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

Out-of-hours emergent surgery for degenerative spinal disease in Canada: a retrospective cohort study from a national registry

Background

Spinal degenerative disease represents a growing burden on our healthcare system, yet little is known about longitudinal trends in access and care. Our goal was to provide an essential portrait of surgical volume trends for degenerative spinal pathologies within Canada.

Methods

The Canadian Institute for Health Information (CIHI) database was used to identify all patients receiving surgery for a degenerative spinal condition from 2006 to 2019. Trends in number of interventions, unscheduled vs scheduled hospitalizations, in-hours vs out-of-hours interventions, resource utilization and adverse events were analyzed retrospectively using linear regression models. Confidence intervals were reported in the expected count ratio scale (CR).

Findings

A total of 338,629 spinal interventions and 256,360 hospitalizations between 2006 and 2019 were analyzed. The mean and SD of the annual mean age of patients was 55.5 (SD 1.6) for elective hospitalizations and 55.6 (SD 1.6) for emergent hospitalizations. The proportion of female patients was 47.8% (91,789/192,027) for elective hospitalizations and 41.4% (26,633/64,333) for emergent hospitalizations. Elective hospitalizations increased an average of 2.0% per year, with CR = 1.020 (95% CI 1.017-1.023, p < 0.0001) while emergent hospitalizations exhibited more rapid growth with an average 3.4% annually, with CR 1.034 (95% CI 1.027-1.040, p < 0.0001). «In-hours » surgeries increased on average 2.7% per year, with CR 1.027 (95% CI 1.021-1.033, p < 0.0001), while « out-of-hours » surgeries increased 6.1% annually, with CR 1.061 (95% CI 1.051-1.071, p < 0.0001). The resource utilization for unscheduled hospitalizations approximates two and a half times that of scheduled hospitalizations. The proportions of spinal interventions with at least one adverse event increased on average 6.3% per year, with CR 1.063 (95% CI 1.049-1.077, p < 0.0001).

Interpretation

This study provides novel data critical for all providers and stakeholders. The rapid growth of emergent out-of-hours hospitalizations demonstrates that the needs of this growing patient population have far exceeded health-care resource allocations. Future studies will analyze the health-related quality of life implications of this system shift and identify demographic and socioeconomic inequities in access to surgical care.

Funding

This work was funded by the Bob and Trish Saunders Spine Research Fund through The VGH and UBC Hospital Foundation. The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the manuscript.

Interpretable machine learning models to predict short-term postoperative outcomes following posterior cervical fusion

By predicting short-term postoperative outcomes before surgery, patients who undergo posterior cervical fusion (PCF) surgery may benefit from more precise patient care plans that reduce the likelihood of unfavorable outcomes. We developed machine learning models for predicting short-term postoperative outcomes and incorporate these models into an open-source web application in this study. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent PCF surgery. Prolonged length of stay, non-home discharges, and readmissions were the three outcomes that were investigated. To predict these three outcomes, machine learning models were developed and incorporated into an open access web application. A total of 6277 patients that underwent PCF surgery were included in the analysis. The most accurately predicted outcome in terms of the area under the receiver operating characteristic curve (AUROC) was the non-home discharges with a mean AUROC of 0.812, and the most accurately predicting algorithm in terms of AUROC was the LightGBM algorithm with a mean AUROC of 0.766. The following URL will take users to the open access web application created to provide predictions for individual patients based on their characteristics: https://huggingface.co/spaces/MSHS-Neurosurgery-Research/NSQIP-PCF. Machine learning techniques have a significant potential for predicting postoperative outcomes following PCF surgery. The development of predictive models as clinically useful decision-making tools may significantly improve risk assessment and prognosis as the amount of data in spinal surgery keeps growing. Here, we present predictive models for PCF surgery that are meant to accomplish the aforementioned goals and make them publicly available.

Factors associated with prolonged postoperative length of hospital stay after laparoscopic colorectal cancer resection: a secondary analysis of a randomized controlled trial

BACKGROUND

The postoperative length of hospital stay (PLOS) is an important indicator of surgical quality. We identified perioperative factors that affect prolonged PLOS (PPLOS) after laparoscopic colorectal cancer resection, which is the preferred surgical approach for colorectal cancer, the third most common cancer.

METHODS

This study was a secondary analysis of a randomized trial (clinicaltrials.gov ID: NCT03160144) that included 280 patients who underwent laparoscopic colorectal cancer resection. The primary outcome was a PPLOS, defined as a PLOS that was longer than the median PLOS. Baseline, anesthetic, surgical, and postoperative management factors were included in the univariate and multivariate analyses to identify factors influencing PPLOS.

RESULTS

The median PLOS was 10 days, and 117 patients had a PPLOS. We identified six influencing factors for PPLOS: preoperative pulse oxygen saturation < 96% (odds ratio [OR], 3.09 [95% confidence interval (CI) 1.38-6.92]; P = 0.006), distant tumor metastasis (OR, 0.34 [95% CI 0.13-0.91]; P = 0.031), the Miles procedure or left hemicolectomy (OR, 4.51 [95% CI 1.67-12.18]; P = 0.003), perioperative surgical events (OR, 2.44 [95% CI 1.25-4.76]; P = 0.009), postoperative albumin infusion (OR, 2.19 [95% CI 1.14-4.19]; P = 0.018), and postoperative early ambulation (OR, 0.35 [95% CI 0.18-0.68]; P = 0.002). Further stratified analysis showed that postoperative albumin infusion might be a risk factor for PPLOS, even in patients with a preoperative albumin level < 40 g/L (OR, 2.29 [95% CI 0.98-5.34]; P = 0.056) or duration of surgery ≥ 3 h (OR, 2.52 [95% CI 1.08-5.87]; P = 0.032).

CONCLUSIONS

A low preoperative pulse oximetry reading, complex surgical procedures, perioperative surgical events, and postoperative albumin infusion may be risk factors for PPLOS after laparoscopic colorectal cancer resection, whereas distant tumor metastasis and postoperative early ambulation might be protective factors. The association between postoperative albumin infusion, a modifiable factor, and PLOS or clinical outcomes warrants further investigation.

Increased Severity of Anemia Is Associated with Postoperative Complications following a Adult Spinal Deformity Surgery

BACKGROUND

Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery.

METHODS

Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed.

RESULTS

Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P < 0.001) and extended length of stay (OR 1.43, P < 0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P = 0.028), death (OR 13.15, P = 0.001), postoperative blood transfusion (OR 2.81, P < 0.001), and extended length of stay (OR 3.02, P < 0.001).

CONCLUSIONS

We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

Variations in LOS and its main determinants overtime at an academic spinal care center from 2006-2019

Objectives

Efforts to safely reduce hospital LOS while maintaining quality outcomes and patient satisfaction are paramount. The primary goal of this study was to assess trends in LOS at a high-volume quaternary care spine center. Secondary goals were to assess trends in factors most associated with prolonged LOS.

Methods

This is a prospective study of all consecutive patients admitted from January 2006 to December 2019. Data included demographics, diagnostic category (degenerative, oncology, deformity, trauma, other), LOS (mean, median, interquartile range, standard deviation, defined as days from admission to discharge), and in-hospital adverse events.

Results

A total of 13,493 patients were included. Overall LOS has not changed over time with an overall median of 6.3 days (p = 0.451). Median LOS significantly increased for patients treated for degenerative pathology from 2.2 days in 2006 to 3.2 days in 2019 (p = 0.019). LOS has not changed for patients treated for deformity (overall median 6.8 days, p = 0.411), oncology (overall median 11.0 days, p = 0.051), or trauma (overall median 11.8 days, p = 0.582). Emergency admissions increased 3.2%/year for degenerative pathologies (p =  < 0.001). Mean age has increased from 48.4 years in 2006 to 58.1 years in 2019 (p =  < 0.001). This trend was observed in the deformity, degenerative and trauma group, not for patients treated for oncological disease. More adverse events were significantly associated with increasing age.

Conclusion

This is the first North American study to comprehensively analyze trends in LOS for spinal surgery overtime in an academic center. Overall, LOS has not changed from 2006–2019. Various factors that influence LOS appear to have balanced each other. It may also be explained by the changing epidemiology of both elective and emergency surgeries. These findings provide opportunities for intervention and improvement, targeted at the geriatric population, to reduce length of hospitalization.

IDENTIFICATION OF RISK FACTORS ASSOCIATED WITH 30-DAY READMISSION OF PATIENTS SUBMITTED TO ANTERIOR OR POSTERIOR ACCESS CERVICAL SPINE SURGERY

ABSTRACT Aim: To conduct a systematic review of the literature to identify risk factors associated with 30-day readmission of patients submitted to anterior or posterior access cervical spine surgery. Methods: The databases used to select the papers were PubMed, Web of Science, and Cochrane, using the following search strategy: patient AND readmission AND (30 day OR “thirty day” OR 30-day OR thirty-day) AND (spine AND cervical). Results: Initially, 179 papers that satisfied the established search stringwere selected. After reading the titles and abstracts, 46 were excluded from the sample for not effectively discussing the theme proposed for this review. Of the 133 remaining papers, 109 were also excluded after a detailed reading of their content, leaving 24 that were included in the sample for the meta-analysis. Conclusions: The average readmission rate in the studies evaluated was 4.85%. Only the occurrence of infections, as well as the presence of patients classified by the American Society of Anesthesiology (ASA) assessment system with scores greater than III, were causal factors that influenced the readmission of patients. No significant differences were noted when comparing the anterior and posterior surgical access routes. Level of evidence II; Systematic Review of Level II or Level I Studies with discrepant results.

Cost and Complications of Single-Level Lumbar Decompression in Those Over and Under 75: A Matched Comparison

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

This study aimed to compare costs and complication rates following single-level lumbar decompression in patients under age 75 versus patients aged 75 and older.

SUMMARY OF BACKGROUND DATA

Lumbar decompression is a common surgical treatment for lumbar pathology; however, its effectiveness can be debated in elderly patients because complication rates and costs by age group are not well-defined.

METHODS

The Medicare database was queried through the PearlDiver server for patients who underwent single-level lumbar decompression without fusion as an index procedure. The 90-day complication and reoperation rates were compared between age groups after matching for sex and comorbidity burden. Same day and 90-day costs are compared.

RESULTS

The matched cohort included 89,388 total patients (n = 44,694 for each study arm). Compared to the under 75 age group, the 75 and older age group had greater rates of deep venous thrombosis (odds ratio [OR] 1.443, P = 0.042) and dural tear (OR 1.560, P = 0.043), and a lower rate of seroma complicating the procedure (OR 0.419, P = 0.009). There was no difference in overall 90-day reoperation rate in patients under age 75 versus patients aged 75 and older (9.66% vs. 9.28%, P = 0.051), although the 75 and older age group had a greater rate of laminectomy without discectomy (CPT-63047; OR 1.175, P < 0.001), while having a lower rate of laminotomy with discectomy (CPT-63042 and CPT-63030; OR 0.727 and 0.867, respectively, P = 0.013 and <0.001, respectively). The 75 and older age group had greater same day ($3329.24 vs. $3138.05, P < 0.001) and 90-day ($5014.82 vs. $4749.44, P < 0.001) mean reimbursement.

CONCLUSION

Elderly patients experience greater rates of select perioperative complications, with mildly increased costs. There is no significant difference in overall 90-day reoperation rates.

LEVEL OF EVIDENCE

3.

Later Surgical Start Time Is Associated With Longer Length of Stay and Higher Cost in Cervical Spine Surgery

STUDY DESIGN

Retrospective study of a surgical cohort from a single, large academic institution.

OBJECTIVE

The aim of this study was to investigate associations between surgical start time, length of stay, cost, perioperative outcomes, and readmission.

SUMMARY OF BACKGROUND DATA

One retrospective study with a smaller cohort investigated associations between surgical start time and outcomes in spine surgery and found that early start times were correlated with shorter length of stay. No examinations of perioperative outcomes or cost have been performed.

METHODS

All patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) were queried from a single institution from January 1, 2008 to November 30, 2016. Patients undergoing surgery that started between 12:00 AM and 6:00 AM were excluded due to their likely emergent nature. Cases starting before and after 2:00 PM were compared on the basis of length of stay and cost as the primary outcomes using multivariable logistic regression.

RESULT

The patients undergoing ACDF and PCDF were both similar on the basis of comorbidity burden, preoperative diagnosis, and number of segments fused. The patients undergoing ACDF starting after 2 PM had longer LOS values (adjusted difference of 0.65 days; 95% confidence interval [CI]: 0.28-1.03; P = 0.0006) and higher costs of hospitalization (adjusted difference of $1177; 95% CI: $549-$1806; P = 0.0002). Patients undergoing PCDF starting after 2 PM also had longer LOS values (adjusted difference of 1.19 days; 95% CI: 0.46-1.91; P = 0.001) and higher costs of hospitalization (adjusted difference of $2305; 95% CI: $826-$3785; P = 0.002).

CONCLUSION

Later surgical start time is associated with longer LOS and higher cost. These findings should be further confirmed in the spine surgical literature to investigate surgical start time as a potential cost-saving measure.

LEVEL OF EVIDENCE

3.

30- and 90-Day Unplanned Readmission Rates, Causes, and Risk Factors After Cervical Fusion: A Single-Institution Analysis

STUDY DESIGN

Retrospective cohort study OBJECTIVE.: To study 30- and 90-day readmission rates, causes, and risk factors after anterior cervical discectomy and fusion (ACDF) and posterior cervical fusion (PCF).

SUMMARY OF BACKGROUND DATA

Existing data on readmission after cervical fusion is majorly derived from national databases. Given their inherent limitations in accuracy, follow-up available, and missing data, we intend to add to literature from our institutional analysis.

METHODS

Patients who underwent ACDF and PCF for degenerative cervical pathology in 2013 and 2014 were identified for the study. Comprehensive chart review was performed to record demographics and clinical patient profile. Hospital readmission within 30 and 90 days was identified, and the causes and management were recorded. Binary logistic regression analysis was done to study risk factors for readmission. ACDF and PCF were studied separately.

RESULTS

Our analysis included a total of 549 patients, stratified as 389 ACDFs and 160 PCFs. The 30- and 90-day unplanned readmission rate was 5.1% and 7.7% after ACDF. These rates were 11.2% and 16.9% after PCF. The most common cause of readmission was systemic infection and sepsis after ACDF and PCF (31.4% and 25.8% of readmitted, respectively), followed by pulmonary complications after ACDF (14.3% of readmitted) and wound complications after PCF (19.4% of readmitted). Predictors of readmission after ACDF included heart failure, history of malignancy, history of deep vein thrombosis/pulmonary embolism, and any intraoperative complication. In the PCF cohort, history of ischemic heart disease, increasing number of fusion levels and longer length of stay were independently predictive.

CONCLUSION

The rates, causes, and risk factors of readmission after ACDF and PCF have been identified. There is variation in published data regarding the incidence and risk factors for readmission after cervical fusion; however, majority of readmissions occur due to medical complications and systemic infection.

LEVEL OF EVIDENCE

3.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Posterior cervical fusion utilizing cages placed bilaterally in the facets for the treatment of the upper cervical adjacent segment disease in the elderly

This is a retrospective review of 24 elderly patients with upper cervical adjacent segment disease (ASD) after anterior cervical discectomy and fusion (ACDF), treated with posterior cervical fusion (PCF) and stabilized with cages placed bilaterally in the facets. Eight out of 24 patients had PCF with laminectomy (PCLF). Length of stay for PCF alone cohort was 30 ± 11 h, operative time was 44 ± 11 min and estimated blood loss was 46 ± 26 cc. In the PCLF cohort, hospital length of stay was 73 ± 32 h, operative time was 92 ± 18 min, and blood loss was 155 ± 58 cc. The pooled sample showed significant decreases in mean NDI and VAS for neck and arm pain at each follow-up visit (6 weeks, 3, 6, 12 months) compared to baseline (p < 0.0001). All 19 patients that returned for an additional visit, after 12 months visit, continued to report an improvement over the baseline VAS and NDI scores. For those patients treated with PCLF, Nurick scores improved by more than one point in 62% of patients. The overall fusion rate was 96%, including all 16 patients treated with PCF alone (fusion defined as less than 2 mm interspinous movement on dynamic X-ray), and in 7 out of 8 patients treated with PCLF (fusion defined as less than 3 degrees angulation). There was one asymptomatic non-union. There were no significant changes in the overall cervical lordosis (p = 0.436) or segmental lordosis (p = 0.449), and no device-related complications.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients

INTRODUCTION

Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure.

METHODS

We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates.

RESULTS

A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of - $1331 (95% CI - $2032 to - $631).

CONCLUSION

Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .