were used to compare 30-day adverse events and readmissions while controlling for baseline clinical characteristics. RESULTS Out of a total of 3728 ALIFs, 149 (4.0%) were performed as outpatient procedure. Following adjustment, outpatient ALIFs versus inpatient ALIFs had lower odds of experiencing any 30-day adverse event (2.0% vs. 9.2%, OR 0.24 [95% CI 0.08-0.76]; P =0.015). No significant differences were noted with regard to severe adverse events 9p=0.261), minor adverse events 9p=0.995), and readmission rates ( P =0.95). CONCLUSION On the basis of the results of the study, it appears that ALIFs may be carried out safely in an outpatient setting in an appropriately selected patient population.
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Affiliation(s)
- Jeremy Jones
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, OH
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Monk SH, Rossi VJ, Atkins TG, Karimian B, Pfortmiller D, Kim PK, Adamson TE, Smith MD, McGirt MJ, Holland CM, Deshmukh VR, Branch BC. Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol. World Neurosurg 2023; 171:e471-e477. [PMID: 36526224 DOI: 10.1016/j.wneu.2022.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Vincent J Rossi
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tyler G Atkins
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Brandon Karimian
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA
| | - Deborah Pfortmiller
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Tim E Adamson
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Mark D Smith
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Matthew J McGirt
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Christopher M Holland
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Vinay R Deshmukh
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Byron C Branch
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
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Ambulatory Lumbar Fusion: A Systematic Review of Perioperative Protocols, Patient Selection Criteria, and Outcomes. Spine (Phila Pa 1976) 2023; 48:278-287. [PMID: 36692157 DOI: 10.1097/brs.0000000000004519] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN/SETTING Systematic review. OBJECTIVE The primary purpose was to propose patient selection criteria and perioperative best practices that can serve as a starting point for an ambulatory lumbar fusion program. The secondary purpose was to review patient-reported outcomes (PROs) after ambulatory lumbar fusion. SUMMARY OF BACKGROUND As healthcare costs rise, there is an increasing emphasis on cost saving strategies (i.e. outpatient/ambulatory surgeries). Lumbar fusion procedures remain a largely inpatient surgery. Early studies have shown that fusion procedures can be safely preformed in an outpatient setting but no review has summarized these findings and best practices. MATERIALS AND METHODS This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed/MEDLINE, The Cochrane Library, and Embase were searched. The following data were collected: (1) study design; (2) number of participants; (3) patient population; (4) procedure types; (5) procedure setting; (6) inclusion criteria; (7) protocols; (8) adverse events; (9) PROs; and (10) associations between patient/surgical factors, setting, and outcomes. RESULTS The search yielded 20 publications. The following selection criteria for ambulatory lumbar fusion were identified: age below 70, minimal comorbidities, low/normal body mass index, no tobacco use, and no opioid use. The perioperative protocol can include a multimodal analgesic regimen. The patient should be observed for at least three hours after surgery. The patient should not be discharged without an alertness check and a neurological examination. Patients experienced significant improvements in PROs after ambulatory lumbar fusion; similarly, when compared to an inpatient group, ambulatory lumbar fusion patients experienced a comparable or superior improvement in PROs. CONCLUSION There are two critical issues surrounding ambulatory lumbar fusion: (1) Who is the ideal patient, and (2) What needs to be done to enable expedited discharge? We believe this review will provide a foundation to assist surgeons in making decisions regarding the performance of lumbar fusion on an ambulatory basis. LEVEL OF EVIDENCE Level III.
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21
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Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis. Spine (Phila Pa 1976) 2023; 48:155-163. [PMID: 36607626 DOI: 10.1097/brs.0000000000004500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up. SUMMARY OF BACKGROUND DATA Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness. MATERIALS AND METHODS A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. RESULTS Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility. CONCLUSION Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.
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Monk SH, O'Brien M, Bernard JD, Kim PK. Is Thoracic Paddle Lead Spinal Cord Stimulator Implantation Safe in an Ambulatory Surgery Center? World Neurosurg 2023; 170:e436-e440. [PMID: 36379362 DOI: 10.1016/j.wneu.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Spinal cord stimulation is an effective treatment modality for chronic pain. Although percutaneous leads are commonly placed in the outpatient setting, paddle leads are typically implanted in the inpatient setting. Given the substantial cost savings associated with the ambulatory setting, we aimed to demonstrate the feasibility and safety of thoracic paddle lead implantation in a freestanding ambulatory surgery center (ASC). METHODS Consecutive patients undergoing thoracic paddle lead implantation at a single freestanding ASC from January 2015 to December 2020 were queried. Demographic, perioperative, and outcome data were collected. Primary outcomes were incidence of intraoperative or immediate postoperative complications and need for inpatient transfer. Secondary outcomes included readmission at 30 and 90 days and reoperation at 30 days, 90 days, and 1 year. RESULTS A total of 46 patients underwent ambulatory thoracic paddle lead implantation over the study period. Two patients (4.3%) suffered an immediate postoperative complication requiring return to surgery at the ASC-one for an epidural hematoma, and one for a flank hematoma. All but one patient (97.8%) were discharged home on the day of surgery. The overall 30- and 90-day readmission rates were 4.3% and 6.5%, respectively. One patient (2.2%) required reoperation for a mechanical complication. No device-related infections were noted during the follow-up period. CONCLUSIONS Thoracic laminotomy for paddle lead spinal cord stimulator implantation can be performed in a freestanding ASC with complication rates comparable to the hospital setting. Future comparative studies that assess clinical outcomes and cost are necessary to determine the cost-effectiveness of the ambulatory setting.
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Affiliation(s)
- Steve H Monk
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA.
| | - Matthew O'Brien
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; University of South Carolina School of Medicine - Columbia, Columbia, South Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
| | - Paul K Kim
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina, USA; SpineFirst, Atrium Health, Charlotte, North Carolina, USA
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Postoperative Pain Management Following Orthopedic Spine Procedures and Consequent Acute Opioid Poisoning: An Analysis of New York State From 2009 to 2018. Spine (Phila Pa 1976) 2022; 47:1270-1278. [PMID: 35867612 DOI: 10.1097/brs.0000000000004395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Considering the high rates of opioid usage following orthopedic surgeries, it is important to explore this in the setting of the current opioid epidemic. This study examined acute opioid poisonings in postoperative spine surgery patients in New York and the rates of poisonings among these patients in the context of New York's 2016 State legislation limiting opioid prescriptions. METHODS Claims for adult patients who received specific orthopedic spine procedures in the outpatient setting were identified from 2009 to 2018 in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were followed to determine if they presented to the emergency department for acute opioid poisoning postoperatively. Multivariable logistic regression was performed to evaluate the effect of patient demographic factors on the likelihood of poisoning. The impact of the 2016 New York State Public Health Law Section 3331, 5. (b), (c) limiting opioid analgesic prescriptions was also evaluated by comparing rates of poisoning prelegislation and postlegislation enactment. RESULTS A total of 107,456 spine patients were identified and 321 (0.3%) presented postoperatively to the emergency department with acute opioid poisoning. Increased age [odds ratio (OR)=0.954, P <0.0001] had a decreased likelihood of poisoning. Other race (OR=1.322, P =0.0167), Medicaid (OR=2.079, P <0.0001), Medicare (OR=2.9, P <0.0001), comorbidities (OR=3.271, P <0.0001), and undergoing multiple spine procedures during a single operative setting (OR=1.993, P <0.0001) had an increased likelihood of poisoning. There was also a significant reduction in rates of postoperative acute opioid poisoning in patients receiving procedures postlegislation with reduced overall likelihood (OR=0.28, P <0.0001). CONCLUSION There is a higher than national average rate of acute opioid poisonings following spine procedures and increased risk among those with certain socioeconomic factors. Rates of poisonings decreased following a 2016 legislation limiting opioid prescriptions. It is important to define factors that may increase the risk of postoperative opioid poisoning to promote appropriate management of postsurgical pain.
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Chatterjee A, Rbil N, Yancey M, Geiselmann MT, Pesante B, Khormaee S. Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 11:100132. [PMID: 35783006 PMCID: PMC9243295 DOI: 10.1016/j.xnsj.2022.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Nada Rbil
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Michael Yancey
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Matthew T. Geiselmann
- New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Benjamin Pesante
- The University of Connecticut School of Medicine, Farmington, CT, United States
| | - Sariah Khormaee
- Weill Cornell Medical College, New York, NY, United States
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
- Corresponding author: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this review is to present an overview of robotic spine surgery (RSS) including its history, applications, limitations, and future directions. SUMMARY OF BACKGROUND DATA The first RSS platform received United States Food and Drug Administration approval in 2004. Since then, robotic-assisted placement of thoracolumbar pedicle screws has been extensively studied. More recently, expanded applications of RSS have been introduced and evaluated. METHODS A systematic search of the Cochrane, OVID-MEDLINE, and PubMed databases was performed for articles relevant to robotic spine surgery. Institutional review board approval was not needed. RESULTS The placement of thoracolumbar pedicle screws using RSS is safe and accurate and results in reduced radiation exposure for the surgeon and surgical team. Barriers to utilization exist including learning curve and large capital costs. Additional applications involving minimally invasive techniques, cervical pedicle screws, and deformity correction have emerged. CONCLUSION Interest in RSS continues to grow as the applications advance in parallel with image guidance systems and minimally invasive techniques. IRB APPROVAL N/A.
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Katz AD, Song J, Ngan A, Job A, Morris M, Perfetti D, Virk S, Silber J, Essig D. Discharge to Rehabilitation Predicts Increased Morbidity in Patients Undergoing Posterior Cervical Decompression and Fusion. Clin Spine Surg 2022; 35:129-136. [PMID: 35383605 DOI: 10.1097/bsd.0000000000001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim was to compare 30-day readmission and postdischarge morbidity for posterior cervical decompression and fusion (PCDF) in patients who were discharged to home versus rehabilitation. SUMMARY OF BACKGROUND DATA An increasing number of patients are being discharged to postacute inpatient care facilities following spine surgery. However, little research has been performed to evaluate the effect of this trend on short-term outcomes. MATERIALS AND METHODS Patients who underwent PCDF from 2011 to 2018 were identified using the National Surgical Quality Improvements Program (NSQIP)-database. Regression was utilized to compare primary outcomes between home and rehabilitation groups and to control for predictors of outcomes. RESULTS We identified 8912 patients. Unadjusted analysis revealed that rehabilitation-discharge patients had greater readmission (10.4% vs. 8.0%, P=0.002) and postdischarge morbidity (7.1% vs. 4.0%, P<0.001) rates. After controlling for patient-related factors, rehabilitation-discharge independently predicted postdischarge morbidity (P<0.001, odds ratio=2.232). Readmission no longer differed between groups (P=0.071, odds ratio=1.311). Rates of discharge to rehabilitation increased from 23.5% in 2011 to 25.3% in 2018, while postdischarge morbidity rates remained stagnant.Patients discharged to rehabilitation were older (66.9 vs. 59.4 y); more likely to be African American (21.4% vs. 13.8%) and have diabetes (27.1% vs. 17.5%), steroid use (6.4% vs. 4.7%, P=0.002), and American Society of Anaesthesiologists (ASA)-class ≥3 (80.2% vs. 57.7%); less likely to be male (53.9% vs. 57.4%, P=0.004) and smokers (20.3% vs. 26.6%); and had greater operative time (198 vs. 170 min) and length of hospital stay (5.9 vs. 3.3 d) (P<0.001). CONCLUSIONS Despite controlling for significant factors, discharge to rehabilitation independently predicted a 2.2 times increased odds of postdischarge morbidity. Rates of discharge to rehabilitation increased overtime without an appreciable decrease in postdischarge morbidity, suggesting that greater resources are being utilized in the postacute care period without an obvious justification. Therefore, home-discharge should be prioritized after hospitalization for PCDF when feasible. These findings are notable in light of reform efforts aimed at reducing costs while improving quality of care.
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Affiliation(s)
- Austen D Katz
- Department of Orthopedic Surgery, North Shore University Hospital-Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY
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Bovonratwet P, Retzky JS, Chen AZ, Ondeck NT, Samuel AM, Qureshi SA, Grauer JN, Albert TJ. Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates. Clin Spine Surg 2022; 35:E306-E313. [PMID: 34654773 DOI: 10.1097/bsd.0000000000001252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective cohort comparison study. OBJECTIVE The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF. MATERIALS AND METHODS Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups. RESULTS In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%). CONCLUSIONS The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Julia S Retzky
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | | | | | - Andre M Samuel
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | | | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Todd J Albert
- Department of Orthopaedic Surgery, Hospital for Special Surgery
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Greenberg JK, Brown DS, Olsen MA, Ray WZ. Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care. J Neurosurg Spine 2022; 36:336-344. [PMID: 34560659 PMCID: PMC8942868 DOI: 10.3171/2021.3.spine2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States. METHODS This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery. RESULTS The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups. CONCLUSIONS Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Derek S. Brown
- Brown School, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Margaret A. Olsen
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Wilson Z. Ray
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
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Reimbursement of Lumbar Decompression at an Orthopedic Specialty Hospital Versus Tertiary Referral Center. Spine (Phila Pa 1976) 2021; 46:1581-1587. [PMID: 34714795 DOI: 10.1097/brs.0000000000004067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the differences in Medicare reimbursement for one- to three-level lumbar decompression procedures performed at a tertiary referral center versus an orthopedic specialty hospital (OSH). SUMMARY OF BACKGROUND DATA Lumbar decompression surgery is one of the most commonly performed spinal procedures. Lumbar decompression also comprises the largest proportion of spinal surgery that has transitioned to the outpatient setting. METHODS Patients who underwent a primary one- to three- level lumbar decompression were retrospectively identified. Reimbursement data for a tertiary referral center and an OSH were compiled through Centers for Medicare and Medicaid Services. Demographic data, surgical characteristics, and time cost data were collected through chart review. Multivariate regression models were used to determine independent factors associated with total episode of care cost, operating room (OR) time, procedure time, and length of stay (LOS), and to determine independent predictors of having the decompression performed at the OSH. RESULTS Total episode of care, facility, and non-facility payments were significantly greater at the tertiary referral center than the OSH, as were OR time for one- to three-level procedures, procedure time of all pooled levels, and LOS for one- and two-level procedures. Three-level procedure was independently associated with increased OR time, procedure time, and LOS. Age and two-level procedure were also associated with increased LOS. Procedure at the OSH was associated with decreased OR time and LOS. Charlson Comorbidity Index was a negative predictor of decompression being performed in the OSH setting. CONCLUSION Significant financial savings to health systems can be expected when performing lumbar decompression surgery at a specialty hospital as opposed to a tertiary referral center. Patients who are appropriate candidates for surgery in an OSH can in turn expect faster perioperative times and shorter LOS.Level of Evidence: 3.
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Zale AD, Song CI, Zhou A, Lai J, Jang M, Lipsett PA, Desai SV, Hanyok LA, Bienstock JL. A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers. JOURNAL OF SURGICAL EDUCATION 2021; 78:1825-1837. [PMID: 34092534 DOI: 10.1016/j.jsurg.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs. DESIGN Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation. SETTING Interviews were conducted using a video conferencing platform. PARTICIPANTS Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments. RESULTS Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured. CONCLUSIONS Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.
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Affiliation(s)
- Andrew D Zale
- Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Ashley Zhou
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan Lai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Minyoung Jang
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela A Lipsett
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sanjay V Desai
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura A Hanyok
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Young S, Pollard RJ, Shapiro FE. Pushing the Envelope: New Patients, Procedures, and Personal Protective Equipment in the Ambulatory Surgical Center for the COVID-19 Era. Adv Anesth 2021; 39:97-112. [PMID: 34715983 PMCID: PMC8313519 DOI: 10.1016/j.aan.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Steven Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Richard J Pollard
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 300 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School
| | - Fred E Shapiro
- Harvard Medical School; Department of Anesthesia, Mass Eye and Ear Infirmary, 243 Charles Street, Suite 712, Boston, MA 02114, USA.
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A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion. J Am Acad Orthop Surg 2021; 29:758-766. [PMID: 33428349 DOI: 10.5435/jaaos-d-20-00894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 12/07/2020] [Indexed: 02/01/2023] Open
Abstract
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.
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Lopez CD, Boddapati V, Schweppe EA, Levine WN, Lehman RA, Lenke LG. Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers. J Bone Joint Surg Am 2021; 103:1383-1391. [PMID: 33780398 DOI: 10.2106/jbjs.20.01105] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.
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Affiliation(s)
- Cesar D Lopez
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York, NY
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34
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Epstein N. Perspective on morbidity and mortality of cervical surgery performed in outpatient/same day/ambulatory surgicenters versus inpatient facilities. Surg Neurol Int 2021; 12:349. [PMID: 34345489 PMCID: PMC8326133 DOI: 10.25259/sni_509_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background: This is an updated analysis of the morbidity and mortality of cervical surgery performed in outpatient/same day (OSD) (Postoperative care unit [PACU] observation 4–6 h), and ambulatory surgicenters (ASC: PACU 23 h) versus inpatient facilities (IF). Methods: We analyzed 19 predominantly level III (retrospective) and IV (case series) studies regarding the morbidity/mortality of cervical surgery performed in OSC/ASC versus IF. Results: A “selection bias” clearly favored operating on younger/healthier patients to undergo cervical surgery in OSD/ASC centers resulting in better outcomes. Alternatively, those selected for cervical procedures to be performed in IF classically demonstrated multiple major comorbidities (i.e. advanced age, diabetes, high body mass index, severe myelopathy, smoking, 3–4 level disease, and other comorbidities) and had poorer outcomes. Further, within the typical 4–6 h. PACU “observation window,” OSD facilities “picked up” most major postoperative complications, and typically showed 0% mortality rates. Nevertheless, the author’s review of 2 wrongful death suits (i.e. prior to 2018) arising from OSD ACDF cervical surgery demonstrated that there are probably many more mortalities occurring following discharges from OSD where cervical operations are being performed that are going underreported/unreported. Conclusion: “Selection bias” favors choosing younger/healthier patients to undergoing cervical surgery in OSD/ ASC facilities resulting in better outcomes. Atlernatively, choosing older patients with greater comorbidities for IF surgery correlated with poorer results. Although most OSD cervical series report 0% mortality rates, a review of 2 wrongful death suits by just one neurosurgeon prior to 2018 showed there are probably many more mortalities resulting from OSD cervical surgery than have been reported.
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Affiliation(s)
- Nancy Epstein
- Clinical Prof. of Neurosurgery, School of Medicine, State University of New York at Stony Brook, NY, and c/o Dr. Marc Aglulnick, 1122 Franklin Avenue Suite 106, Garden City, NY, USA
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Katz AD, Perfetti DC, Job A, Willinger M, Goldstein J, Kiridly D, Olivares P, Satin A, Essig D. Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity Between Lumbar Disc Arthroplasty Performed in the Inpatient and Outpatient Settings Utilizing the ACS-NSQIP Dataset. Global Spine J 2021; 11:640-648. [PMID: 32734775 PMCID: PMC8165934 DOI: 10.1177/2192568220941458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings. METHODS Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof. RESULTS We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly (P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes (P < .001, OR = 7.365), baseline dyspnea (P = .039, OR = 6.447), and increased platelet count (P = .048, OR = 1.007) predicted readmission. Diabetes (P = .016, OR = 6.533) and baseline dyspnea (P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea (P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 (P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit (P = .008) and increased operative time (P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis. CONCLUSIONS Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.
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Affiliation(s)
- Austen David Katz
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA,Austen Katz, Department of Orthopedic Surgery, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040, USA.
| | - Dean Cosmo Perfetti
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | - Alan Job
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | - Max Willinger
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | - Jeffrey Goldstein
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | - Daniel Kiridly
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | - Peter Olivares
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
| | | | - David Essig
- North Shore University Hospital–Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra University, New Hyde Park, NY, USA
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Beschloss A, Ishmael T, Dicindio C, Hendow C, Ha A, Louie P, Lombardi J, Pugely A, Ozturk A, Arlet V, Saifi C. The Expanding Frontier of Outpatient Spine Surgery. Int J Spine Surg 2021; 15:266-273. [PMID: 33900984 DOI: 10.14444/8036] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In 2014, inpatient spinal fusion surgery had the highest aggregate cost of any inpatient surgery performed in the United States, costing 12 billion dollars. As the national health care system seeks to improve value-based care, there is increased motivation to perform surgery on an outpatient basis. To ensure improved patient outcomes with this transition, patient selection has become increasingly important to identify who would most benefit from outpatient spine fusion, for example. This demands an improved understanding of the demographics of patients who have been receiving outpatient spine fusion on which the spine surgery community can build to improve cost-effective care delivered. METHODS The Healthcare Cost and Utilization Project, State Ambulatory Surgery Databases, and Agency for Healthcare Research and Quality databases were queried for demographic data regarding all-cause outpatient spine surgery between 2012 and 2014. Outpatient surgery volume was compared with inpatient surgery volume-which was provided by the State Inpatient Databases. RESULTS A total of 1,164,040 spine fusion procedures were identified between 2012 and 2014, of which 132,900 procedures were performed as outpatient surgery (11.4%). Of all fusion procedures amongst 18- to 44-year-old patients, 18.4% were outpatient. A larger proportion of white patients, rather than black or Hispanic patients, underwent ambulatory procedures (12.14% vs 9.53% vs 7.46%, respectively); 16.54% of spinal fusion procedures for patients with private insurance was performed on an outpatient basis. Based on patient income, 76% of all outpatient fusions were performed on patients who live in "not low" income ZIP codes. CONCLUSIONS There has been a gradual trend toward performing more outpatient spinal fusion procedures over the studied period. This study has also revealed unique trends in the demographics of patients who have received outpatient spine fusion during this time. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Alex Beschloss
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Terrance Ishmael
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Christina Dicindio
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Chelsea Hendow
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Alex Ha
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, New York
| | - Philip Louie
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Joseph Lombardi
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital at New York-Presbyterian, New York, New York
| | - Andrew Pugely
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Ali Ozturk
- Department of Neurological Surgery, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Vincent Arlet
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
| | - Comron Saifi
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, The Spine Center at Pennsylvania Hospital, University of Pennsylvania Hospital System, Philadelphia, Pennsylvania
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Elsharydah A, Duncan KL, Rosero EB, Minhajuddin A, Somasundaram A, Joshi GP. Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings. Clin Spine Surg 2021; 34:E1-E6. [PMID: 32341325 DOI: 10.1097/bsd.0000000000000990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/25/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015. OBJECTIVE Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings. SUMMARY OF BACKGROUND DATA In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge. METHODS The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients. RESULTS A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002). CONCLUSIONS After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | | | - Abu Minhajuddin
- Clinical Sciences, University of Texas Southwestern Medical Center
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Harris A, Guadix SW, Riley LH, Jain A, Kebaish KM, Skolasky RL. Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014. Spine J 2021; 21:64-70. [PMID: 32768655 DOI: 10.1016/j.spinee.2020.07.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/19/2020] [Accepted: 07/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients. PURPOSE To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA. STUDY DESIGN Retrospective analysis. PATIENT SAMPLE Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014. OUTCOME MEASURES Racial disparities in discharge rates before versus after ACA passage. METHODS Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders. RESULTS All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001). CONCLUSION Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.
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Affiliation(s)
- Andrew Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Sergio W Guadix
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Lee H Riley
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA; Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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Lopez CD, Boddapati V, Lombardi JM, Sardar ZM, Dyrszka MD, Lehman RA, Riew KD. Recent trends in medicare utilization and reimbursement for anterior cervical discectomy and fusion. Spine J 2020; 20:1737-1743. [PMID: 32562771 DOI: 10.1016/j.spinee.2020.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure. PURPOSE This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates. STUDY DESIGN/SETTING Retrospective analysis of patients undergoing ACDF PATIENT SAMPLE: Medicare patients undergoing ACDF between 2012 and 2017 OUTCOME MEASURES: ACDF volume, utilization rates, and surgeon/hospital reimbursement rates METHODS: This study tracked annual Medicare claims and payments to ACDF surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates. RESULTS A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001). CONCLUSIONS While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.
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Affiliation(s)
- Cesar D Lopez
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY.
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Zeeshan M Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Marc D Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - K Daniel Riew
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Health Care Resource Utilization and Management of Chronic, Refractory Low Back Pain in the United States. Spine (Phila Pa 1976) 2020; 45:E1333-E1341. [PMID: 32453242 PMCID: PMC8875812 DOI: 10.1097/brs.0000000000003572] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN: Retrospective analysis of inpatient and outpatient medical insurance claims data from a database containing over 100 million individuals. OBJECTIVE: To quantify the healthcare resource utilization (HCRU) of non-surgical treatments in the first 2 years after a chronic, refractory low back pain (CRLBP) diagnosis. SUMMARY OF BACKGROUND DATA: Patients with persistent low back pain (LBP) despite conventional medical management and who are not candidates for spine surgery are considered to have chronic, refractory low back pain (CRLBP) and incur substantial healthcare costs over time. Few data exist on the HCRU of this specific population. METHODS: The IBM MarketScan Research databases from 2009 to 2016 were retrospectively analyzed to identify US adults with a diagnosis of non-specific LBP and without cancer, spine surgery, failed back surgery syndrome, or recent pregnancy. We required >30 days of utilization of pain medications or non-pharmacologic therapies within both the 3–12- and 12–24-month periods post-diagnosis. Annual total healthcare costs, costs subdivided by insurance type, and use of non-surgical therapies were determined for 2 years after diagnosis of LBP. RESULTS: 55,945 patients with CRLBP were identified. Median total cost was $6,590 (Q1 $2,710, Q3 $13,922) in the first year, almost doubling the baseline cost; costs were highest for patients with Medicare Supplemental insurance, reaching $10,156 (Q1 $5,481, Q3 $18,570). 33,664 (60.2%) patients engaged physical therapy, 28,016 (50.1%) engaged chiropractors, and 14,488 (25.9%) had steroid injections. 36,729 (65.7%) patients used prescription pain medications, most commonly opioids (N=31,628, 56.5%) and muscle relaxants (N=21,267, 38.0%). CONCLUSION: This study is one of the first to investigate the HCRU of a large, longitudinal US cohort of patients with CRLBP. These patients experience substantial healthcare costs. Contrary to LBP management guidelines, most patients used opioids, and several non-pharmacologic therapies were used by only a few patients.
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Lopez CD, Boddapati V, Lombardi JM, Lee NJ, Saifi C, Dyrszka MD, Sardar ZM, Lenke LG, Lehman RA. Recent trends in medicare utilization and reimbursement for lumbar spine fusion and discectomy procedures. Spine J 2020; 20:1586-1594. [PMID: 32534133 DOI: 10.1016/j.spinee.2020.05.558] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements. PURPOSE This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017. STUDY DESIGN Retrospective database study. PATIENT SAMPLE Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files. OUTCOME MEASURES Procedure numbers and payments per episode. METHODS This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements. RESULTS A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, -5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, -0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%). CONCLUSIONS This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries.
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Affiliation(s)
- Cesar D Lopez
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Venkat Boddapati
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA.
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Nathan J Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Comron Saifi
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Marc D Dyrszka
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Zeeshan M Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Lawrence G Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Irving Medical Center, 622 W. 168th St. PH-11, New York, NY 10032, USA
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Lombardi JM, Bottiglieri T, Desai N, Riew KD, Boddapati V, Weller M, Bourgois C, McChrystal S, Lehman RA. Addressing a national crisis: the spine hospital and department's response to the COVID-19 pandemic in New York City. Spine J 2020; 20:1367-1378. [PMID: 32492529 PMCID: PMC7261362 DOI: 10.1016/j.spinee.2020.05.539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/29/2020] [Accepted: 05/18/2020] [Indexed: 02/03/2023]
Abstract
In a very brief period, the COVID-19 pandemic has swept across the planet leaving governments, societies, and healthcare systems unprepared and under-resourced. New York City now represents the global viral epicenter with roughly one-third of all mortalities in the United States. To date, our hospital has treated thousands of COVID-19 positive patients and sits at the forefront of the United States response to this pandemic. The goal of this paper is to share the lessons learned by our spine division during a crisis when hospital resources and personnel are stretched thin. Such experiences include management of elective and emergent cases, outpatient clinics, physician redeployment, and general health and wellness. As peak infections spread across the United States, we hope this article will serve as a resource for other spine departments on how to manage patient care and healthcare worker deployment during the COVID-19 crisis.
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Affiliation(s)
- J M Lombardi
- The Och Spine Hospital, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 5141 Broadway at W 220th Street, New York, NY 10034.
| | - T Bottiglieri
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 622 W 168th Street, PH 11-Center, New York, NY 10032
| | - N Desai
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 622 W 168th Street, PH 11-Center, New York, NY 10032
| | - K D Riew
- The Och Spine Hospital, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 5141 Broadway at W 220th Street, New York, NY 10034
| | - V Boddapati
- The Och Spine Hospital, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 5141 Broadway at W 220th Street, New York, NY 10034
| | - M Weller
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, 622 W 168th Street, PH 11-Center, New York, NY 10032
| | - C Bourgois
- Department of Anesthesiology, Columbia University Medical Center, New York Presbyterian Hospital, 622 W 168th Street, PH 11-Center, New York, NY 10032
| | - S McChrystal
- The McChrystal Group, 333 N Fairfax Street, Alexandria, VA, 22314
| | - R A Lehman
- The Och Spine Hospital, Department of Orthopaedic Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 5141 Broadway at W 220th Street, New York, NY 10034
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Karukonda TR, Mancini N, Katz A, Cote MP, Moss IL. Lumbar Laminectomy in the Outpatient Setting Is Associated With Lower 30-Day Complication Rates. Global Spine J 2020; 10:384-392. [PMID: 32435556 PMCID: PMC7222675 DOI: 10.1177/2192568219850095] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To compare the incidence of complications in patients undergoing single-level and 2-level lumbar laminectomy in either the inpatient or outpatient settings. METHODS Patients who underwent single-level and 2-level lumbar laminectomy were identified in the ACS NSQIP database from the years 2006 to 2015. Independent patient variables were recorded, including demographics and preoperative health characteristics. Logistic regression was used to determine the risk of postoperative complications for both a 1- and 2-level lumbar laminectomy as well as to identify independent risk factors for a complication. Comparisons were made between 2 groups: (1) inpatient and (2) outpatient as determined by billing data. RESULTS A total of 18 076 single- and 2-level lumbar laminectomy cases were identified with 10 743 (59.4%) inpatient procedures and 7333 (40.6%) outpatient procedures. The incidence of any postoperative complication was significantly lower in the outpatient group than in the inpatient group among all cohorts including 1-level lumbar laminectomy (1.9% vs 6.7%), 2-level lumbar laminectomy (3.17% vs 7.38%), as well as in the combined cohort of 1- and 2-level laminectomies (2.47% vs 7.01%). Significant independent risk factors for complications after lumbar laminectomy were identified, including body mass index (BMI) >30 kg/m2, age ≥55 years, a functional status of partially dependent, chronic obstructive pulmonary disease (COPD), chronic steroid use, American Society of Anesthesiologists (ASA) class 3 or 4, and operative time >90 minutes. CONCLUSIONS This study reports a lower overall complication rate in the 30-day postoperative period following 1- and 2-level lumbar laminectomy performed in an outpatient versus inpatient setting. Significant risk factors for complications included BMI >30 kg/m2, age ≥55 years, a functional status of partially dependent, COPD, chronic steroid use, ASA class 3 or 4, and operative time >90 minutes.
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Affiliation(s)
| | | | - Austen Katz
- University of Connecticut Health Center, Farmington, CT, USA
| | - Mark P. Cote
- University of Connecticut Health Center, Farmington, CT, USA
| | - Isaac L. Moss
- University of Connecticut Health Center, Farmington, CT, USA,Isaac L. Moss, Department of Orthopaedic Surgery, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-5353, USA.
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Malik AT, Xie J, Retchin SM, Phillips FM, Xu W, Yu E, Khan SN. Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department-an analysis of 90-day outcomes and costs. Spine J 2020; 20:882-887. [PMID: 32044429 DOI: 10.1016/j.spinee.2020.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT While free-standing ambulatory surgical centers (ASCs) have been extolled as lower cost settings than hospital outpatient facilities/departments (HOPDs) for performing routine elective spine surgeries, differences in 90-day costs and complications have yet to be compared between the two types of treatment facilities. PURPOSE We carried a comprehensive analysis to report the differences on payments to providers and facilities as a reflection of true costs to patients, employers and health plans for patients undergoing primary, single-level lumbar microdiscectomy/decompression at ASC versus HOPD. STUDY DESIGN Retrospective review of Medicare advantage and commercially insured enrollees from the Humana dataset from 2007 to 2017Q1. OUTCOME MEASURES To understand the differences in 90-day complications, readmissions, emergency department visits and costs for patients undergoing primary, single-level lumbar microdiscectomy/decompressions at an ASC versus HOPD. METHODS The Humana 2007 to 2017Q1 was queried using Current Procedural Terminology codes to identify patients undergoing primary, single-level lumbar microdiscectomy/decompressions. Patients undergoing two-level surgery, open laminectomies, fusions, revision discectomies, and/or deformities were excluded. Service Location codes for HOPD (Location Code 22) and free-standing ASC (Location Code 24) were used to determine surgery treatment facilities. Using propensity scoring, we matched two groups who had surgery performed in ASCs or HOPDs based on age, gender, race, region and Elixhauser comorbidity index. Multivariable logistic regression analyses were performed on matched cohorts to assess for differences in 90-day outcomes between facilities, while controlling for age, gender, race, region, plan, and Elixhauser comorbidity index. RESULTS A total of 1,077 and 10,475 primary single-level decompressions were performed in ASCs and HOPDs, respectively. Following a matching algorithm with propensity scoring, the two cohorts were comprised of 990 patients each. Observed differences in 90-day complication rates were not statistically or clinically significant (ASC=9.1% vs. HOPD=10.3%; p=.362) nor were readmissions (ASC=4.5% vs. HOPD=5.3%; p=.466). On average, performing surgery in an ASC versus HOPD resulted in significant cost savings of over $2,000/case in Medicare Advantage ($5,814 vs. $7,829) and over $3,500/case ($10,116 vs. $13,623) in commercial beneficiaries. CONCLUSION Performing single-level decompression surgeries in an ASC compared with HOPDs was associated with approximately $2,000 to $3,500 cost-savings per case with no statistically significant impact on complication or readmission rates.
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Affiliation(s)
- Azeem Tariq Malik
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Jack Xie
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Sheldon M Retchin
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, The Ohio State University and Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Frank M Phillips
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL
| | - Wendy Xu
- Division of General Internal Medicine, Department of Internal Medicine, College of Medicine, The Ohio State University and Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Elizabeth Yu
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Safdar N Khan
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, OH.
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Trends in Ambulatory Laminectomy in the USA and Key Factors Associated with Successful Same-Day Discharge: A Retrospective Cohort Study. HSS J 2020; 16:72-80. [PMID: 32015743 PMCID: PMC6974217 DOI: 10.1007/s11420-019-09703-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laminectomy is commonly used in the treatment of lumbar spine pathology. Laminectomies are increasingly being performed in outpatient settings, but patient safety concerns remain. QUESTIONS/PURPOSES We aimed to describe trends in outpatient lumbar laminectomy between 2008 and 2016 and to identify factors associated with successful same-day discharge. METHODS We identified patients who underwent single-level lumbar laminectomy between 2008 and 2016 in the American College of Surgeons' National Surgical Quality Improvement Program database and divided them into two groups according to their admission status, either inpatient or outpatient. Inpatient and outpatient groups were further divided according to actual length of stay (LOS): did not remain in the hospital overnight (LOS = 0) or stayed in the hospital overnight or longer (LOS ≥ 1). We then analyzed patient characteristics and complications for significance and to identify factors associated with successful same-day discharge. RESULTS We identified 85,769 patients, 41,149 classified as outpatient status and 44,620 as inpatient status. Between 2008 and 2016, the proportion of procedures performed on an outpatient basis increased from 24.1 to 56.74%. Overall, 27.3% of all patients were discharged on the day of surgery, representing 52.8% of outpatients and 3.8% of inpatients. Older age and longer duration of surgery predicted that patients were less likely to have same-day discharge. Patients with a primary diagnosis other than intervertebral disk disorder, Hispanic ethnic background, or an American Society of Anesthesiologists physical status classification of III were less likely to achieve same-day discharge. Patients under the care of orthopedic surgeons (as opposed to neurosurgeons) were more likely to be discharged on the day of surgery. We also found an association between sex and day of discharge, with female patients being less likely to be discharged on the day of surgery. CONCLUSIONS Laminectomy is increasingly being performed in the outpatient setting. Younger, healthier non-Hispanic male patients undergoing uncomplicated surgery have a higher likelihood of successful same-day discharge.
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Witiw CD, Wilson JR, Fehlings MG, Traynelis VC. Ambulatory Surgical Centers: Improving Quality of Operative Spine Care? Global Spine J 2020; 10:29S-35S. [PMID: 31934517 PMCID: PMC6947680 DOI: 10.1177/2192568219849391] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Narrative review with commentary. OBJECTIVE Present healthcare reform focuses on cost-optimization and quality improvement. Spine surgery has garnered particular attention; owing to its costly nature. Ambulatory Surgical Centers (ASC) present a potential avenue for expenditure reduction. While the economic advantage of ASCs is being defined, cost saving should not come at the expense of quality or safety. METHODS This narrative review focuses on current definitions, regulations, and recent medical literature pertinent to spinal surgery in the ASC setting. RESULTS The past decade witnessed a substantial rise in the proportion of certain spinal surgeries performed at ASCs. This setting is attractive from the payer perspective as remuneration rates are generally less than for equivalent hospital-based procedures. Opportunity for physician ownership and increased surgeon productivity afforded by more specialized centers make ASCs attractive from the provider perspective as well. These factors serve as extrinsic motivators which may optimize and improve quality of surgical care. Much data supports the safety of spine surgery in the ASC setting. However, health care providers and policy makers must recognize that current regulations regarding safety and quality are less than comprehensive and the data is predominately from selected case-series or comparative cohorts with inherent biases, along with ambiguities in the definition of "outpatient." CONCLUSIONS ASCs hold promise for providing safe and efficient surgical management of spinal conditions; however, as more procedures shift from the hospital to the ASC rigorous quality and safety data collection is needed to define patient appropriateness and track variability in quality-related outcomes.
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Affiliation(s)
| | | | | | - Vincent C. Traynelis
- Rush University Medical Center, Chicago, IL, USA,Vincent C. Traynelis, Department of Neurological Surgery, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612, USA.
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Mummareddy N, Ahluwalia R, Zuckerman SL, Lakomkin N, Asher A, Devin CJ. Identifying the most appropriate lumbar decompression patients for ambulatory surgery centers - A pilot study using inpatient and outpatient hospital data. J Clin Neurosci 2019; 72:206-210. [PMID: 31859177 DOI: 10.1016/j.jocn.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 12/01/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION To minimize healthcare related costs, ambulatory surgery centers (ASCs) have become increasingly favored venues for outpatient spine surgery. Using a national cohort of patients undergoing elective lumbar decompression (LD) in an inpatient or outpatient hospital setting, the current objectives were to: 1) outline specific factors that were associated with complications, and 2) describe potentially catastrophic complications. METHODS Adults who underwent LD between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure LD (CPT 63030), elective, neurologic/orthopaedic surgeons, length of stay (LOS) of 0/1 days, and discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. Univariate/multivariable logistic regression was performed. RESULTS A total of 19,908 patients met the inclusion criteria. 564 (2.83%) patients experienced a complication. Cardiac intervention remained the only independent predictor of complications after multivariate testing (OR: 2.02, 95% CI: 1.00, 4.07, p = 0.049). Approximate comorbidity score cut-offs associated with <2% risk of complication were: ASA ≤ 3, CCI ≤ 5, mFI ≤ 0.182. A total of 96 (0.48%) patients experienced potentially catastrophic complications. CONCLUSIONS We utilized a national cohort of patients undergoing elective inpatient and outpatient LD in a hospital setting to identify preoperative risk factors for postoperative complications. Previous cardiac intervention was the sole independent predictor of complications. Although no patients treated at ASCs were studied, we believe these factors can aid in selecting patients most appropriate for ASCs and begin the process of selecting the best patients for an ambulatory setting.
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Affiliation(s)
- Nishit Mummareddy
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Anthony Asher
- Charlotte Neurosurgical Associates, Charlotte, NC, United States
| | - Clinton J Devin
- Orthopaedic of Steamboat Springs, Steamboat Springs, CO, United States
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Rossi V, Asher A, Peters D, Zuckerman SL, Smith M, Henegar M, Dyer H, Coric D, Pfortmiller D, Adamson T, McGirt M. Outpatient anterior cervical discectomy and fusion in the ambulatory surgery center setting: safety assessment for the Medicare population. J Neurosurg Spine 2019; 32:360-365. [PMID: 31731271 DOI: 10.3171/2019.7.spine19480] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Several studies have demonstrated that anterior cervical discectomy and fusion (ACDF) surgery in the outpatient versus hospital setting provides improved efficiency, cost-effectiveness, and patient satisfaction without a compromise in safety or outcome. Recent anecdotal reports, however, have questioned whether outpatient ACDF surgery is safe in the > 65-year-old Medicare population. To date, no clinical study has assessed the safety of outpatient ACDF in an ambulatory surgery center (ASC), specifically in a Medicare population. The authors set out to analyze their 3-year experience with Medicare-enrolled patients undergoing ACDF surgery at a single ASC to determine its safety profile, perioperative care protocol, and associated outcomes. METHODS A retrospective analysis of 119 consecutive patients > 65 years (Medicare-eligible) who underwent 1-, 2-, or 3-level ACDF at a single ASC from 2015 to 2018 (since Medicare payment approval) was conducted. All patients were in American Society of Anesthesiologists classes I-III. Postoperatively, patients were observed for a minimum of 4 hours in a recovery setting for the following factors: neck swelling, neurological status, ability to swallow solid food, and urination capacity. All patients received a multimodal pain management regimen prior to discharge home. Data were collected on patient demographics, comorbidities, operative details, and all perioperative and 90-day morbidity. RESULTS Complete data were available for all 119 consecutive Medicare-eligible patients, 97 (81.5%) of whom were actively enrolled in Medicare. One-, 2-, and 3-level ACDFs were performed in 103 (86.6%), 15 (12.6%), and 1 (0.8%) patients, respectively. No patients required return to the operating room for intervention within the 4-hour postanesthesia care unit observation window. No patients required transfer from the ASC to the hospital setting for further observation or intervention. Thirty-day adverse events were reported in 2.4% of cases, all of which resolved by 90 days after surgery. The incidence of 90-day hospital readmission was 1.7% (n = 2), with 1 patient (0.8%) requiring reoperation at the index level for deep infection. All-cause 90-day mortality was 0%. CONCLUSIONS An analysis of consecutive Medicare patients (American Society of Anesthesiologists classes I-III) who underwent mostly 1-level and some 2-level ACDFs in an ASC setting demonstrates that surgical complications occur at a low rate with a safety profile similar to that reported for both inpatient ACDF and patients younger than 65 years. In an effort to reduce cost and improve efficiency of care, surgeons can safely perform ACDF in the Medicare population in an ASC environment utilizing patient selection criteria and perioperative management similar to those reported here.
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Azad TD, Varshneya K, Ho AL, Veeravagu A, Sciubba DM, Ratliff JK. Laminectomy Versus Corpectomy for Spinal Metastatic Disease—Complications, Costs, and Quality Outcomes. World Neurosurg 2019; 131:e468-e473. [DOI: 10.1016/j.wneu.2019.07.206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/26/2019] [Accepted: 07/27/2019] [Indexed: 12/14/2022]
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Patel DV, Yoo JS, Karmarkar SS, Lamoutte EH, Singh K. Minimally invasive lumbar decompression in an ambulatory surgery center. JOURNAL OF SPINE SURGERY 2019; 5:S166-S173. [PMID: 31656871 DOI: 10.21037/jss.2019.04.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background There is limited data regarding clinical and surgical outcomes of minimally invasive lumbar decompression (MIS LD) as an outpatient procedure. In this context, our purpose is to evaluate a single surgeon's experience with performing MIS LD in the outpatient versus inpatient setting and determining if there are differences in surgical and clinical outcomes. Methods Patients undergoing primary, one- to three-level MIS LD were retrospectively reviewed and stratified by surgical setting: ambulatory surgical center (ASC) versus hospital. The cohorts were compared with respect to demographics, perioperative characteristics, complications, postoperative pain and narcotics consumption, and improvements in patient-reported outcomes. Results Five hundred and nine patients were included: 332 patients underwent surgery at an ASC and 177 patients underwent surgery at a hospital. The ASC patients were younger, more likely to be male, and carry Workers' Compensation insurance. The hospital patients were older, more likely to be diabetic, and had a greater comorbidity burden. Patients undergoing MIS LD in an ASC were less likely to have multi-level procedures and more likely to have decompression with discectomy compared to patients in the hospital cohort. There were two cases of superficial wound infection in the ASC cohort and a single case of a pulmonary embolus in the hospital cohort. Additionally, a total of 28 patients had recurrent herniated nucleus pulposus in the ASC cohort compared to 12 patients in the hospital cohort. There was one case of residual stenosis in the ASC cohort compared to eight cases in the hospital cohort. Both cohorts demonstrated similar preoperative ODI, VAS back pain, and VAS leg pain scores through 12-month follow-up. Conclusions MIS LD is a safe and effective procedure in an ASC, however, appropriate patient selection and postoperative protocols are imperative in minimizing complications and optimizing safety and efficacy in the outpatient setting.
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Affiliation(s)
- Dil V Patel
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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