Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis

Background

Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.

Methods

A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.

Results

Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).

Conclusions

Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Social determinants of health and the prediction of 90-day mortality among brain tumor patients

OBJECTIVE

Within the neurosurgical oncology literature, the effect of structural and socioeconomic factors on postoperative outcomes remains unclear. In this study, the authors quantified the effects of social determinant of health (SDOH) disparities on hospital complications, length of stay (LOS), nonroutine discharge, 90-day readmission, and 90-day mortality following brain tumor surgery.

METHODS

The authors retrospectively reviewed the records of brain tumor patients who had undergone resection at a single institution in 2017-2019. The prevalence of SDOH disparities among patients was tracked using International Classification of Diseases Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Bivariate (Mann-Whitney U-test and Fisher's exact test) and multivariate (logistic and linear) regressions revealed whether there was an independent relationship between SDOH status and postoperative outcomes.

RESULTS

The patient cohort included 2519 patients (mean age 55.27 ± 15.14 years), 187 (7.4%) of whom experienced at least one SDOH disparity. Patients who experienced an SDOH disparity were significantly more likely to be female (OR 1.36, p = 0.048), Black (OR 1.91, p < 0.001), and unmarried (OR 1.55, p = 0.0049). Patients who experienced SDOH disparities also had significantly higher 5-item modified frailty index (mFI-5) scores (p < 0.001) and American Society of Anesthesiologists (ASA) classes (p = 0.0012). Experiencing an SDOH disparity was associated with a significantly longer hospital LOS (p = 0.0036), greater odds of a nonroutine discharge (OR 1.64, p = 0.0092), and greater odds of 90-day mortality (OR 2.82, p = 0.0016) in the bivariate analysis. When controlling for patient demographics, tumor diagnosis, mFI-5 score, ASA class, surgery number, and SDOH status, SDOHs independently predicted hospital LOS (coefficient = 1.22, p = 0.016) and increased odds of 90-day mortality (OR 2.12, p = 0.028).

CONCLUSIONS

SDOH disparities independently predicted a prolonged hospital LOS and 90-day mortality in brain tumor patients. Working to address these disparities offers a new avenue through which to reduce patient morbidity and mortality following brain tumor surgery.

Health insurance status and its determinants among patients with type 2 diabetes mellitus in a tertiary teaching hospital in Malaysia

Introduction

Even in a country with a tax-based healthcare financing system, health insurance can play an important role, especially in the management of chronic diseases with high disease and economic burden such as Type 2 Diabetes Mellitus (T2DM). The insurance coverage among T2DM patients in Malaysia is currently unclear. The aim of this study was to determine the insurance status of T2DM patients in public and private healthcare facilities in Malaysia, and the association between this status and patients’ sociodemographic and economic factors.

Methods

A cross-sectional study among T2DM patients seeking inpatient or outpatient treatment at a public tertiary hospital (Hospital Canselor Tuanku Muhriz) and a private tertiary hospital (Universiti Kebangsaan Malaysia Specialist Centre) in Kuala Lumpur between August 2019 and March 2020. Patients were identified via convenience sampling using a self-administered questionnaire. Data collection focused on identifying insurance status as the dependent factor while the independent factors were the patients’ sociodemographic characteristics and economic factors.

Results

Of 400 T2DM patients, 313 responded (response rate, 78.3%) and 76.0% were uninsured. About 69.6% of the respondents had low monthly incomes of <RM5000. Two-thirds of participants (59.1%) spent RM100–500 for outpatient visits whilst 58.5% spent <RM100 on medicines per month (RM1 = USD0.244). Patients who visited a private facility had five times more likely to have insurance than patients who visited a public facility. Participants aged 18–49 years with higher education levels were 4.8 times more likely to be insured than participants aged ≥50 years with low education levels (2 times).

Conclusions

The majority of T2DM patients were uninsured. The main factors determining health insurance status were public facilities, age of ≥ 50 years, low education level, unemployment, and monthly expenditure on medicines.

Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in Neurosurgical Care for Intracranial Tumors

BACKGROUND

The impact of race, socioeconomic status (SES), insurance status, and other social metrics on the outcomes of patients with intracranial tumors has been reported in several studies. However, these findings have not been comprehensively summarized.

METHODS

We conducted a PRISMA systematic review of all published articles between 1990 and 2020 that analyzed intracranial tumor disparities, including race, SES, insurance status, and safety-net hospital status. Outcomes measured include access, standards of care, receipt of surgery, extent of resection, mortality, complications, length of stay (LOS), discharge disposition, readmission rate, and hospital charges.

RESULTS

Fifty-five studies were included. Disparities in mortality were reported in 27 studies (47%), showing minority status and lower SES associated with poorer survival outcomes in 14 studies (52%). Twenty-seven studies showed that African American patients had worse outcomes across all included metrics including mortality, rates of surgical intervention, extent of resection, LOS, discharge disposition, and complication rates. Thirty studies showed that privately insured patients and patients with higher SES had better outcomes, including lower mortality, complication, and readmission rates. Six studies showed that worse outcomes were associated with treatment at safety-net and/or low-volume hospitals. The influence of Medicare or Medicaid status, or inequities affecting other minorities, was less clearly delineated. Ten studies (18%) were negative for evidence of disparities.

CONCLUSIONS

Significant disparities exist among patients with intracranial tumors, particularly affecting patients of African American race and lower SES. Efforts at the hospital, state, and national level must be undertaken to identify root causes of these issues.

Influence of Insurance Status on Curve Magnitude in Adolescent Idiopathic Scoliosis in Mainland China

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine whether there is an association between insurance status and curve magnitude in idiopathic scoliosis pediatric patients in mainland China.

METHODS

Medical records of patients with adolescent idiopathic scoliosis in 4 tertiary spine centers across China from January 2013 to December 2017 were analyzed. Data was extracted on insurance status, curve magnitude, recommended treatment at presentation, source of referral, and treatment initiated. Additional information was collected for patients requiring corrective surgery, including time from recommendation for surgery to surgery and clinically relevant parameters such as, postoperative complications, and pre-/postoperative Scoliosis Research Society-22 scores were also collected for patients requiring corrective surgery.

RESULTS

Of the 1785 patients included, 1032 were Urban Resident Basic Medical Insurance Scheme (URBMS) insured and 753 were New Rural Cooperative Medical Scheme (NRCMS) insured. NRCMS patients presented with a larger major curve than URBMS patients (32.9° ± 15.1° vs 29.3° ± 12.6°, P = .028). For patients having surgery recommended, NRCMS patients presented with a larger mean Cobb angle at the first presentation (57.7° vs 50.9°, P < .0001) and at time of surgery (61.3° vs 52.2°, P < .0001), and experienced a significantly longer time from surgery recommendation to decision for surgery. Complication rates were comparable between the 2 groups, except for pulmonary complications (NRCMS 7.3% vs URBMS 2.8%, P = .04). Postoperatively, patients covered by NRCMS insurance experienced greater overall improvement in health-related quality of life and were less satisfied with the treatments.

CONCLUSIONS

This study shows that health insurance may influence the severity of scoliosis on presentation, with implications on early diagnosis and surgery time.

Outcome prediction in brain tumor surgery: a literature review on the influence of nonmedical factors

The purpose of the present study was to review the existing data on preoperative nonmedical factors that are predictive of outcome in brain tumor surgery. Our hypothesis was that also the individual characteristics (e.g., emotional state, cognitive status, social relationships) could influence the postoperative course in addition to clinical factors usually investigated in brain tumor surgery. PubMed, Embase, and Scopus were searched from 2008 to 2018 using terms relating to brain tumors, craniotomy, and predictors. All types of outcome were considered: clinical, cognitive, and psychological. Out of 6.288 records identified, 16 articles were selected for analysis and a qualitative synthesis of the prognostic factors was performed. The following nonmedical factors were found to be predictive of surgical outcomes: socio-demographic (age, marital status, type of insurance, gender, socio-economic status, type of hospital), cognitive (preoperative language and cognitive deficits, performance at TMT-B test), and psychological (preoperative depressive symptoms, personality traits, autonomy for daily activities, altered mental status). This review showed that nonmedical predictors of outcome exist in brain tumor surgery. Consequently, individual characteristics (e.g., emotional state, cognitive status, social relationships) can influence the postoperative course in addition to clinical factors.

Comparing Standard Performance and Outcome Measures in Hospitalized Pituitary Tumor Patients with Secretory versus Nonsecretory Tumors

BACKGROUND

Patient safety indicators (PSIs) and hospital-acquired conditions (HACs) are reported quality measures. We compared their prevalence in patients with secretory and nonsecretory pituitary adenoma using the National (Nationwide) Inpatient Sample (NIS), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

METHODS

The NIS was queried for hospitalizations 2002-2014 involving pituitary adenomas. Prevalence of PSI, HAC, and 9 pituitary-related complications was determined using International Classification of Diseases, Ninth Revision codes. Patient risk factors were evaluated through multivariate analysis.

RESULTS

A total of 20,743 patients with nonsecretory tumor and 3385 patients with secretory tumor were identified. Among patients with nonsecretory tumor, 3.79% experienced any PSI or HAC. Of patients with secretory tumor, 2.54% had any PSI or HAC. Before adjusting for covariation, secretory patients were less likely to have any PSI or HAC (odds ratio [OR], 0.652; P = 0.0002), experience any pituitary-related complication (OR, 0.804; P < 0.0001), have a poor outcome (hazard ratio [HR], 0.435; P < 0.0001), and die during hospitalization (HR, 0.293; P = 0.0015). Secretory patients had significantly shorter mean hospital length of stay (secretory/nonsecretory percent difference, -11.95%; P < 0.0001). However, inverse propensity score-weighted ORs comparing the groups' outcomes showed that there was no significant difference in the prevalence of any PSIs and HACs (OR, 0.963; P = 0.8570), pituitary-related complications (OR, 0.894; P = 0.1321), poor outcomes (HR, 0.990; P = 0.9287), in-hospital death (HR, 0.663; P = 0.2967), and length of stay (percent difference, -2.31%; P = 0.2967) between groups.

CONCLUSIONS

Lack of significant difference in outcome measures after controlling for covariation is consistent with our finding that patients with nonsecretory tumor have more comorbidities on presentation for treatment. PSIs and HACs have limited ability to measure complications specific to pituitary tumors.

The effects of hyperglycemia on outcomes in surgical high-grade glioma patients

OBJECTIVE

To define the glucose values associated with an increase in complication rates in post-operative brain tumor patients.

PATIENTS AND METHODS

Patients who underwent craniotomy for resection of WHO Grade III or IV glioma from 2011 to 2014 were retrospectively reviewed. Post-operative blood glucose values were recorded for post-operative day #0, #1, and #2. Medians were obtained and assessed for significance. Multivariate analysis was performed to assess patient demographics, pre-operative findings, steroid use, and blood glucose values with respect to post-operative complications and to 30-day readmission.

RESULTS

108 patients underwent craniotomy for resection of high-grade glioma and had postoperative blood glucose values documented. Median blood glucose values greater than 167 mg/dL were associated with increased serious post-operative complications, and values greater than 163 mg/dL were associated with increased 30-day readmissions.

CONCLUSION

Post-operative hyperglycemia in patients with high-grade gliomas places this vulnerable patient population to undue post-operative complications and readmissions, potentially delaying further treatment of their disease.

The association of inflammatory bowel disease and immediate postoperative outcomes following lumbar fusion

BACKGROUND CONTEXT

The United States Centers for Disease Control and Prevention estimates the prevalence of inflammatory bowel disease (IBD) at more than 3.1 million people. As diagnostic techniques and treatment options for IBD improve, the prevalence of IBD is expected to increase. For spine surgeons, patients with IBD have a unique complication profile because patients with IBD may present with poor nutritional status and because the medications used to manage IBD have been associated with poor vertebral bone mineralization and immunosuppression. Presently, there are very limited data regarding perioperative outcomes among patients with IBD who undergo spinal surgery. The present study begins to address this knowledge gap by describing trends in patients with IBD undergoing lumbar fusion and by quantifying the association between IBD and immediate postoperative outcomes using a large, national database.

PURPOSE

To advance our understanding of the potential pitfalls and risks associated with lumbar fusion surgery in patients with IBD.

DESIGN/SETTING

Retrospective cross-sectional analysis.

PATIENT SAMPLE

The Nationwide Inpatient Sample (NIS) database was queried from 1998 to 2011 to identify adult patients (18+) who underwent primary lumbar fusion operations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding.

OUTCOME MEASURES

Incidence of lumbar fusion procedures, prevalence of IBD, complication rates, length of stay, and total hospital charges.

METHODS

The annual number of primary lumbar fusion operations performed between 1998 and 2011 was obtained from the NIS database. Patients younger than 18 years of age were excluded. The prevalence of IBD in this population (both Crohn disease and ulcerative colitis) was determined using ICD-9-CM codes. Logistic regression models were estimated to determine the association between IBD and the odds of postoperative medical and surgical complications, while controlling for patient demographics, comorbidity burden, and hospital characteristics. The complex survey design of the NIS was taken into account by clustering on hospitals and assuming an exchangeable working correlation using the discharge weights supplied by the NIS. We accounted for multiple comparisons using the Bonferroni correction and an alpha level for statistical significance of . 0028.

RESULTS

The prevalence of IBD is increasing among patients undergoing lumbar fusion, from 0.21% of all patients undergoing lumbar fusion in 1998 to 0.48% of all patients undergoing lumbar fusion in 2011 (p<.001). The odds of experiencing a postoperative medical or surgical complication were not significantly different when comparing patients with IBD with control patients without IBD after controlling for patient demographics, comorbidity burden, and hospital characteristics (adjusted odds ratio=1.1, 95% confidence interval [CI] 0.99-1.3, p=.08). On multivariable analysis, the presence of IBD in patients undergoing lumbar fusion surgery was associated with longer length of stay and greater hospitalization charges.

CONCLUSIONS

Among patients who underwent lumbar fusion, IBD is a rare comorbidity that is becoming increasingly more common. Importantly, patients with IBD were not at increased risk of postoperative complications. Spine surgeons should be prepared to treat more patients with IBD and should incorporate the present findings into preoperative risk counseling and patient selection.

Predictive performance of the American College of Surgeons universal risk calculator in neurosurgical patients

OBJECTIVE

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) universal Surgical Risk Calculator is an online decision-support tool that uses patient characteristics to estimate the risk of adverse postoperative events. Further validation of this risk calculator in the neurosurgical population is needed; therefore, the object of this study was to assess the predictive performance of the ACS NSQIP Surgical Risk Calculator in neurosurgical patients treated at a tertiary care center.

METHODS

A single-center retrospective review of 1006 neurosurgical patients treated in the period from September 2011 through December 2014 was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted complications were compared with actual occurrences identified through chart review and administrative quality coding data. Statistical models were used to assess the predictive performance of risk scores. Traditionally, an ideal risk prediction model demonstrates good calibration and strong discrimination when comparing predicted and observed events.

RESULTS

The ACS NSQIP risk calculator demonstrated good calibration between predicted and observed risks of death (p = 0.102), surgical site infection (SSI; p = 0.099), and venous thromboembolism (VTE; p = 0.164) Alternatively, the risk calculator demonstrated a statistically significant lack of calibration between predicted and observed risk of pneumonia (p = 0.044), urinary tract infection (UTI; p < 0.001), return to the operating room (p < 0.001), and discharge to a rehabilitation or nursing facility (p < 0.001). The discriminative performance of the risk calculator was assessed using the c-statistic. Death (c-statistic 0.93), UTI (0.846), and pneumonia (0.862) demonstrated strong discriminative performance. Discharge to a rehabilitation facility or nursing home (c-statistic 0.794) and VTE (0.767) showed adequate discrimination. Return to the operating room (c-statistic 0.452) and SSI (0.556) demonstrated poor discriminative performance. The risk prediction model was both well calibrated and discriminative only for 30-day mortality.

CONCLUSIONS

This study illustrates the importance of validating universal risk calculators in specialty-specific surgical populations. The ACS NSQIP Surgical Risk Calculator could be used as a decision-support tool for neurosurgical informed consent with respect to predicted mortality but was poorly predictive of other potential adverse events and clinical outcomes.

National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population.

METHODS

All patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA.

RESULTS

We identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA.

CONCLUSION

The national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.

National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population

BACKGROUND

The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA.

METHODS

All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics.

RESULTS

In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76).

CONCLUSION

The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population.

Association between insurance status and patient safety in the lumbar spine fusion population

BACKGROUND CONTEXT

Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients.

PURPOSE

This study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population.

STUDY DESIGN

A retrospective cohort study was carried out.

PATIENT SAMPLE

The sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011.

OUTCOME MEASURE

The incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable.

METHODS

The NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI.

RESULTS

A total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if "other" or "missing" was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid and self-pay patients had significantly greater odds of experiencing one or more PSI during the inpatient episode relative to privately insured patients (odds ratio 1.16, 95% confidence interval 1.07-1.27).

CONCLUSIONS

Among patients undergoing inpatient lumbar fusion, insurance status is associated with the adverse health-care quality events used to determine hospital reimbursement by the CMS. The source of this disparity must be studied to improve the quality of care delivered to vulnerable patient populations.

Disparities in reportable quality metrics by insurance status in the primary spine neoplasm population

BACKGROUND CONTEXT

The Centers for Medicare and Medicaid Services (CMS) defines "adverse quality events" as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population.

PURPOSE

We aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population.

STUDY DESIGN

This is a retrospective cohort study.

PATIENT SAMPLE

We included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011.

OUTCOME MEASURES

Incidence of PSI from 1998 to 2011 served as outcome variable.

METHODS

The NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients.

RESULTS

We identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with "other" or "missing" primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11-2.95) relative to privately insured patients.

CONCLUSIONS

Among patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care.

Insurance status and reportable quality metrics in the cervical spine fusion population

BACKGROUND CONTEXT

The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown.

PURPOSE

This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events.

STUDY DESIGN

This is a retrospective cohort design.

PATIENT SAMPLE

All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included.

OUTCOME MEASURES

Incidence of HAC and PSI from 1998 to 2011 served as outcome variables.

METHODS

We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC.

RESULTS

We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort.

CONCLUSIONS

Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.

Surgery for CNS Tumors in the Brazilian National Health Care System

Purpose

Resource limitations in low- and middle-income countries make the management of CNS tumors challenging, particularly in Brazil, a country with major disparities in socioeconomic status and access to health care. We aimed to evaluate cancer-related neurosurgical procedures in the public health care system.

Methods

On the basis of Brazil’s public health system database, we collected data for neurosurgical procedures related to CNS tumors performed between January 2008 and November 2013. Information about the number of procedures, costs, length of stay, and number of inpatient deaths were analyzed for each state and then correlated to the state-specific population, gross domestic product per capita, and number of procedures.

Results

In all, 57,361 procedures were performed, the majority of them in the Southeast region. The mean length of hospital stay was 14.4 days, but longer hospital stay was reported for patients treated in the North. The inpatient mortality rate was 7.11%. Mortality rates decreased as the number of procedures (P < .001), gross domestic product per capita (P < .001), or state population increased (P < .001). On multivariate analysis, only the number of procedures (odds ratio, 0.93; 95% CI, 0.91 to 0.96; P < .001) and state population (odds ratio, 1.25; 95% CI, 1.13 to 1.38; P < .001) had an independent association with mortality.

Conclusion

To the best of our knowledge, this is the first study to evaluate disparities in CNS tumor surgery in a middle-income country, confirming that regional disparities exist and that clinical and economic outcomes correlate with income level, number of procedures, and state population.

The Impact of Socioeconomic Status on the Utilization of Spinal Imaging

BACKGROUND

Few studies have examined the general correlation between socioeconomic status and imaging. This study is the first to analyze this relationship in the spine patient population.

OBJECTIVE

To assess the effect of socioeconomic status on the frequency with which imaging studies of the lumbar spine are ordered and completed.

METHODS

Patients that were diagnosed with lumbar radiculopathy and/or myelopathy and had at least 1 subsequent lumbar magnetic resonance imaging (MRI), computed tomography (CT), or X-ray ordered were retrospectively identified. Demographic information and the number of ordered and completed imaging studies were among the data collected. Patient insurance status and income level (estimated based on zip code) served as representations of socioeconomic status.

RESULTS

A total of 24,105 patients met the inclusion criteria for this study. Regression analyses demonstrated that uninsured patients were significantly less likely to have an MRI, CT, or X-ray study ordered (P < .001 for all modalities) and completed (P < .001 for MRI and X-ray, P = .03 for CT). Patients with lower income had higher rates of MRI, CT, and X-ray (P < .001 for all) imaging ordered but were less likely to have an ordered X-ray be completed (P = .009). There was no significant difference in the completion rate of ordered MRIs or CTs.

CONCLUSION

Disparities in image utilization based on socioeconomic characteristics such as insurance status and income level highlight a critical gap in access to health care. Physicians should work to mitigate the influence of such factors when deciding whether to order imaging studies, especially in light of the ongoing shift in health policy in the United States.

Predictors of outcomes and hospital charges following atlantoaxial fusion

BACKGROUND CONTEXT

Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown.

PURPOSE

This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies.

STUDY DESIGN

A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States.

PATIENT SAMPLE

We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission.

OUTCOME MEASURES

Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition.

METHODS

Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results.

RESULTS

From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition.

CONCLUSION

This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion.