Investigate the differences in spine surgery cost for metabolic syndrome patients.
Included were patients ≥18 undergoing fusion. Patients were divided into cervical, thoracic, and lumbar groups based ...on their upper instrumented vertebrae (UIV). Metabolic syndrome patients (MetS) included those with body mass index >30, diabetes mellitus, dyslipidemia, and hypertension. Propensity score matching for invasiveness between non-MetS and MetS used to assess cost differences. Total surgery costs for MetS and non-MetS adult spinal deformity patients were compared. Quality-adjusted life years (QALYs) and cost per QALY for UIV groups were calculated.
A total of 312 invasiveness matched surgeries met inclusion criteria. Baseline demographics and surgical details included age 57.7 ± 14.5, 54% female, body mass index 31.1 ± 6.6, 17% anterior approach, 70% posterior approach, 13% combined approach, and 3.8 ± 4.1 levels fused. The average costs of surgery between MetS and non-Mets patients was $60,579.30 versus $52,053.23 (P < 0.05). When costs were compared between UIV groups, MetS patients had higher cervical and thoracic surgery costs ($23,203.43 vs. $19,153.43, $75,230.05 vs. $65,746.16, all P < 0.05) and lower lumbar costs ($31,775.64 vs. $42,643.37, P < 0.05). However, the average cost per QALY at 1 year was $639,069.32 for MetS patients and $425,840.30 for non-Mets patients (P < 0.05). At life expectancy, the cost per QALY was $45,456.83 versus $26,026.84 (P < 0.05).
When matched by invasiveness, MetS patients had an average 16.4% higher surgery costs, 50% higher costs per QALY at 1 year, and 75% higher cost per QALY at life expectancy. Further research is needed on the possible utility of reducing comorbidities in preoperative patients.
Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in ...improving patient selection and care.
The present study aimed to develop a risk index for DJK development in the first year after surgery.
This is a retrospective review of a prospective multicenter cervical deformity database.
Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2–7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2–C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°).
Development of DJK at any time before 1 year.
Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<−10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <−10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size.
Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio OR: 3.71, confidence interval CI: 0.11–0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99–16.14); (2) kyphosis<−50.6° (OR: 5.89, CI: 0.07–0.43); (3) C2–C7 lordosis<−12° (OR: 5.7, CI: 0.08–0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28–13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20–13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90–13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21–5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02–6.34) were the most important predictors of DJK.
In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.
STUDY DESIGN.Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010 to 2015.
OBJECTIVE.Investigate which short-term ...outcomes differ for cervical laminoplasty and laminectomy and fusion surgeries.
SUMMARY OF BACKGROUND DATA.Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology.
METHODS.Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in National Surgical Quality Improvement Program (NSQIP) based on Current Procedural Terminology (CPT) codelaminoplasty 63,050 and 63,051, posterior cervical laminectomy 63,015 and 63,045, and instrumentation 22,842. Propensity-adjusted multivariate regressions assessed differences in postoperative length of stay, adverse events, discharge disposition, and readmission.
RESULTS.Three thousand seven hundred ninety-six patients were included2397 (63%) underwent cervical laminectomy and fusion and 1399 (37%) underwent cervical laminoplasty. Both groups were similar in age, sex, body mass index (BMI), American Society of Anesthesiologist Classification (ASA), Charleston Comorbidity Index (CCI), and had similar rates of malnutrition, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age more than 70 and age less than 50 were not associated with one treatment group over the other (P > 0.05). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5 vs. 3.7 d, P < 0.01) and increased rates of adverse events (41.7% vs. 35.9%, P < 0.01), discharge to rehab (16.4% vs. 8.6%, P < 0.01), and skilled nursing facilities (12.2% vs. 9.7%, P = 0.02), and readmission (6.2% vs. 4.5%, P = 0.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection, and reoperation (P > 0.05 for all).
CONCLUSION.Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar pre-op demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology.Level of Evidence3
STUDY DESIGN.Retrospective review of a prospective database.
OBJECTIVE.The aim of this study was to evaluate postop clinical recovery among adult spinal deformity (ASD) patients between frailty ...states undergoing primary procedures
SUMMARY OF BACKGROUND DATA.Frailty severity may be an important determinant for impaired recovery after corrective surgery.
METHODS.It included ASD patients with health-related quality of life (HRQLs) at baseline (BL), 1 year (1Y), and 3 years (3Y). Patients stratified by frailty by ASD-frailty index scale 0-1(no frailty<0.3 NF, mild0.3–0.5 MF, severe>0.5 SF). Demographics, alignment, and SRS-Schwab modifiers were assessed with χ/paired t tests to compare HRQLsScoliosis Research Society 22-question Questionnaire (SRS-22), Numeric Rating Scale (NRS) Back/Leg Pain, Oswestry Disability Index (ODI). Area-under-the-curve (AUC) method generated normalized HRQL scores at baseline (BL) and f/u intervals (1Y, 3Y). AUC was calculated for each f/u, and total area was divided by cumulative f/u, generating one number describing recovery (Integrated Health State IHS).
RESULTS.A total of 191 patients were included (59 years, 80% females). Breakdown of patients by frailty status43.6% NF, 40.8% MF, 15.6% SF. SF patients were older (P = 0.003), >body mass index (P = 0.002). MF and SF were significantly (P < 0.001) more malaligned at BLpelvic tilt (NF21.6°; MF27.3°; SF22.1°), pelvic incidence and lumbar lordosis (7.4°, 21.2°, 19.7°), sagittal vertical axis (31 mm, 87 mm, 82 mm). By SRS-Schwab, NF were mostly minor (40%), and MF and SF markedly deformed (64%, 57%). Frailty groups exhibited BL to 3Y improvement in SRS-22, ODI, NRS Back/Leg (P < 0.001). After HRQL normalization, SF had improvement in SRS-22 at year 1 and year 3 (P < 0.001), and NRS Back at 1Y. 3Y IHS showed a significant difference in SRS-22 (NF1.2 vs. MF1.32 vs. SF1.69, P < 0.001) and NRS Back Pain (NF0.52, MF0.66, SF0.6, P = 0.025) between frailty groups. SF had more complications (79%). SF/marked deformity had larger invasiveness score (112) compared to MF/moderate deformity (86.2). Controlling for baseline deformity and invasiveness, SF showed more improvement in SRS-22 IHS (NF1.21, MF1.32, SF1.66, P < 0.001).
CONCLUSION.Although all frailty groups exhibited improved postop disability/pain scores, SF patients recovered better in SRS-22 and NRS Back. Despite SF patients having more complications and larger invasiveness scores, they had overall better patient-reported outcomes, signifying that with frailty severity, patients have more room for improvement postop compared to BL quality of life.Level of Evidence3
With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections ...infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.
Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.
This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.
Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.
Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.
Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.
A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio OR: 0.28, confidence interval CI: 0.22–0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35–0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40–0.64), interbody device placement (OR: 0.80, CI: 0.64–0.98), and fixation to the iliac (OR: 0.54, CI: 0.41–0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21–0.57) and blood transfusions (OR: 0.42, CI: 0.34–0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).
Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility.
STUDY DESIGN.Retrospective review.
OBJECTIVE.Develop a simplified frailty index for cervical deformity (CD) patients.
SUMMARY OF BACKGROUND DATA.To improve preoperative risk stratification for ...surgical CD patients, a CD frailty index (CD-FI) incorporating 40 health deficits was developed. While novel, the CD-FI is clinically impractical due to the large number of factors needed for its calculation. To increase clinical utility, a simpler, modified CD-FI (mCD-FI) is necessary.
METHODS.CD patients (C2-C7 Cobb>10°, CL>10°, cSVA>4 cm, or CBVA>25°) >18 year with preoperative CD-FI component factors. Pearson bivariate correlation assessed relationships between component deficits of the CD-FI and overall CD-FI score. Top deficits contributing to CD-FI score were included in multiple stepwise regression models. Deficits from model with largest R were dichotomized, and the mean score of all deficits calculated, resulting in mCD-FI score from 0 to 1. Patients were stratified by mCD-FINot Frail (NF, <0.3), Frail (0.3–0.5), Severely Frail (SF, >0.5). Means comparison tests established correlations between frailty category and clinical outcomes.
RESULTS.Included121 CD patients (61 ± 11 yr, 60%F). Multiple stepwise regression models identified 15 deficits as responsible for 86% of the variation in CD-FI; these factors were used to construct the mCD-FI. Overall, mean mCD-FI was 0.31 ± 0.14. Breakdown of patients by mCD-FI categoryNF47.9%, Frail46.3%, SF5.8%. Compared with NF and Frail, SF patients had the longest inpatient hospital stays (P = 0.042), as well as greater baseline neck pain (P = 0.033), inferior Neck Disability Index scores (P<0.001) and inferior EQ-5D scores (P < 0.001). Frail patients had higher odds of superficial infection (OR:1.11.0–1.2), and SF patients had increased odds of mortality (OR:8.31.3–53.9).
CONCLUSION.Increased frailty, assessed by mCD-FI, correlated with increased length of stay, neck pain, and decreased health-related quality of life. Frail patients were at greater risk for infection, and severely frail patients had greater odds of mortality. This relationship between frailty and clinical outcomes suggests that mCD-FI offers clinical utility as a preoperative risk stratification tool.Level of Evidence3
ABSTRACT
BACKGROUND
Distal junctional kyphosis (DJK) development after cervical deformity (CD)-corrective surgery is a growing concern for surgeons and patients. Few studies have investigated risk ...factors that predict the occurrence of DJK.
OBJECTIVE
To predict DJK development after CD surgery using predictive modeling.
METHODS
CD criteria was at least one of the following: C2-C7 Coronal/Cobb > 10°, C2-7 sagittal vertical axis (cSVA) > 4 cm, chin-brow vertical angle > 25°. DJK was defined as the development of an angle <−10° from the end of fusion construct to the second distal vertebra, and change in this angle by <−10° from baseline to postoperative. Baseline demographic, clinical, and surgical information were used to predict the occurrence of DJK using generalized linear modeling both as one overall model and as submodels using baseline demographic and clinical predictors or surgical predictors.
RESULTS
One hundred seventeen CD patients were included. At any postoperative visit up to 1 yr, 23.1% of CD patients developed DJK. DJK was predicted with high accuracy using a combination of baseline demographic, clinical, and surgical factors by the following factors: preoperative neurological deficit, use of transition rod, C2-C7 lordosis (CL)<−12°, T1 slope minus CL > 31°, and cSVA > 54 mm. In the model using only baseline demographic/clinical predictors of DJK, presence of comorbidities, presence of baseline neurological deficit, and high preoperative C2-T3 angle were included in the final model (area under the curve = 87%). The final model using only surgical predictors for DJK included combined approach, posterior upper instrumented vertebrae below C4, use of transition rod, lack of anterior corpectomy, more than 3 posterior osteotomies, and performance of a 3-column osteotomy.
CONCLUSION
Preoperative assessment and consideration should be given to these factors that are predictive of DJK to mitigate poor outcomes.
Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic-assisted spine surgery. However, it is unknown how these advances have impacted the cost of ...care.
Compare the economic outcomes of lumbar spine fusion between open, MIS, and robot-assisted surgery patients.
Retrospective review of a single center spine surgery database.
Three hundred sixty propensity matched patients.
Costs, EuroQol-5D (EQ5D), cost per quality adjusted life years (QALY).
Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS, or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot-assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robotic cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities and major complications and comorbidities were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit. A 10,000 trial Monte Carlo simulation with probabilistic sensitivity analysis (PSA) assessed our model parameters and costs.
Three hundred sixty propensity matched patients (120 open, 120 MIS, 120 robotic) met inclusion criteria. Descriptive statistics for the cohort were: age 58.8±13.5, 50% women, BMI 29.4±6.3, operative time 294.4±119.0, LOS 4.56±3.31 days, estimated blood loss 515.9±670.0 cc, and 2.3±2.2 average levels fused. Rates of post-op complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a subanalysis of 42 patients with baseline (BL) and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot-assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot-assisted cases. Results of the PSA were consistent with MIS surgery having the most incremental cost effectiveness when compared to open and robotic surgery.
Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot-assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes were not optimal for robotic surgery cases, the projected costs per QALYs at life expectancy were well below established acceptable thresholds. The above findings may be reflective of an educational learning curve and emerging surgical technologies undergoing progressive refinement.
Purpose: The aim is to investigate the relationship between cervical parameters and the modified Japanese Orthopedic Association scale (mJOA).
Materials and Methods: Surgical adult cervical deformity ...(CD) patients were included in this retrospective analysis. After determining data followed a parametric distribution through the Shapiro-Wilk Normality (P = 0.15, P > 0.05), Pearson correlations were run for radiographic parameters and mJOA. For significant correlations, logistic regressions were performed to determine a threshold of radiographic measures for which the correlation with mJOA scores was most significant. mJOA score of 14 and <12 reported cut-off values for moderate (M) and severe (S) disability. New modifiers were compared to an existing classification using Spearman's rho and logistic regression analyses to predict outcomes up to 2 years.
Results: A total of 123 CD patients were included (60.5 years, 65%F, 29.1 kg/m2). For significant baseline factors from Pearson correlations, the following thresholds were predicted: MGS (M:-12 to-9° and 0°-19°, P = 0.020; S: >19° and <−12°, χ2 = 4.291, P = 0.036), TS-CL (M: 26°to 45°, P = 0.201; S: >45°, χ2 = 7.8, P = 0.005), CL (M:-21° to 3°, χ2 = 8.947, P = 0.004; S: <−21°, χ2 = 9.3, P = 0.009), C2-T3 (M: −35° to −25°, χ2 = 5.485, P = 0.046; S: <−35°, χ2 = 4.1, P = 0.041), C2 Slope (M: 33° to 49°, P = 0.122; S: >49°, χ2 = 5.7, P = 0.008), and Frailty (Mild: 0.18-0.27, P = 0.129; Severe: >0.27, P = 0.002). Compared to existing Ames- International Spine Study Group classification, the novel thresholds demonstrated significant predictive value for reoperation and mortality up to 2 years.
Conclusions: Collectively, these radiographic values can be utilized in refining existing classifications and developing collective understanding of severity and surgical targets in corrective surgery for adult CD.
STUDY DESIGN.Retrospective review of prospectively collected data.
OBJECTIVE.To assess the clinical impact and economic burden of the three most common hospital-acquired conditions (HACs) that occur ...within 30-day postoperatively for all spine surgeries and to compare these rates with other common surgical procedures.
SUMMARY OF BACKGROUND DATA.HACs are part of a non-payment policy by the Centers for Medicare and Medicaid Services and thus prompt hospitals to improve patient outcomes and safety.
METHODS.Patients more than 18 years who underwent elective spine surgery were identified in American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2013. Primary outcomes were cost associated with the occurrence of three most common HACs. Cost associated with HAC occurrence derived from the PearlDiver database.
RESULTS.Ninety thousand five hundred fifty one elective spine surgery patients were identified, where 3021 (3.3%) developed at least one HAC. Surgical site infection (SSI) was the most common HAC (1.4%), then urinary tract infection (UTI) (1.3%) and venous thromboembolism (VTE) (0.8%). Length of stay (LOS) was longer for patients who experienced a HAC (5.1 vs. 3.2 d, P < 0.001). When adjusted for age, sex, and Charlson Comorbidity Index, LOS was 1.48 ± 0.04 days longer (P < 0.001) and payments were $8893 ± $148 greater (P < 0.001) for patients with at least one HAC. With the exception of craniotomy, patients undergoing common procedures with HAC had increased LOS and higher payments (P < 0.001). Adjusted additional LOS was 0.44 ± 0.02 and 0.38 ± 0.03 days for total knee arthroplasty and total hip arthroplasty, and payments were $1974 and $1882 greater. HACs following hip fracture repair were associated with 1.30 ± 0.11 days LOS and $4842 in payments (P < 0.001). Compared with elective spine surgery, only bariatric and cardiothoracic surgery demonstrated greater adjusted additional payments for patients with at least one HAC ($9975 and $10,868, respectively).
CONCLUSION.HACs in elective spine surgery are associated with a substantial cost burden to the health care system. When adjusted for demographic factors and comorbidities, average LOS is 1.48 days longer and episode payments are $8893 greater for patients who experience at least one HAC compared with those who do not.Level of Evidence3
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