Health care burden of anterior cervical spine surgery: national trends in hospital charges and length of stay, 2000-2009

Risk factors for extended hospital stay following minimally invasive transforaminal lumbar interbody fusion

BACKGROUND

Prior literature has examined predictors of length of stay (LOS) for lumbar fusion broadly, grouping multiple surgical approaches into one sample. Evaluating minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) specifically can reduce variability introduced by other approaches to effectively identify predictors of LOS. The purpose of this study is to evaluate preoperative predictors of extended LOS in patients undergoing MIS-TLIF.

METHODS

MIS-TLIF patients were identified from a spine surgeon's database. Preoperative predictors of LOS, including demographics, comorbidity data, spinal pathology, patient-reported back pain, leg pain, physical function, disability, general physical health, mental health, and depressive burden scores were analyzed. Univariate analysis was performed to identify predictors of LOS ≥ 48 and LOS ≥ 72 h, a multivariate analysis confirmed significance. Eight-hundred-one patients were included.

RESULTS

African-American patients were 4.3 times more likely to have a LOS≥48 h compared to Caucasians (p ≤ 0.001). Diagnosis of herniated nucleus pulposus and foraminal stenosis were negative predictors of an LOS ≥ 72 h (p ≤ 0.014, both). Self-identified African American patients were approximately twice as likely to have a LOS ≥ 72 h compared to Caucasians. Preoperative Oswestry Disability Index (ODI) was positively correlated with LOS ≥ 48 h (p = 0.008). Other baseline patient-reported outcomes (PROs) were not predictive of LOS ≥ 48 or 72 h (p > 0.050, all).

CONCLUSIONS

Further research should explore why different demographic characteristics may be associated with extended postoperative LOS to target interventions toward potential health disparities. Understanding preoperative risk factors can help target increased healthcare costs and improve patient care through tailored interventions and future research.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Risk Factors for Unexpected Conversion From Ambulatory to Inpatient Admission Among One-level or Two-level ACDF Patients

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.

Few Randomized Controlled Trials in Spine Surgery in the United States Include Sociodemographic Patient Data: A Systematic Review

INTRODUCTION

The importance of sociodemographic factors such as race, education, and income on spine surgery outcomes has been well established, yet the representation of sociodemographic data within randomized controlled trials (RCTs) in spine literature remains undefined in the United States (U.S).

METHODS

Medical literature was reviewed within PubMed for RCTs with "spine" in the title or abstract published within the last 8 years (2014 to 2021) in seven major spine journals. This yielded 128 results, and after application of inclusion criteria (RCTs concerning adult spine pathologies conducted in the U.S), 54 RCTs remained for analysis. Each article's journal of publication, year of publication, and spinal pathology was recorded. Pathologies included cervical degeneration, thoracolumbar degeneration, adult deformity, cervical trauma, and thoracolumbar trauma. Sociodemographic variables collected were race, ethnicity, insurance status, income, work status, and education. The Fisher's exact test was used to compare inclusion of sociodemographic data by journal, year, and spinal pathology.

RESULTS

Sociodemographic data were included in the results and in any section of 57.4% (31/54) of RCTs. RCTs reported work status in 25.9% (14/54) of results and 38.9% (21/54) of RCTs included work status in any section. Income was included in the results and mentioned in any section in 13.0% (7/54) of RCTs. Insurance status was in the results or any section of 9.3% (5/54) and 18.5% (10/54) of RCTs, respectively. There was no association with inclusion of sociodemographic data within the results of RCTs as a factor of journal (P = 0.337), year of publication (P = 0.286), or spinal pathology (P = 0.199).

DISCUSSION

Despite evidence of the importance of sociodemographic factors on the natural history and treatment outcomes of myriad spine pathologies, this study identifies a surprising absence of sociodemographic data within contemporary RCTs in spine surgery. Failure to include sociodemographic factors in RCTs potentially bias the generalizability of outcome data.

Impact of meteorological factors on hospital admissions for spinal diseases in Shanghai during 2015-2019

PURPOSE

To assess the correlation between meteorological factors and spinal disease admissions.

METHODS

Data was obtained from the electronic medical records of a tertiary general hospital. Meteorological data was collected from China Meteorological Science Data Sharing Service. Distributed lag nonlinear models were used to evaluate the impact of meteorological variables on weekly spinal disease admissions.

RESULTS

A total of 2739 spinal cases were documented. Compared with estimates at the 50^th, the cumulative relative risk (RR) for extremely high temperatures at the 97.5^th over lag week 18 to lag week 20 increased by 75.7%. When the weekly maximum temperature reached 38°C during lag week 20, the maximum RR was 1.96 (95% CI:1.095-3.506). Moreover, the effects of extremely high temperatures on spinal disease admissions were more obvious in females and the age group ≥65 years old compared with males and the age group<65 years old.

CONCLUSIONS

Extremely high temperatures were significantly associated with higher risks of spinal disease admissions.

Racial Differences in Patients Undergoing Anterior Cervical Discectomy and Fusion: A Multi-Site Study

STUDY DESIGN

This was a retrospective chart review.

OBJECTIVE

The objective of this study was to examine disparities within patients undergoing anterior cervical discectomy and fusion (ACDF) at a multi-site tertiary referral center with specific focus on factors related to length of stay (LOS).

SUMMARY OF BACKGROUND DATA

There are previously described racial disparities in spinal surgery outcomes and quality metrics.

METHODS

A total of 278 consecutive patients undergoing ACDF by 8 different surgeons over a 5-year period were identified retrospectively. Demographic data, including age at time of surgery, sex, smoking status, and self-identified race [White or African American (AA)], as well as surgical data and postoperative course were recorded. Preoperative health status was recorded, and comorbidities were scored by the Charlson Comorbidity Index. Univariable and multivariable linear regression models were employed to quantify the degree to which a patient's LOS was related to their self-identified race, demographics, and perioperative clinical data.

RESULTS

Of the 278 patients who received an ACDF, 71.6% (199) self-identified as White and 28.4% (79) identified as AA. AA patients were more likely to have an ACDF due to myelopathy, while White patients were more likely to have an ACDF due to radiculopathy (P=0.001). AA patients had longer LOS by an average of half a day (P=0.001) and experienced a larger percentage of extended stays (P=0.002). AA patients experienced longer overall operation times on average (P=0.001) across all different levels of fusion. AA race was not an independent driver of LOS (β=0.186; P=0.246).

CONCLUSIONS

As hypothesized, and consistent with previous literature on racial surgical disparities, AA race was associated with increased LOS, increased operative times, and increased indication of myelopathy in this study. Additional research is necessary to evaluate the underlying social determinants of health and other factors that may contribute to this study's results.

LEVEL OF EVIDENCE

Level III.

Effect of patient's sex on early perioperative outcomes following anterior cervical discectomy and fusion

OBJECTIVE

Differences in morbidity and mortality measures between males and females have been demonstrated for a variety of spinal surgeries, however, studies of anterior cervical discectomy and fusion (ACDF) are limited. To investigate the impact ofsexon 30-day perioperative outcomes of ACDF.

METHODS

Retrospective 1:1 propensity score-matched cohort study. Patients who underwent ACDF between 2016 and 2018 were reviewed from the ACS-NSQIP database.Propensity score matchingand subgroup analysis were used.

RESULTS

21,180 patients met inclusion criteria. 11,194 patients underwent single-level ACDF and 9986 patients underwent multi-level ACDF. In the single-level group, there were 6168 (55.1%) males and 5026 (44.9%) females. In the multi-level group, there were 5033 (50.4%) males and 4953 (49.6%) females. In both single/multi-level groups, females were more likely to be of older age, be functionally dependent, and have higher BMI and lower preoperative hematocrit level. Males were more likely to be Caucasian, smokers, have myelopathy, diabetes mellitus, hypertension and bleeding disorders. In both single/multi-level groups, except for the higher incidence of urinary tract infection (UTI) in females and myocardial infarction (MI) in males, there were no significant differences in morbidity and mortality between males and females.

CONCLUSIONS

Several differences in demographics and baseline health status exist between males and females undergoing ACDF. When attempting to control for comorbid conditions, we found that sex by itself is not an independent risk factor for higher perioperative morbidity or mortality in patients undergoing ACDF, except for the higher incidence of UTI in females and MI in males. These results are important findings for clinicians and spine surgeons while counseling patients undergoing this type of procedure.

Administrative Data Are Unreliable for Ranking Hospital Performance Based on Serious Complications After Spine Fusion

STUDY DESIGN

Retrospective analysis of administrative billing data.

OBJECTIVE

To evaluate the extent to which a metric of serious complications determined from administrative data can reliably profile hospital performance in spine fusion surgery.

SUMMARY OF BACKGROUND DATA

While payers are increasingly focused on implementing pay-for-performance measures, quality metrics must reliably reflect true differences in performance among the hospitals profiled.

METHODS

We used State Inpatient Databases from nine states to characterize serious complications after elective cervical and thoracolumbar fusion. Hierarchical logistic regression was used to risk-adjust differences in case mix, along with variability from low case volumes. The reliability of this risk-stratified complication rate (RSCR) was assessed as the variation between hospitals that was not due to chance alone, calculated separately by fusion type and year. Finally, we estimated the proportion of hospitals that had sufficient case volumes to obtain reliable (>0.7) complication estimates.

RESULTS

From 2010 to 2017 we identified 154,078 cervical and 213,133 thoracolumbar fusion surgeries. 4.2% of cervical fusion patients had a serious complication, and the median RSCR increased from 4.2% in 2010 to 5.5% in 2017. The reliability of the RSCR for cervical fusion was poor and varied substantially by year (range 0.04-0.28). Overall, 7.7% of thoracolumbar fusion patients experienced a serious complication, and the RSCR varied from 6.8% to 8.0% during the study period. Although still modest, the RSCR reliability was higher for thoracolumbar fusion (range 0.16-0.43). Depending on the study year, 0% to 4.5% of hospitals had sufficient cervical fusion case volume to report reliable (>0.7) estimates, whereas 15% to 36% of hospitals reached this threshold for thoracolumbar fusion.

CONCLUSION

A metric of serious complications was unreliable for benchmarking cervical fusion outcomes and only modestly reliable for thoracolumbar fusion. When assessed using administrative datasets, these measures appear inappropriate for high-stakes applications, such as public reporting or pay-for-performance.Level of Evidence: 3.

Influence of Sex on Early Outcomes of Elective Lumbar Fusions: An Updated Propensity-Matched and Subgroup Analysis

OBJECTIVE

Existing data have demonstrated significant differences in morbidity and mortality measures between men and women undergoing various spinal surgeries. However, studies of lumbar fusion surgery have been limited. Thus, we investigated the effects of patient sex on 30-day perioperative outcomes after elective lumbar fusion spine surgery.

METHODS

Patients who had undergone lumbar fusion from 2015 to 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching was used to determine whether the patient's sex had influenced the 30-day perioperative complications.

RESULTS

A total of 44,526 cases had met the inclusion criteria and were reviewed. Of the 44,526 patients, 13,715 had undergone posterior lumbar fusion, 21,993 had undergone posterior/transforaminal lumbar interbody fusion, and 8818 had undergone anterior/lateral lumbar interbody fusion. The women were more likely to be older, functionally dependent, and taking steroids for chronic conditions and to have a higher body mass index and lower preoperative hematocrit level. The men were more likely to be white, to smoke, and to have diabetes mellitus, hypertension, and bleeding disorders. In all cohorts, except for a higher incidence of urinary tract infection in the female patients and myocardial infarction in the male patients, no significant differences were found in morbidity and mortality between the sexes.

CONCLUSIONS

Several differences in demographics and baseline health status were found between men and women undergoing lumbar fusion. When attempting to control for comorbid conditions using propensity score matching, we found that sex was an independent predictor of urinary tract infection in women and myocardial infarction in men across major morbidity and mortality categories in patients undergoing lumbar fusion surgery.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Portending Influence of Racial Disparities on Extended Length of Stay after Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The aim of this study was to investigate whether race is an independent predictor of extended length of stay (LOS) after elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult patients undergoing ACDF for CSM were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification coding system.

RESULTS

A total of 15,400 patients were identified, of whom 13,250 (86.0%) were Caucasian (C) and 2150 (14.0%) were African American (AA). The C cohort tended to be older, whereas the AA cohort had 2 times as many patients in the 0-25th income quartile. The prevalence of comorbidities was greater in the AA cohort. Intraoperative fusion levels were similar between the cohorts, whereas the AA cohort had a higher rate of cerebrospinal fluid leak/dural tear. In relation to the number of complications, the C cohort had a lower rate compared with the AA cohort (P = 0.006), including no complication (89.4% vs. 85.3%), 1 complication (9.9% vs. 12.8%), and >1 complication (0.7% vs. 1.9%). The AA cohort experienced significantly longer hospital stays (C, 1.9 ± 2.3 days vs. AA, 2.7 ± 3.5; P < 0.001), greater proportion of extended LOS (C, 17.5% vs. AA, 29.1%; P < 0.001) and nonroutine discharges (C, 16.1% vs. AA, 28.6%; P < 0.001). AA race was a significant independent risk factor for extended LOS (odds ratio, 1.98; 95% confidence interval, 1.50-2.61; P < 0.001).

CONCLUSIONS

Our study suggests that AA patients have a significantly higher risk of prolonged LOS after elective ACDF for CSM compared with C patients.

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

STUDY DESIGN

Retrospective.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identifying the Characteristics of Patients With Cervical Degenerative Disease for Surgical Treatment From 17-Year Real-World Data: Retrospective Study

Background

Real-world data (RWD) play important roles in evaluating treatment effectiveness in clinical research. In recent decades, with the development of more accurate diagnoses and better treatment options, inpatient surgery for cervical degenerative disease (CDD) has become increasingly more common, yet little is known about the variations in patient demographic characteristics associated with surgical treatment.

Objective

This study aimed to identify the characteristics of surgical patients with CDD using RWD collected from electronic medical records.

Methods

This study included 20,288 inpatient surgeries registered from January 1, 2000, to December 31, 2016, among patients aged 18 years or older, and demographic data (eg, age, sex, admission time, surgery type, treatment, discharge diagnosis, and discharge time) were collected at baseline. Regression modeling and time series analysis were conducted to analyze the trend in each variable (total number of inpatient surgeries, mean age at surgery, sex, and average length of stay). A P value <.01 was considered statistically significant. The RWD in this study were collected from the Orthopedic Department at Peking University Third Hospital, and the study was approved by the institutional review board.

Results

Over the last 17 years, the number of inpatient surgeries increased annually by an average of 11.13%, with some fluctuations. In total, 76.4% (15,496/20,288) of the surgeries were performed in patients with CDD aged 41 to 65 years, and there was no significant change in the mean age at surgery. More male patients were observed, and the proportions of male and female patients who underwent surgery were 64.7% (13,126/20,288) and 35.3% (7162/20,288), respectively. However, interestingly, the proportion of surgeries performed among female patients showed an increasing trend (P<.001), leading to a narrowing sex gap. The average length of stay for surgical treatment decreased from 21 days to 6 days and showed a steady decline from 2012 onward.

Conclusions

The RWD showed its capability in supporting clinical research. The mean age at surgery for CDD was consistent in the real-world population, the proportion of female patients increased, and the average length of stay decreased over time. These results may be valuable to guide resource allocation for the early prevention and diagnosis, as well as surgical treatment of CDD.

Early Self-directed Home Exercise Program After Anterior Cervical Discectomy and Fusion: A Pilot Study

STUDY DESIGN

Pilot randomized controlled trial.

OBJECTIVE

To examine the acceptability and preliminary safety and outcome effects of an early self-directed home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Little is known regarding optimal postoperative management after ACDF.

METHODS

Thirty patients (mean ± standard deviation, age = 50.6 ± 11.0 years, 16 women) undergoing ACDF were randomized to receive an early HEP (n = 15) or usual care (n = 15). The early HEP was a 6-week self-directed program with weekly supportive telephone calls to reduce pain and improve activity. Treatment acceptability was assessed after the intervention period (6 weeks after surgery). Safety (adverse events, radiographic fusion, revision surgery) was determined at routine postoperative visits. Disability (Neck Disability Index), pain intensity (Numeric Rating Scale for neck and arm pain), physical and mental health (SF-12), and opioid use were assessed preoperatively, and at 6 weeks and 6 and 12 months after surgery by an evaluator blinded to group assignment.

RESULTS

Participants reported high levels of acceptability and no serious adverse events with the early HEP. No difference in fusion rate was observed between groups (P > 0.05) and no participants underwent revision surgery. The early self-directed HEP group reported lower 6-week neck pain than the usual care group (F = 3.3, P = 0.04, r = 0.3, mean difference = -1.7 [-3.4; -0.05]) and lower proportion of individuals (13% vs. 47%) using opioids at 12 months (P = 0.05). No other between-group outcome differences were observed (P > 0.05).

CONCLUSION

An early self-directed HEP program was acceptable to patients and has the potential to be safely administered to patients immediately after ACDF. Benefits were noted for short-term neck pain and long-term opioid utilization. However, larger trials are needed to confirm safety with standardized and long-term radiograph assessment and treatment efficacy.

LEVEL OF EVIDENCE

2.

Interaction patterns of trauma providers are associated with length of stay

Background

Trauma-related hospitalizations drive a high percentage of health care expenditure and inpatient resource consumption, which is directly related to length of stay (LOS). Robust and reliable interactions among health care employees can reduce LOS. However, there is little known about whether certain patterns of interactions exist and how they relate to LOS and its variability. The objective of this study is to learn interaction patterns and quantify the relationship to LOS within a mature trauma system and long-standing electronic medical record (EMR).

Methods

We adapted a spectral co-clustering methodology to infer the interaction patterns of health care employees based on the EMR of 5588 hospitalized adult trauma survivors. The relationship between interaction patterns and LOS was assessed via a negative binomial regression model. We further assessed the influence of potential confounders by age, number of health care encounters to date, number of access action types care providers committed to patient EMRs, month of admission, phenome-wide association study codes, procedure codes, and insurance status.

Results

Three types of interaction patterns were discovered. The first pattern exhibited the most collaboration between employees and was associated with the shortest LOS. Compared to this pattern, LOS for the second and third patterns was 0.61 days (P = 0.014) and 0.43 days (P = 0.037) longer, respectively. Although the 3 interaction patterns dealt with different numbers of patients in each admission month, our results suggest that care was provided for similar patients.

Discussion

The results of this study indicate there is an association between LOS and the extent to which health care employees interact in the care of an injured patient. The findings further suggest that there is merit in ascertaining the content of these interactions and the factors that induce these differences in interaction patterns within a trauma system.

Non-medical factors significantly influence the length of hospital stay after surgery for degenerative spine disorders

BACKGROUND

Unnecessarily long hospital stays are costly and inefficient. Studies have shown that the length of hospital stay (LOS) for spine surgical procedures is influenced by various disease-related or medical factors, but few have examined the role of socio-demographic/socio-economic (SDE) factors.

METHODS

This was a retrospective analysis of data from 10,770 patients (5056 men, 5714 women; 62 ± 15 years) with degenerative spinal disorders, collected prospectively in an in-house database within the framework of EUROSPINE's Spine Tango Registry. Surgeons completed the Tango surgery form (clinical history, demographics, surgical measures, complications), and patients, a baseline Core Outcome Measures Index. Stepwise linear regression analyses examined SDE predictors of LOS, controlling for potential medical/biological factors.

RESULTS

The mean LOS was 7.9 ± 5.2 days. The final model accounted for 42% of variance in LOS, with SDE variables explaining 13% variance and medical/surgical predictors, 29%. In the final model, the SDE factors age and being female were significant independent predictors of LOS, whereas others were either non-significant (insurance status, being of Swiss nationality, being a smoker) or reached only borderline significance (p < 0.1) (BMI). Controlling for all other SDE and medical/surgical confounders, being female was associated with 1.11-day longer LOS (95% CI 0.96-1.27; p < 0.0001).

CONCLUSIONS

Patients of advanced age and female gender are at increased risk of longer hospital stay after surgery for degenerative spinal disorders. Further studies should seek to understand the reasoning behind the gender disparity, in order to minimise potentially unnecessary costs of prolonged LOS. Targeted preoperative discharge planning may improve the utilisation of hospital resources. These slides can be retrieved under Electronic Supplementary Material.

Safety and feasibility of an early telephone-supported home exercise program after anterior cervical discectomy and fusion: a case series

Objective: To describe the safety, feasibility, and preliminary outcomes of an early telephone-supported home exercise program (HEP) performed within the first 6 weeks after anterior cervical discectomy and fusion (ACDF) surgery.Methods: Eight patients (mean ± SD age = 53.4 ± 14.9 years, 5 females) were enrolled in this case series. Immediately after surgery, patients began a 6-week HEP including daily walking, deep breathing, distraction techniques, and cervical and upper body exercises. The HEP was supported by weekly telephone calls by a physical therapist. Safety for performing early exercise was examined with radiographic imaging at 6 months. Adverse events were assessed through weekly calls with a physical therapist. HEP adherence and acceptability data were obtained by patient self-report. Clinical measures were assessed preoperatively, at 6 weeks and at 6 months, and included the Neck Disability Index, Numeric Rating Scale for pain, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, and accelerometry for physical activity.Results: Early radiographic imaging showed no signs of nonunion at 6 months. There were no reports of serious adverse events. At 6 months, all patients reported clinically significant changes in pain catastrophizing. Seven (88%) patients had clinically significant changes in disability and arm pain, six (75%) patients for neck pain and pain self-efficacy, and five (53%) patients for fear of movement. Only three (43%) of seven patients showed increased physical activity at 6 months.Conclusion: Based on this small case series, an early telephone-supported HEP appears safe for patients, feasible to implement, and promising for clinical benefits.

Platysma sparing approach to anterior cervical spine surgery: A less exposure surgery technique

Introduction

Authors aim to demonstrate the surgical technique and outcomes of using a platysma sparing approach to anterior cervical spine surgery.

Methods

Medical records of 496 prospective patients, group 1 (259 patients) with an outpatient platysma muscle-sparing approach. Group 2 (237 patients) with inpatient standard muscle-splitting approach.

Results

Intergroup comparison showed statistical significant improvement in VAS neck and NDI scores p = 0.009 and p = 0.012 and surgical operative time and estimated blood loss, p = 0.003 and p = 0.006 respectively.

Conclusion

This anatomy sparing technique demonstrates a safe, effective and reproducible approach to cervical spine surgery which is a goal of less exposure surgery philosophy.

Racial Disparities in Surgical Outcomes After Spine Surgery: An ACS-NSQIP Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Racial disparities in postoperative outcomes are unfortunately common. We present data assessing race as an independent risk factor for postoperative complications after spine surgery for Native American (NA) and African American (AA) patients compared with Caucasians (CA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for spine procedures performed in 2015. Data was subdivided by surgery, demography, comorbidity, and 30-day postoperative outcomes, which were then compared by race. Regression was performed holding race as an independent risk factor.

RESULTS

A total of 4803 patients (4106 CA, 522 AA, 175 NA) were included in this analysis. AA patients experienced longer length of stay (LOS) and operative times (P < .001) excluding lumbar fusion, which was significantly shorter (P = .035). AA patients demonstrated higher comorbidity burden, specifically for diabetes and hypertension (P < .005), while NA individuals were higher tobacco consumers (P < .001). AA race was an independent risk factor associated with longer LOS across all cervical surgeries (β = 1.54, P <.001), lumbar fusion (β = 0.77, P = .009), and decompression laminectomy (β = 1.23, P < .001), longer operative time in cervical fusion (β = 12.21, P = .032), lumbar fusion (β = -24.00, P = .016), and decompression laminectomy (OR = 20.95, P < .001), greater risk for deep vein thrombosis in lumbar fusion (OR = 3.72, P = .017), and increased superficial surgical site infections (OR = 5.22, P = .001) and pulmonary embolism (OR = 5.76, P = .048) in decompression laminectomy. NA race was an independent risk factor for superficial surgical site infections following cervical fusion (OR = 14.58, P = .044) and decompression laminectomy (OR = 4.80, P = .021).

CONCLUSION

AA and NA spine surgery patients exhibit disproportionate comorbidity burden and greater 30-day complications compared with CA patients. AA and NA race were found to independently affect rates of complications, LOS, and operation time.

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

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

The effectiveness of exercise on cervical radiculopathy: A protocol for systematic review and meta-analysis

BACKGROUND

Significant functional limitations and disabilities are common presenting complaints for people suffering from cervical radiculopathy. Exercise is a common conservative treatment for this disease. Therefore, we conducted a systematic review and meta-analysis to explore the efficacy of exercise in the treatment of cervical radiculopathy.

METHODS

A systematic literature search for studies will be performed in 7 databases, including PubMed, Web of Science, Embase, the Cochrane Library, the Chinese National Knowledge Infrastructure Database (CNKI), Wanfang database, and VIP database. The methodological quality of the included studies using the risk bias assessment tool of Cochrane and the level of evidence for results are assessed by the GRADE method. Statistical analysis is conducted with Revman 5.3.

RESULTS

This systematic review and meta-analysis will provide a synthesis of existed evidences for exercise on cervical radiculopathy.

CONCLUSION

The conclusion of this study will provide evidence to assess effectiveness of exercise on cervical radiculopathy, which can further guide clinical decision-making.

PROSPERO REGISTRATION NUMBER

CRD42019121886.

What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?

STUDY DESIGN

Retrospective, observational study.

OBJECTIVE

To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery.

METHODS

The Humana claims dataset (2007-2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention.

RESULTS

Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193).

CONCLUSION

The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step.

LEVEL OF EVIDENCE

3.

Postoperative Complications Following Orthopedic Spine Surgery: Is There a Difference Between Men and Women?

Background

Patient sex is known to affect outcomes following surgery. Prior studies have not specifically examined sex-stratified outcomes following spine surgery. The objective is to determine the differences between men and women in terms of 30-day complications following spine surgery.

Methods

The National Surgical Quality Improvement Program database was queried for patients undergoing spine surgery from 2005 to 2014. Postoperative data were analyzed to determine the differences between men and women with regard to 30-day complications.

Results

A total of 41 315 patients (49.0% women, 51% men) were analyzed. Men were more likely to have diabetes (P = .004) and be active smokers (P < .001). Women were more likely to be taking steroids for chronic conditions (P < .001). Postoperatively, women were at increased risk for superficial surgical site infection, urinary tract infection, transfusions, and longer length of stay, whereas men were at increased risk of pneumonia and reintubation. On multivariate analysis, women were associated with urinary tract infections (odds ratio = 2.17) and transfusions (odds ratio = 1.63).

Conclusions

Differences in complications are evident between men and women following spine surgery. These differences should be considered during preoperative planning and when consenting patients for surgery.

Level of Evidence

4.

Factors Contributing to Increases in Diabetes-Related Preventable Hospitalization Costs Among U.S. Adults During 2001-2014

OBJECTIVE

To examine changes in diabetes-related preventable hospitalization costs and to determine the contribution of each underlying factor to these changes.

RESEARCH DESIGN AND METHODS

We used data from the 2001-2014 U.S. National (Nationwide) Inpatient Sample (NIS) for adults (≥18 years old) to estimate the trends in hospitalization costs (2014 USD) in total and by condition (short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputation). Using regression and growth models, we estimated the relative contribution of following underlying factors: total number of hospitalizations, rate of hospitalization, the number of people with diabetes, mean cost per admission, length of stay, and cost per day.

RESULTS

During 2001-2014, the estimated total cost of diabetes-related preventable hospitalizations increased annually by 1.6% (92.9 million USD; P < 0.001). Of this 1.6% increase, 75% (1.2%) was due to the increase in the number of hospitalizations, which is a result of a 3.8% increase in diabetes population and a 2.6% decrease in the hospitalization rate, and 25% (0.4%) was due to the increase in cost per admission, for a net result of a 1.6% increase in cost per day and a 1.3% decline in mean length of stay. By component, the cost of short-term complications, lower-extremity amputations, and long-term complications increased annually by 4.2, 1.9, and 1.5%, respectively, while the cost of uncontrolled diabetes declined annually by 2.6%.

CONCLUSIONS

The total cost of diabetes-related preventable hospitalizations had been increasing during 2001-2014, mainly resulting from increases in number of people with diabetes and cost per hospitalization day. The underlying factors identified in our study could lead to efforts that may lower future hospitalization costs.

Sex Differences for Anterior Cervical Fusion: Complications and Length of Stay

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To assess differences in baseline characteristics between sexes of patients undergoing anterior cervical discectomy and fusion (ACDF) and risk factors for adverse outcomes according to sex.

SUMMARY OF BACKGROUND DATA

ACDF is a common treatment for cervical spine disease. To reduce the rate of complications, risk factors associated with adverse events have been identified. However, few studies have examined the risk for inferior outcomes or complications after ACDF by sex.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent ACDF from 2005 through 2014. Data collected included demographics, comorbidities, operative characteristics, and postoperative adverse events. Demographic and comorbidity variables were compared between men and women using chi-squared analysis. Perioperative outcomes were compared between groups using multivariate linear regression or Poisson regression with robust error variance controlling for preoperative characteristics.

RESULTS

In the 20,383 patients who met inclusion criteria, the male cohort was slightly older, less likely to be normal weight or morbidly obese, and had a higher incidence of diabetes and hypertension (P < 0.001 for each). Male sex was associated with a greater risk of any adverse event (relative risk = 1.2; P = 0.043), as well as any severe adverse event (relative risk  = 1.4; P = 0.001). Moreover, male sex exhibited longer operative times compared to the female group (127 vs. 117 min; β = 10; P < 0.001).

CONCLUSION

The results of the current study suggest male sex is associated with an increased risk of adverse events following ACDF. Male sex has previously been demonstrated to correlate with medical comorbidities, which may be partly responsible for the increased morbidity. Because of the contrasting evidence throughout the literature, further studies are required to better elucidate this effect.

LEVEL OF EVIDENCE

3.

Surgeon Reimbursement Relative to Hospital Payments for Spinal Fusion: Trends From 10-year Medicare Analysis

STUDY DESIGN

Retrospective, economic analysis.

OBJECTIVE

The aim of this study was to analyze the trend in hospital charge and payment adjusted to corresponding surgeon charge and payment for cervical and lumbar fusions in a Medicare sample population from 2005 to 2014.

SUMMARY OF BACKGROUND DATA

Previous studies have reported trends and variation in hospital charges and payments for spinal fusion, but none have incorporated surgeon data in analysis. Knowledge of the fiscal relationship between hospitals and surgeons over time will be important for stakeholders as we move toward bundled payments.

METHODS

A 5% Medicare sample was used to capture hospital and surgeon charges and payments related to cervical and lumbar fusion for degenerative disease between 2005 and 2014. We defined hospital charge multiplier (CM) as the ratio of hospital/surgeon charge. Similarly, the hospital/surgeon payment ratio was defined as hospital payment multiplier (PM). The year-wise and regional trend in patient profile, length of stay, discharge disposition, CM, and PM were studied for all fusion approaches separately.

RESULTS

A total of 40,965 patients, stratified as 15,854 cervical and 25,111 lumbar fusions, were included. The hospital had successively higher charges and payments relative to the surgeon from 2005 to 2014 for all fusions with an inverse relation to hospital length of stay. Increasing complexity of fusion such as for anterior-posterior cervical fusion had higher hospital reimbursements per dollar earned by the surgeon. There was regional variation in how much the hospital charged and received per surgeon dollar.

CONCLUSION

Hospital charge and payment relative to surgeon had an increasing trend despite a decreasing length of stay for all fusions. Although the hospital can receive higher payments for higher-risk patients, this risk is not reflected proportionally in surgeon payments. The shift toward value-based care with shared responsibility for outcomes and cost will likely rely on better aligning incentives between hospital and providers.

LEVEL OF EVIDENCE

3.

National Trends in Demographics and Outcomes Following Cervical Fusion for Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective trends analysis.

OBJECTIVES

Cervical fusion is a common adjunctive surgical modality used in the treatment of cervical spondylotic myelopathy (CSM). The purpose of this study was to quantify national trends in patient demographics, hospital characteristics, and outcomes in the surgical management of CSM.

METHODS

This was a retrospective study that used the National Inpatient Sample. The sample included all patients over 18 years of age with a diagnosis of CSM who underwent cervical fusion from 2003 to 2013. The outcome measures were in-hospital mortality, length of stay, and hospital charges. Chi-square tests were performed to compare categorical variables. Independent t tests were performed to compare continuous variables.

RESULTS

We identified 62 970 patients with CSM who underwent cervical fusion from 2003 to 2013. The number of fusions performed per year in the treatment of CSM increased from 3879 to 8181. The average age of all fusion patients increased from 58.2 to 60.6 years (P < .001). Length of stay did not change significantly from a mean of 3.7 days. In-hospital mortality decreased from 0.6% to 0.3% (P < .01). Hospital charges increased from $49 445 to $92 040 (P < .001).

CONCLUSIONS

This study showed a dramatic increase in cervical fusions to treat CSM from 2003 to 2013 concomitant with increasing age of the patient population. Despite increases in average age and number of comorbidities, length of stay remained constant and a decrease in mortality was seen across the study period. However, hospital charges increased dramatically.

Costs in Pituitary Surgery: Racial, Socioeconomic, and Hospital Factors

Objective  To investigate the influence of patient demographic factors and hospital factors on cost and length of stay in patients undergoing pituitary surgery. Design/Setting  A retrospective cross-sectional study of the 2008 to 2012 Nationwide/National Inpatient Sample. Participants  Patient demographics and hospital characteristics for patients undergoing pituitary surgery were compared between white, black, and Hispanic patients. Main Outcome Measures  Variables associated with increased cost and increased length of hospital stay were ascertained and compared against each racial and ethnic group via multiple linear regression analysis. Results  Of 8,812 patients who underwent pituitary surgery, 5,924 (67.2%) patients were white, 1,590 (18.0%) were black, and 1,296 (14.7%) were Hispanic. Patient variables found to be significantly different between racial groups via univariate analysis were age, chronic conditions, gender, income, and primary payer. Hospital variables found to be significantly different were location/teaching status, region, and ownership. Hospitalization cost was significantly lower for whites (-$3,082, 95% confidence interval [CI] -$3,961 to -$2,202) and significantly higher for both blacks ($1,889, 95% CI $842-$2,937) and Hispanics ($2,997, 95% CI $1,842-$4,152). Length of hospital stay was also significantly lower in whites (-1.01, 95% CI -1.31 to -0.72) and significantly higher for both blacks (0.65, 95% CI 0.30 to 1.00) and Hispanics (0.96, 95% CI 0.57-1.35). Conclusions  Racial and ethnic factors contribute to differences in hospital utilization and cost for patients undergoing pituitary surgery. Further investigations are necessary to uncover the sources of these disparities in an effort to provide safer and more affordable care to all patients.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions:

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

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

This study analyzed prospectively collected data.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors Affecting Length of Stay and Complications After Elective Anterior Cervical Discectomy and Fusion: A Study of 2164 Patients From The American College of Surgeons National Surgical Quality Improvement Project Database (ACS NSQIP)

STUDY DESIGN

Retrospective review of the prospective American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database with 30-day follow-up of 2164 patients undergoing elective anterior cervical discectomy and fusion (ACDF).

OBJECTIVE

To determine factors independently associated with increased length of stay (LOS) and complications after ACDF to facilitate preoperative planning and setting of realistic expectations for patients and providers.

SUMMARY OF BACKGROUND DATA

The effect of individual preoperative factors on LOS and complications has been evaluated in small-scale studies. Large database analysis with multivariate analysis of these variables has not been reported.

METHODS

The ACS NSQIP database from 2005 to 2010 was queried for patients undergoing ACDF procedures. Preoperative and perioperative variables were collected. Multivariate regression determined significant predictors (P<0.05) of extended LOS and complications.

RESULTS

Average LOS was 2.0±4.0 days (mean±SD) with a range of 0-103 days. By multivariate analysis, age 65 years and above, functional status, transfer from facility, preoperative anemia, and diabetes were the preoperative factors predictive of extended LOS. Major complications, minor complications, and extended surgery time were the perioperative factors associated with increased LOS. The elongating effect of these variables was determined, and ranged from 0.5 to 5.0 days. Seventy-one patients (3.3%) had a total of 92 major complications, including return to operating room (40), venous thrombotic events (13), respiratory (21), cardiac (6), mortality (5), sepsis (4), and organ space infection (3). Multivariate analysis determined ASA score ≥3, preoperative anemia, age 65 years and above, extended surgery time, and male sex to be predictive of major complications (odds ratios ranging between 1.756 and 2.609). No association was found between levels fused and LOS or complications.

CONCLUSION

Extended LOS after ACDF is associated with factors including age, anemia, and diabetes, as well as the development of postoperative complications. One in 33 patients develops a major complication postoperatively, which are associated with an increased LOS of 5 days.

Medicare Charges and Payments for Cervical Spine Surgery: Association With Hospital Characteristics

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To determine the association of hospital and patient population characteristics with charges and payments for Medicare patients undergoing cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Third-party payers such as Medicare pay negotiated rates for health care services that represent a substantial savings from hospitals' list prices. Previous research has shown geographical variation in hospital charges. However, the association with other hospital and patient population characteristics is poorly understood.

METHODS

We determined the association of hospital characteristics (hospital size, ownership, location, teaching status, procedure volume, and geographical region) and patient population characteristics (proportion female, nonwhite, or with ≥1 comorbid conditions) with excess charges (difference between hospital charges and payments) and cost-to-charge ratio (ratio of payments to hospital charges) for Medicare patients undergoing cervical spine fusion without complication (MS-DRG 473). Significance levels were set at a P value less than 0.05.

RESULTS

The median excess charge was $59,799 (interquartile range, $41,668, $69,576) and cost-to-charge ratio was 25.8% (interquartile range, 20.4%, 32.7%). Higher excess charges were observed for urban hospitals (P = 0.003). There was an association between excess charges and procedure volume (P = 0.034) and proportion of patients with 1 or more comorbid conditions (P = 0.008). There were no differences based on hospital size, ownership, teaching status, geographical region, or proportion of female or nonwhite patients.Private hospitals had higher cost-to-charge ratios than government hospitals (P = 0.017). There was no association with hospital size, teaching status, geographical region, procedure volume, or proportion of patients who were female, nonwhite, or who had 1 or more comorbid conditions.

CONCLUSION

The relationship between hospital charges and payments for cervical spine surgery without complication is associated with certain hospital and patient population characteristics. Further study is needed to determine whether these differences are associated with health outcomes.

LEVEL OF EVIDENCE

3.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

Retrospective cohort analysis.

PATIENT SAMPLE

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

OUTCOME MEASURES

Total hospital costs during single admission.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Elixhauser comorbidity method outperforms the Charlson index in predicting inpatient death after orthopaedic surgery

BACKGROUND

Scores derived from comorbidities can help with risk adjustment of quality and safety data. The Charlson and Elixhauser comorbidity measures are well-known risk adjustment models, yet the optimal score for orthopaedic patients remains unclear.

QUESTIONS/PURPOSES

We determined whether there was a difference in the accuracy of the Charlson and Elixhauser comorbidity-based measures in predicting (1) in-hospital mortality after major orthopaedic surgery, (2) in-hospital adverse events, and (3) nonroutine discharge.

METHODS

Among an estimated 14,007,813 patients undergoing orthopaedic surgery identified in the National Hospital Discharge Survey (1990-2007), 0.80% died in the hospital. The association of each Charlson comorbidity measure and Elixhauser comorbidity measure with mortality was assessed in bivariate analysis. Two main multivariable logistic regression models were constructed, with in-hospital mortality as the dependent variable and one of the two comorbidity-based measures (and age, sex, and year of surgery) as independent variables. A base model that included only age, sex, and year of surgery also was evaluated. The discriminative ability of the models was quantified using the area under the receiver operating characteristic curve (AUC). The AUC quantifies the ability of our models to assign a high probability of mortality to patients who die. Values range from 0.50 to 1.0, with 0.50 indicating no ability to discriminate and 1.0 indicating perfect discrimination.

RESULTS

Elixhauser comorbidity adjustment provided a better prediction of in-hospital case mortality (AUC, 0.86; 95% CI, 0.86-0.86) compared with the Charlson model (AUC, 0.83; 95% CI, 0.83-0.84) and to the base model with no comorbidities (AUC, 0.81; 95% CI, 0.81-0.81). In terms of relative improvement in predictive performance, the Elixhauser measure performed 60% better than the Charlson score in predicting mortality. The Elixhauser model discriminated inpatient morbidity better than the Charlson measure, but the discriminative ability of the model was poor and the difference in the absolute improvement in predictive power between the two models (AUC, 0.01) is of dubious clinical importance. Both comorbidity models exhibited the same degree of discrimination for estimating nonroutine discharge (AUC, 0.81; 95% CI, 0.81-0.82 for both models).

CONCLUSIONS

Provider-specific outcomes, particularly inpatient mortality, may be evaluated differently depending on the comorbidity risk adjustment model selected. Future research assessing and comparing the performance of the Charlson and Elixhauser measures in predicting long-term outcomes would be of value.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

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

STUDY DESIGN

Retrospective cohort study of 183 patients who underwent elective anterior cervical discectomy and fusion (ACDF) at a single institution during a 2-year period.

OBJECTIVE

To determine which preoperative factors were independently associated with a prolonged hospital length of stay (LOS) after ACDF.

SUMMARY OF BACKGROUND DATA

ACDF has become the most common treatment modality for addressing cervical spine pathology. Extended LOS after ACDF is associated with increased costs and complications. There is a lack of conclusive data for factors affecting LOS after ACDF. This study aims to create a multivariate model to determine the association of various patient and operative characteristics with LOS after ACDF.

METHODS

Patients who underwent elective ACDF at a single academic institution between January 2011 and February 2013 were identified using billing records. Their charts were reviewed to collect variables available preoperatively such as patient demographics, comorbidities, and surgery planned. Patients were categorized as normal or extended LOS, with extended LOS defined as LOS more than the 75th percentile. A multivariate logistic regression was used to determine which factors were independently associated with extended LOS.

RESULTS

A total of 183 patients with ACDF were identified. The average LOS for this cohort was 2.0 ± 2.5 days (mean ± standard deviation). Extended LOS was defined as 3 days or more. Multivariate analysis revealed that preoperative factors independently associated with extended LOS were history of nonspinal malignancy (odds ratio [OR] = 4.9), history of pulmonary disease (OR = 4.0), and procedures that included corpectomy (OR = 4.5).

CONCLUSION

Patients with a history of nonspinal malignancy or pulmonary disease, as well as patients who underwent corpectomy, were more likely to have an extended LOS (ORs, 4.0-4.9). Of significant note, other factors that one might expect to be associated with extended LOS did not independently predict extended LOS in this analysis.

LEVEL OF EVIDENCE

3.

Diabetes as a risk factor for poorer early postoperative outcomes after shoulder arthroplasty

BACKGROUND

Although diabetes has been associated with increased perioperative morbidity and mortality after hip and knee arthroplasty, its impact on early postoperative outcomes after shoulder replacement remains relatively unexplored. The purpose of the study was to determine the association of diabetes with in-hospital death, complications, length of stay, non-homebound disposition, and cost in patients undergoing shoulder arthroplasty.

METHODS

By use of the Nationwide Inpatient Sample database for the year 2011, an estimated 66,485 patients having undergone shoulder arthroplasty were identified and separated into groups with (21%) and without (79%) diabetes mellitus. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed by bivariate and multivariable analyses with logistic regression modeling.

RESULTS

Diabetes mellitus was independently associated with in-hospital death, a number of perioperative complications, prolonged hospital stay, and increased non-homebound disposition after shoulder arthroplasty. The presence of diabetes was not associated with increased hospital cost.

CONCLUSION

Patients with preexisting diabetes are at higher risk for perioperative morbidity and mortality after shoulder arthroplasty. Future prospective research should explore in more detail the relationship between diabetes and shoulder arthroplasty outcomes.