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Covell MM, Rumalla KC, Bhalla S, Bowers CA. Risk analysis index predicts mortality and non-home discharge following posterior lumbar interbody fusion: a nationwide inpatient sample analysis of 429,380 patients (2019-2020). 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/s00586-024-08373-9. [PMID: 38902536 DOI: 10.1007/s00586-024-08373-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/18/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE Frailty is an independent risk factor for adverse postoperative outcomes following spine surgery. The ability of the Risk Analysis Index (RAI) to predict adverse outcomes following posterior lumbar interbody fusion (PLIF) has not been studied extensively and may improve preoperative risk stratification. METHODS Patients undergoing PLIF were queried from Nationwide Inpatient Sample (NIS) (2019-2020). The relationship between RAI-measured preoperative frailty and primary outcomes (mortality, non-home discharge (NHD)) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS A total of 429,380 PLIF patients (mean age = 61y) were identified, with frailty cohorts stratified by standard RAI convention: 0-20 "robust" (R)(38.3%), 21-30 "normal" (N)(54.3%), 31-40 "frail" (F)(6.1%) and 41+ "very frail" (VF)(1.3%). The incidence of primary and secondary outcomes increased as frailty thresholds increased: mortality (R 0.1%, N 0.1%, F 0.4%, VF 1.3%; p < 0.001), NHD (R 6.5%, N 18.1%, F 36.9%, VF 42.0%; p < 0.001), eLOS (R 18.0%, N 21.9%, F 31.6%, VF 43.8%; p < 0.001) and complication rates (R 6.6%, N 8.8%, F 11.1%, VF 12.2%; p < 0.001). The RAI demonstrated acceptable discrimination for NHD (C-statistic: 0.706) and mortality (C-statistic: 0.676) in AUROC curve analysis. CONCLUSION Increasing RAI-measured frailty is significantly associated with increased NHD, eLOS, complication rates, and mortality following PLIF. The RAI demonstrates acceptable discrimination for predicting NHD and mortality, and may be used to improve frailty-based risk assessment for spine surgeons.
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Affiliation(s)
| | - Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shubhang Bhalla
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 8342 S Levine Ln, Sandy, UT, 87122, USA.
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Miller AK, Cederman MR, Park DK. Growing utilization of ambulatory spine surgery in Medicare patients from 2010-2021. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100314. [PMID: 38370335 PMCID: PMC10869941 DOI: 10.1016/j.xnsj.2024.100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/20/2024]
Abstract
Background There is growing interest in transitioning various surgical procedures to the outpatient care setting. However, for Medicare patients, the site of service for surgical procedures is influenced by regulations within the Inpatient and Outpatient Prospective Payment Systems. The purpose of this study is to quantify changes in utilization of outpatient spine surgery within the Medicare population, as well as to determine changes in outpatient volume after removal of a procedure from the "inpatient-only" list. Methods This is a cross-sectional study of Medicare billing database information for selected spine procedures included in the Medicare Physician/Supplier Procedure Summary (PSPS) public use files from 2010-2021. These files include aggregated data from Medicare Part B fee-for-service claims, published yearly. Procedures from Healthcare Common Procedural Coding System (HCPCS) code ranges 22010-22899 and 62380-63103 were selected for analysis, limited to surgical services delivered in the inpatient, hospital outpatient department (HOPD), and ambulatory surgical center (ASC) settings. For each HCPCS code included, estimates of the total number of services and corresponding changes in volume were calculated. Results Within the range of codes included in the study, the total number of outpatient spine procedures rose approximately 193% from 2010 to 2021, with compound annual growth rate (CAGR) for outpatient procedures per year of 9.9% for HOPDs and 15.7% for ASCs (-2.2% for inpatient procedures). Within this period, the ASC list grew from 12 procedures to 58 procedures. In 2021, the highest volume ASC procedure was HCPCS 63047, at approximately 4970 procedures. Conclusions This study demonstrates a trend of increasing utilization of HOPDs and ASCs for spine procedures among Medicare beneficiaries from 2010 to 2021. Though HOPDs are currently more widely utilized, the ongoing additions of spine procedures to the ASC covered procedures list may shift this balance.
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Affiliation(s)
- Alex K Miller
- Corewell Health East William Beaumont University Hospital, 3535 W. 13 Mile Road Suite 744, Royal Oak, MI, 48073, United States
| | - Matthew R Cederman
- Oakland University William Beaumont School of Medicine, 3535 W. 13 Mile Road, Royal Oak, MI, 48073, United States
| | - Daniel K Park
- Corewell Health East William Beaumont University Hospital, 3535 W. 13 Mile Road Suite 744, Royal Oak, MI, 48073, United States
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Issa TZ, Lee Y, Lambrechts MJ, D'Antonio ND, Toci GR, Mazmudar A, Kalra A, Sherman M, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion. Spine (Phila Pa 1976) 2024; 49:138-145. [PMID: 37235801 DOI: 10.1097/brs.0000000000004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN Retrospective single-institution cohort. OBJECTIVE To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (β: $11,728, P =0.001; β: $11,643, P =0.002). Postoperatively, length of stay in days (β: $-2,982, P <0.001), any readmission (β: -$18,825, P =0.001), and discharge to AIR (β: $-61,256, P <0.001) or SNF (β: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Nicholas D D'Antonio
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Aditya Mazmudar
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Andrew Kalra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Matthew Sherman
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Malik AT, Quatman CE, Khan SN, Phieffer LS, Rao P, Ly TV. Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications, Readmissions, and Costs. J Foot Ankle Surg 2021; 59:502-506. [PMID: 31685364 DOI: 10.1053/j.jfas.2019.09.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 08/15/2019] [Accepted: 09/26/2019] [Indexed: 02/03/2023]
Abstract
Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.
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Affiliation(s)
- Azeem Tariq Malik
- Research Fellow, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carmen E Quatman
- Assistant Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Safdar N Khan
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Laura S Phieffer
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Prakruti Rao
- Research Coordinator, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Thuan V Ly
- Associate Professor, Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH.
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Preoperative and Postoperative Spending Among Working-Age Adults Undergoing Posterior Spinal Fusion Surgery for Degenerative Disease. World Neurosurg 2020; 138:e930-e939. [PMID: 32251816 DOI: 10.1016/j.wneu.2020.03.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the health care resource utilization and the associated 6 months preoperative and 6 months postoperative spending among patients undergoing posterior lumbar fusion. METHODS We retrospectively reviewed a private insurance claims database for patients who underwent single-level posterior spinal fusion from January 2011 to December 2015. Outpatient health services, prescription pain medications, and inpatient admissions were assessed. RESULTS Among 25,401 patients (mean age, 52 years; 58% female) in the final cohort, median spending during the period from 6 months before surgery to 6 months after surgery was $60,714 (interquartile range [IQR], $46,961-$79,892)/patient. Preoperative spending accounted for 7% ($121 million) of the total costs, and postoperative spending accounted for 8% ($135 million). Median preoperative spending was $3566 (IQR, $2144-$5857) per patient, with imaging accounting for the highest proportion (33%) of preoperative spending. In the 6 months period preceding surgery, 46% patients received injections and 47% received physical therapy. The median postoperative spending was $1954/patient (IQR, $735-$4416). Total postoperative spending was significantly higher among those not discharged home (median, $7525; IQR, $6779-$19,602) compared with those discharged home (median, $1617/patient; IQR, $648-$4033) and home with home care services (median, $2921; IQR, $1406-$5662) (P < 0.001). CONCLUSIONS Unplanned readmission after posterior spinal fusion was the highest contributor to postoperative spending and the second highest contributor to overall costs. Understanding factors that contribute to the costs in the preoperative and postoperative period in patients undergoing single-level posterior lumbar fusion for degenerative pathology is essential to identify targets for cost containment.
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Malik AT, Deiparine S, Khan SN, Kim J, Yu E. Costs Associated With a 90-Day Episode of Care After Single-Level Anterior Lumbar Interbody Fusion. World Neurosurg 2020; 135:e716-e722. [DOI: 10.1016/j.wneu.2019.12.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/11/2022]
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Solid Organ Transplant Is Associated With Increased Morbidity and Mortality in Patients Undergoing One or Two-level Anterior Cervical Decompression and Fusion. Spine (Phila Pa 1976) 2020; 45:158-162. [PMID: 31513110 DOI: 10.1097/brs.0000000000003230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied. METHODS A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality. RESULTS A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p<0.001), higher rate of major medical complications (8.2% vs. 4.5%; OR 1.85, 95% CI 1.45-2.33, p<0.001) and hospital readmission (19.5% vs. 7.5%, OR 2.05, 95% CI 1.74-2.41, p<0.001). In addition, SOT patients had increased mortality within one year of surgery (5.8% vs. 1.3%; OR 3.01, 95% CI 2.26-3.94, p<0.001) compared to non-SOT patients. SOT was not independently associated with SSI (OR 1.25, 95% CI 0.85-1.75, p=0.230), and there was no significant difference in revision rate (0.9% vs. 0.5%; OR 1.54, 95% CI 0.73-2.82, p=0.202) between both groups. CONCLUSION SOT is independently associated with longer hospital stay, increased rate of major medical complications, hospital readmission and mortality. Spine surgeons should be aware of the higher rates of morbidity and mortality in these patients and take it into consideration when developing patient-specific treatment plans. LEVEL OF EVIDENCE 3.
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Understanding Costs in a 90-Day Episode of Care Following Posterior Spinal Fusions for Adolescent Idiopathic Scoliosis. World Neurosurg 2019; 130:e535-e541. [DOI: 10.1016/j.wneu.2019.06.149] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 11/22/2022]
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Bundled Payment Models in Spine Surgery: Current Challenges and Opportunities, a Systematic Review. World Neurosurg 2019; 123:177-183. [DOI: 10.1016/j.wneu.2018.12.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 12/19/2022]
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Continued Inpatient Care After Elective 1- to 2-level Posterior Lumbar Fusions Increases 30-day Postdischarge Readmissions and Complications. Clin Spine Surg 2018; 31:E453-E459. [PMID: 30067516 DOI: 10.1097/bsd.0000000000000700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The main objective of this article was to investigate the impact of discharge destination on postdischarge outcomes following an elective 1- to 2-level posterior lumbar fusion (PLF) for degenerative pathology. BACKGROUND DATA Discharge to an inpatient care facility may be associated with adverse outcomes as compared with home discharge. MATERIALS AND METHODS The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to query for patients undergoing PLFs using Current Procedural Terminology (CPT) codes (22612, 22630, and 22633). Additional levels were identified using CPT-22614, CPT-22632, and CPT-22634. Records were filtered to include patients undergoing surgery for degenerative spine pathologies. Only patients undergoing a single-level or 2-level PLF were included in the study. A total of 23,481 patients were included in the final cohort. RESULTS A total of 3938 (16.8%) patients were discharged to a skilled care or rehabilitation facility following the primary procedure. Following adjustment for preoperative, intraoperative, and predischarge clinical characteristics, discharge to a skilled care or rehabilitation facility was associated with higher odds of any complication [odds ratio (OR), 1.70; 95% confidence interval (CI), 1.43-2.02], wound complications (OR, 1.73; 95% CI, 1.36-2.20), sepsis-related complications (OR, 1.64; 95% CI, 1.08-2.48), deep venous thrombosis/pulmonary embolism complications (OR, 1.72; 95% CI, 1.10-2.69), urinary tract infections (OR, 1.96; 95% CI, 1.45-2.64), unplanned reoperations (OR, 1.49; 95% CI, 1.23-1.80), and readmissions (OR, 1.29; 95% CI, 1.10-1.49) following discharge. CONCLUSIONS After controlling for predischarge characteristics, discharge to skilled care or rehabilitation facilities versus home following 1- to 2-level PLF is associated with higher odds of complications, reoperations, and readmissions. These results stress the importance of careful patient selection before discharge to inpatient care facilities to minimize the risk of complications. Furthermore, the results further support the need for uniform and standardized care pathways to promote home discharge following hospitalization for elective PLFs. LEVEL OF EVIDENCE Level III.
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