A National Analysis on Predictors of Discharge to Rehabilitation After Corrective Surgery for Adolescent Idiopathic Scoliosis

Perioperative Complications and Health-related Quality of Life Outcomes in Severe Pediatric Spinal Deformity

STUDY DESIGN

Prospective multicenter cohort study.

OBJECTIVE

To evaluate perioperative complications and mid-term outcomes for severe pediatric spinal deformity.

SUMMARY OF BACKGROUND DATA

Few studies have evaluated the impact of complications on health-related quality of life (HRQoL) outcomes in severe pediatric spinal deformity.

METHODS

Patients from a prospective, multicenter database with severe pediatric spinal deformity (minimum of 100 degree curve in any plane or planned vertebral column resection (VCR)) with a minimum of 2-years follow-up were evaluated (n=231). SRS-22r scores were collected preoperatively and at 2-years postoperatively. Complications were categorized as intraoperative, early postoperative (within 90-days of surgery), major, or minor. Perioperative complication rate was evaluated between patients with and without VCR. Additionally, SRS-22r scores were compared between patients with and without complications.

RESULTS

Perioperative complications occurred in 135 (58%) patients, and major complications occurred in 53 (23%) patients. Patients that underwent VCR had a higher incidence of early postoperative complications than patients without VCR (28.9% vs. 16.2%, P =0.02). Complications resolved in 126/135 (93.3%) patients with a mean time to resolution of 91.63 days. Unresolved major complications included motor deficit (n=4), spinal cord deficit (n=1), nerve root deficit (n=1), compartment syndrome (n=1), and motor weakness due to recurrent intradural tumor (n=1). Patients with complications, major complications, or multiple complications had equivalent postoperative SRS-22r scores. Patients with motor deficits had lower postoperative satisfaction subscore (4.32 vs. 4.51, P =0.03), but patients with resolved motor deficits had equivalent postoperative scores in all domains. Patients with unresolved complications had lower postoperative satisfaction subscore (3.94 vs. 4.47, P =0.03) and less postoperative improvement in self-image subscore (0.64 vs. 1.42, P =0.03) as compared to patients with resolved complications.

CONCLUSION

Most perioperative complications for severe pediatric spinal deformity resolve within 2-years postoperatively and do not result in adverse HRQoL outcomes. However, patients with unresolved complications have decreased HRQoL outcomes.

Racial Disparities in Health Care Resource Utilization After Pediatric Cervical and/or Thoracic Spinal Injuries

OBJECTIVE

This study aimed to investigate the impact of race on hospital length of stay (LOS) and hospital complications among pediatric patients with cervical/thoracic injury.

METHODS

A retrospective cohort was performed using the 2017 admission year from 753 facilities utilizing the National Trauma Data Bank. All pediatric patients with cervical/thoracic spine injuries were identified using the ICD-10-CM diagnosis coding system. These patients were segregated by their race, non-Hispanic white (NHW), non-Hispanic black (NHB), non-Hispanic Asian (NHA), and Hispanic (H). Demographic, hospital variable, hospital complications, and LOS data were collected. A linear and logistic multivariate regression analysis was performed to determine the risk ratio for hospital LOS as well as complication rate, respectively.

RESULTS

A total of 4,125 pediatric patients were identified. NHB cohort had a greater prevalence of cervical-only injuries (NHW: 37.39% vs. NHB: 49.93% vs. NHA: 34.29% vs. H: 38.71%, P < 0.001). While transport accident was most common injury etiology for both cohorts, NHB cohort had a greater prevalence of assault (NHW: 1.53% vs. NHB: 17.40% vs. NHA: 2.86% vs. H: 6.58%, P < 0.001) than the other cohorts. Overall complication rates were significantly higher among NHB patients (NHW: 9.39% vs. NHB: 15.12% vs. NHA: 14.29% vs. H: 13.60%, P < 0.001). Compared with the NHW cohort, NHB, NHA, and H had significantly longer hospital LOS (NHW: 6.15 ± 9.03 days vs. NHB: 9.24 ± 20.78 days vs. NHA: 9.09 ± 13.28 days vs. H: 8.05 ± 11.45 days, P < 0.001). NHB race was identified as a significant predictor of increased LOS on multivariate regression analysis (risk ratio: 1.14, 95% confidence interval: 0.46, 1.82; P = 0.001) but not hospital complications (P = 0.345).

CONCLUSIONS

Race may significantly impact health care resource utilization following pediatric cervical/thoracic spinal trauma.

Factors associated with extended length of stay in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To investigate whether certain patient, surgical, and recovery-related factors may be associated with extended LOS following posterior spinal fusion for Adolescent Idiopathic Scoliosis (AIS). Understanding determinants of hospital length of stay (LOS) following surgical procedures is important for perioperative planning and improvements in quality of care.

METHODS

Using a private insurance claims database, AIS patients ages 10-21 that underwent posterior spinal fusion from 2010 to 2016 in the United States were identified. Extended LOS was defined as > 7.2 days (+ 1 standard deviation from the mean). Univariate and multivariate analyses were performed to identify factors associated with extended LOS. Significance was set at p < 0.05.

RESULTS

5864 patients met the inclusion criteria (mean age 14.4 ± 2.2 years; 75% girls). Mean LOS was 4.7 ± 2.5 days (median 4 days). 69% patients had 7-12 levels fused, and 25% had 13+ levels fused. On multivariate analysis, factors associated with extended LOS were: longer fusion construct (13+ levels fused) (OR 2.1, p = 0.020), thoracoplasty (OR 3.8, p < 0.001), and postoperative complications: wound problems (OR 13, p < 0.001), respiratory problems (OR 7.9, p < 0.001), urinary tract infection (OR 6.0, p < 0.001), and constipation (OR 2.4, p < 0.001). Postoperative ICU admission, female gender, and surgery performed on Wednesday were significant on univariate analysis but not on multivariate analysis. Extended LOS was associated with an increase of $50,494 in net hospital payments (p < 0.001).

CONCLUSION

Patient, surgical and recovery factors are associated with extended LOS in AIS patients who undergo posterior spinal fusion surgery. Extended LOS significantly increases healthcare spending.

LEVEL OF EVIDENCE

Level III.

Quality and Safety Improvement in Spine Surgery

STUDY DESIGN

Review article.

OBJECTIVES

A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery.

METHODS

A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review.

RESULTS

Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature.

CONCLUSION

Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.

The effect of hospital characteristics on pediatric neuromuscular scoliosis fusion cost

OBJECTIVE

Spinal fusion is used in the treatment of pediatric neuromuscular scoliosis (NMS) to improve spine alignment and delay disease progression. However, patients with NMS are often medically complex and require a higher level of care than those with other types of scoliosis, leading to higher treatment costs. The purpose of this study was to 1) characterize the cost of pediatric NMS fusion in the US and 2) determine hospital characteristics associated with changes in overall cost.

METHODS

Patients were identified from the National Inpatient Sample (2012 to the first 3 quarters of 2015). Inclusion criteria selected for patients with NMS, spinal fusion of at least 4 vertebral levels, and elective hospitalization. Patients with no cost information were excluded. Sociodemographics, treating hospital characteristics, disease etiology/severity, comorbidities, length of stay, and hospital costs were collected. Univariable analysis and multivariable gamma log-link regression were used to determine hospital characteristics associated with changes in cost.

RESULTS

A total of 1780 weighted patients met inclusion criteria. The median cost was $68,815. Following multivariable regression, both small (+$11,580, p < 0.001) and medium (+$6329, p < 0.001) hospitals had higher costs than large hospitals. Rural hospitals had higher costs than urban teaching hospitals (+$32,438, p < 0.001). Nonprofit hospitals were more expensive than both government (-$4518, p = 0.030) and investor-owned (-$10,240, p = 0.001) hospitals. There was significant variability by US census division; compared with the South Atlantic, all other divisions except for the Middle Atlantic had significantly higher costs, most notably the West North Central (+$15,203, p < 0.001) and the Pacific (+$22,235, p < 0.001). Hospital fusion volume was not associated with total cost.

CONCLUSIONS

A number of hospital factors were associated with changes in fusion cost. Larger hospitals may be able to achieve decreased costs due to economies of scale. Regional differences could reflect uncontrolled-for variability in underlying patient populations or systems-level and policy differences. Overall, this analysis identified multiple systemic patterns that could be targets of further cost-related interventions.

Impact of patient and hospital-level risk factors on extended length of stay following spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

Health policy changes have led to increased emphasis on value-based care to improve resource utilization and reduce inpatient hospital length of stay (LOS). Recently, LOS has become a major determinant of quality of care and resource utilization. For adolescent idiopathic scoliosis (AIS), the determinants of extended LOS after elective posterior spinal fusion (PSF) remain relatively unknown. In the present study, the authors investigated the impact of patient and hospital-level risk factors on extended LOS following elective PSF surgery (≥ 4 levels) for AIS.

METHODS

The Kids' Inpatient Database (KID) was queried for the year 2012. Adolescent patients (age range 10-17 years) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended hospital LOS was defined as greater than the 75th percentile for the entire cohort (> 6 days), and patients were dichotomized as having normal LOS or extended LOS. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were recorded. A multivariate logistic regression model was used to determine the odds ratio for risk-adjusted LOS. The primary outcome was the degree to which patient comorbidities or postoperative complications correlated with extended LOS.

RESULTS

Comorbidities were overall significantly higher in the extended-LOS cohort than the normal-LOS cohort. Patients with extended LOS had a significantly greater proportion of blood transfusion (p < 0.001) and ≥ 9 vertebral levels fused (p < 0.001). The overall complication rates were greater in the extended-LOS cohort (20.3% [normal-LOS group] vs 43.5% [extended-LOS group]; p < 0.001). On average, the extended-LOS cohort incurred $18,916 more in total cost than the normal-LOS group ($54,697 ± $24,217 vs $73,613 ± $38,689, respectively; p < 0.001) and had more patients discharged to locations other than home (p < 0.001) than did patients in the normal-LOS cohort. On multivariate logistic regression, several risk factors were associated with extended LOS, including female sex, obesity, hypertension, fluid electrolyte disorder, paralysis, blood transfusion, ≥ 9 vertebrae fused, dural injury, and nerve cord injury. The odds ratio for extended LOS was 1.95 (95% CI 1.50-2.52) for patients with 1 complication and 5.43 (95% CI 3.35-8.71) for patients with > 1 complication.

CONCLUSIONS

The authors' study using the KID demonstrates that patient comorbidities and intra- and postoperative complications all contribute to extended LOS after spinal fusion for AIS. Identifying multimodality interventions focused on reducing LOS, bettering patient outcomes, and lowering healthcare costs are necessary to improve the overall value of care for patients undergoing spinal fusion for AIS.

Predictors of a Non-home Discharge Destination Following Spinal Fusion for Adolescent Idiopathic Scoliosis (AIS)

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Analyze risk factors associated with a non-home discharge following spinal fusions in adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Current evidence is limited with regard to which patient-level and provider/hospital-level factors predict a non-home discharge disposition following spinal fusions in AIS. Identifying these factors can allow providers to identify which patients would ultimately require facility care and can be discharged early to these facilities to reduce hospital costs.

METHODS

The 2012 to 2016 American College of Surgeons-National Surgical Quality Improvement Program Pediatric database was queried using Current Procedural Terminology codes for posterior spinal fusions (22800, 22802, and 22804) and anterior spinal fusions (22808, 22810, and 22812). Patients were categorized into those receiving a posterior-only fusion, anterior-only fusion, and combined anterior-posterior fusion. Only patients aged 10 to 18 undergoing corrective surgery for idiopathic scoliosis were included in the study.

RESULTS

Out of a total of 8452 patients-90 (1.1%) were discharged to a destination other than home (skilled-care facility, separate acute care unit, and/or rehabilitation unit). Following multivariate analysis, children with a body mass index of 20 to 30 (P = 0.002) or >30 (P = 0.003), structural pulmonary abnormality (P = 0.030), past history of childhood cancer (P = 0.018), an ASA grade >II (P<0.001), undergoing a revision surgery versus a primary surgery (P = 0.039), a length of stay >4 days (P<0.001), and the occurrence of a predischarge complication (P = 0.003) were independent predictors associated with a non-home discharge disposition.

CONCLUSION

In the current era of evolving health-care in which there is an increased focus toward decreasing costs, providers should consider utilizing these data to preoperatively identify patients who can be discharged to facility, and tailor an appropriate postoperative course of care aimed at expediting discharge processes to curb the financial burden of a prolonged length of stay.

LEVEL OF EVIDENCE

3.