A systematic review of spinal research conducted using the National Surgical Quality Improvement Program

Developing a Standardized Process to Visualize, Analyze, and Communicate NSQIP Data Using an Advanced Visual Data Analytics Tool

BACKGROUND

To help surgeons improve quality, the American College of Surgeons National Quality Improvement Program (ACS NSQIP) Semiannual Reports and Interim Semiannual Reports provide high-level views of 30-day morbidity and mortality rates. Surgeons at one hospital requested the ability to visualize data with interactive navigation and analysis of comorbidities monthly. Using advanced visual data analytics, the authors constructed a surgical scorecard to provide the desired feedback.

METHODS

The authors undertook a proof-of-concept project tracking surgical site infections (SSIs) and associated medical comorbidities. An anonymized training dataset of 3,438 patients was sampled between January 1, 2021, and October 31, 2022, from the hospital's NSQIP data. For proof-of-concept interface/system testing and to maintain data privacy, a synthetic 5,000-patient NSQIP database was generated using the Synthetic Data Vault, Python 3.7. Comorbidity variables were: diabetes mellitus, HgbA1c, immunosuppressive therapy, hypertension requiring medication, body mass index, and smoking within one year. The primary outcome was SSI. The research team generated scorecards for SSIs as a function of time, surgical department, and medical comorbidity. Odds ratios with confidence intervals and chi-square tests were used to analyze the relationships between SSI and comorbidities.

RESULTS

Advanced visual data analytics improved the timeliness of NSQIP Semiannual Reports and Interim Semiannual Reports from 6 months to 45 days. The scorecard allowed for visualization of data trends as a function of time, specialty, and procedural group. Statistical testing allowed for the identification of surgeons who were statistical outliers with regard to SSIs.

CONCLUSION

Implementation of an on-demand scorecard for data visualization and analysis allowed for up-to-date analysis of the relationship between medical comorbidities and SSI and identification of performance outliers.

The effect of low preoperative platelet count on adverse outcomes following lumbar microdiscectomy

Background

Low preoperative platelet count, or thrombocytopenia, has previously been associated with increased complications in elective spine surgeries. No other study has investigated the effects of abnormal coagulation profiles on postoperative outcomes specific to lumbar microdiscectomy (MLD) using a propensity matched cohort.

Methods

Patient data was retrospectively retrieved from the National Surgical Quality Improvement Program database using Current Procedural Terminology (CPT) code 63030 to isolate patients who solely underwent MLD. Data was collected from 2010 to 2019 and included preoperative, perioperative, and 30-day postoperative variables. Patients were grouped into four platelet categories for ANOVA analysis and pairwise comparisons: Severe Thrombocytopenia (≤100), Thrombocytopenia (101-150), Moderate (151-199), and Normal (200-450). Variables that were significant in the univariate analysis were used in the multivariate analysis to determine the likelihood of experiencing adverse postoperative events – unplanned return to the operating room and surgical site infection. A propensity matched analysis was performed to control for confounding variables.

Results

A total of 64,747 patients were identified within the 10-year period. The results of the multivariate analysis and the propensity matched analysis showed no significant differences in low preoperative platelet count as an independent predictor of experiencing a return to the operating room or surgical site infection. Furthermore, patients who had diabetes, history of smoking, or had emergency cases were associated with a high likelihood of experiencing these negative adverse events.

Conclusion

Thrombocytopenia does not appear to independently predict return to the operating room or postoperative infection following MLD. Proper preoperative management strategies should be implemented to monitor comorbidity burden which would otherwise influence adverse outcomes in patients with thrombocytopenia undergoing MLD.

Quality and Safety Improvement in Spine Surgery

STUDY DESIGN

Review article.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neurologic Disease Is a Risk Factor for Revision After Lumbar Spine Fusion

STUDY DESIGN

Medicare database analysis.

OBJECTIVE

The purpose of this study was to investigate whether neurologic disorders represent a risk factor for revision after lumbar spine surgery.

METHODS

Patients who underwent lumbar spine surgery were identified from 5% Medicare Part B claims between 2005 and 2008. Cox regression analysis was used to evaluate risk factors for revision within the 7 years after the index lumbar surgery. Covariates included age, gender, race, census region, Medicare buy-in status, Charlson score, year, prior lumbar fusion within 2 years of index surgery, prior diagnosis of cervical spondylotic myelopathy treated with or without cervical spine surgery, and diagnoses of other neuromuscular conditions.

RESULTS

Of 8665 cases who had decompression only, 401 (5%) had a revision within 7 years after the index surgery. Factors predictive of revision were prior lumbar fusion (hazard ratio [HR] = 2.78, confidence interval [CI] = 1.43-5.37, P = .002) and being female (HR = 1.61, CI = 1.31-1.97, P < .001). Of 5501 cases who had a decompression and fusion, 752 (14%) had a revision surgery within 7 years after the index surgery. Factors predictive of revision were the presence of a neurologic disorder (HR = 1.24, CI = 1.05-1.46, P = .010), prior lumbar fusion (HR = 3.09, CI = 2.05-4.63, P < .001), and being female (HR = 1.35, CI = 1.15-1.57, P < .001).

CONCLUSIONS

An increase in revision rate (P = 0.01, HR = 1.24) was seen in patients with neurologic disorders undergoing lumbar decompression and fusion, although not for patients undergoing decompression alone. This suggests an opportunity to improve clinical outcome and reduce revision rate through improved surgical decision making or treatment of the neurologic disorder.