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Gill VS, Tummala SV, Haglin JM, Sullivan G, Spangehl MJ, Bingham JS. Differences in Reimbursements, Procedural Volumes, and Patient Characteristics Based on Surgeon Gender in Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00484-4. [PMID: 38763482 DOI: 10.1016/j.arth.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Prior studies have suggested there may be differences in reimbursement and practice patterns by gender. The purpose of this study was to comprehensively evaluate differences in reimbursement, procedural volume, and patient characteristics in total hip arthroplasty (THA) between men and women surgeons from 2013 to 2021. METHODS The Medicare Physician and Other Practitioners database from 2013 to 2021 was queried. Inflation-adjusted reimbursement, procedural volume, surgeon information, and patient demographics were extracted for surgeons performing over 10 primary THAs each year. Wilcoxon, t-tests, and multivariate linear regressions were utilized to compare men and women surgeons. RESULTS Only 1.4% of THAs billed to Medicare between 2013 and 2021 were billed by women surgeons. Men surgeons earned significantly greater reimbursement nationally in 2021 compared to women surgeons per THA ($1018.56 versus $954.17, P = 0.03), but no difference was found when assessing each region separately. Reimbursement declined at similar rates for both men and women surgeons (-18.3 versus -19.8%, P = 0.38). An increase in the proportion of women surgeons performing THA between 2013 and 2021 was seen in all regions except the South. In 2021, the proportion of all THAs performed by women surgeons was highest in the West (3.5%) and lowest in the South (1.0%). Women surgeons had comparable patient populations in terms of age, race, comorbidity status, and Medicaid eligibility to their men counterparts, but performed significantly fewer services per beneficiary (5.6 versus 8.1, P < 0.001) and fewer unique services (51.1 versus 69.6, P < 0.001). CONCLUSIONS Average reimbursement per THA has declined at a similar rate for men and women physicians between 2013 and 2021. Women's representation in THA surgery nationwide has nearly doubled between 2013 and 2021, with the greatest increase in the West. However, there are notable differences in billing practices between genders.
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Affiliation(s)
- Vikram S Gill
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ; Mayo Clinic Alix School of Medicine, Phoenix, AZ.
| | | | - Jack M Haglin
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ
| | - Georgia Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ; Mayo Clinic Alix School of Medicine, Phoenix, AZ
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Shen B, Gao Z, Wang B, Huang Y, Wu D. Relationship between intervertebral disc height and post operative dysphagia secondary to single-level anterior cervical discectomy and fusion- a retrospective study. BMC Musculoskelet Disord 2024; 25:369. [PMID: 38730401 PMCID: PMC11084003 DOI: 10.1186/s12891-024-07461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND One goal of Anterior Cervical Discectomy and Fusion (ACDF) is to restore the loss of intervertebral disc height (IDH) results from the degenerative process. However, the effects of IDH on postoperative dysphagia after ACDF remain unclear. METHODS Based on the results of a one-year telephone follow-up, A total of 217 consecutive patients after single-level ACDF were enrolled. They were divided into dysphagia and non-dysphagia groups. The age, BMI, operation time and blood loss of all patients were collected from the medical record system and compared between patients with and without dysphagia. Radiologically, IDH, spinous process distance (SP) of the operated segment, and C2-7 angle (C2-7 A) were measured preoperatively and postoperatively. The relationship between changes in these radiological parameters and the development of dysphagia was analyzed. RESULTS Sixty-three (29%) cases exhibited postoperative dysphagia. The mean changes in IDH, SP, and C2-7 A were 2.84 mm, -1.54 mm, and 4.82 degrees, respectively. Changes in IDH (P = 0.001) and changes in C2-7 A (P = 0.000) showed significant differences between dysphagia and non-dysphagia patients. Increased IDH and increased C2-7 A (P = 0.037 and 0.003, respectively) significantly and independently influenced the incidence of postoperative dysphagia. When the change in IDH was ≥ 3 mm, the chance of developing postoperative dysphagia for this patient was significantly greater. No significant relationship was observed between the change in spinous process distance (SP) and the incidence of dysphagia. The age, BMI, operation time and blood loss did not significantly influence the incidence of postoperative dysphagia. CONCLUSION The change in IDH could be regarded as a predictive factor for postoperative dysphagia after single-level ACDF.
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Affiliation(s)
- Beiduo Shen
- Department of Spine Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Zhiqiang Gao
- Department of Bone & Joint Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Bijun Wang
- Department of Spine Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yufeng Huang
- Department of Spine Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Desheng Wu
- Department of Spine Surgery, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
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Gordon AM, Golub IJ, Lam AW, Ng MK, Saleh A. Primary Cervical Disc Arthroplasty Among Medicare Beneficiaries Versus Alternative Payers: Is It Time to Consider Nationwide Coverage? Global Spine J 2024; 14:1148-1154. [PMID: 36214218 DOI: 10.1177/21925682221134498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES As of 2022, the Centers for Medicare and Medicaid Services does not provide nationwide coverage for cervical disc arthroplasty (CDA). The aim was to determine whether Medicare beneficiaries have differences in: (1) lengths of stay (LOS); (2) complications; (3) readmissions; and (4) costs of care. METHODS Using the 2010 to 2020 PearlDiver database, we queried patients undergoing primary CDA for degenerative disc pathology. Study groups patients were those undergoing CDA with Medicare coverage (n = 1467); patients without Medicare coverage were the comparison cohort (n = 15,389). Endpoints were to compare demographics and comorbidities within the Elixhauser comorbidity index (ECI), LOS, 90-day complications, 90-day readmissions, and 90-day reimbursements. A multivariate logistic regression was used to calculate odds (OR) of medical complications and readmissions within 90-days. A P-value less than .003 was significant. RESULTS Patients with Medicare coverage undergoing CDA had higher mean ECI compared to alternative payers (5.24 vs 3.26; P < .0001). Mean LOS was significantly higher for Medicare beneficiaries (2.20 vs 1.76 days; P < .010). There was no significant differences in odds of all medical complications (OR: 1.19, 95% CI: .98-1.44; P = .069) or readmission rates (1.77% vs 1.33%, OR:0.82, 95% CI: .50-1.29; P = .417) within 90-days following the index procedure among Medicare beneficiaries vs alternative payers. Non-Medicare beneficiaries had higher 90-day reimbursements compared to Medicare beneficiaries ($6,700 vs $7,086,P < .001). CONCLUSIONS Medicare beneficiaries despite having slightly longer lengths of stay did not have higher rates of medical complications or readmissions. Surgeons and policy makers may use this data to consider alternative treatments in Medicare patients.
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Affiliation(s)
- Adam M Gordon
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Ivan J Golub
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Aaron W Lam
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Ahmed Saleh
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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Wu JY, Touponse GC, Theologitis M, Ahmad HS, Zygourakis CC. Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic. World Neurosurg 2024; 182:e107-e125. [PMID: 38000672 DOI: 10.1016/j.wneu.2023.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic. METHODS We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables. RESULTS Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased. CONCLUSIONS We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S. POPULATION
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Affiliation(s)
- Janet Y Wu
- School of Medicine, Stanford University, Stanford, California, USA
| | - Gavin C Touponse
- School of Medicine, Stanford University, Stanford, California, USA
| | | | - Hasan S Ahmad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corinna C Zygourakis
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
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Powers AY, Nin DZ, Chen YW, Niu R, Kim DH, Chang DC, Hwang RW. Anterior Cervical Discectomy and Fusion With Structural Allograft is Associated With Lower Postoperative Health Care Utilization and Reoperations Compared With Cage Implants. Oper Neurosurg (Hagerstown) 2024; 26:16-21. [PMID: 37707420 DOI: 10.1227/ons.0000000000000900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/30/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Implants represent a large component of surgical cost, with several available options for anterior cervical discectomy and fusion (ACDF). Rising ACDF volume highlights the need for accurate cost characterization among implant configurations to inform efficient utilization. METHODS A cohort study of patients who underwent 1-level or 2-level ACDF in 2017 was conducted using the MarketScan national insurance databases, which contain deidentified clinical and financial data. Implant configurations included plate with cage, standalone cage, and plate with structural allograft. Patients who switched insurance providers within 2 years after surgery or underwent concurrent posterior cervical surgery, cervical disk arthroplasty, or cervical corpectomy were excluded. A combined plate/cage and standalone cage group was compared with the allograft group followed by the comparison of the plate/cage and standalone cage groups. In total, 30-day, 90-day, and 2-year aggregate costs; component costs of physical therapy, injections, medications, psychological treatment, and subsequent spine surgery; and reoperation rates were evaluated. RESULTS Of 1723 patients identified, 360 (20.9%) underwent surgery with plate/cage, 184 (10.7%) with standalone cage, and 1179 (68.4%) with allograft. Aggregate costs were lower in the allograft group compared with the combined cage group at 90 days ($36 428 vs $39 875, P = .04) and 2 years ($64 951 vs $74 965, P = .005) postoperatively. There were no significant differences in aggregate costs between the plate/cage and standalone cage groups. The 2-year reoperation rate was higher in the combined cage compared with the allograft group (23.9% vs 10.9%, P < .001) and was also higher in the standalone cage compared with the plate/cage group (32.0% vs 19.7%, P = .002). CONCLUSION Compared with alternative ACDF constructs, allograft is associated with lower postoperative costs and reoperation rates. Although costs are similar, reoperation rates are lower with plate/cage constructs compared with those of standalone cages. Surgeons should consider these financial and clinical differences when selecting implant configurations.
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Affiliation(s)
- Andrew Y Powers
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Darren Z Nin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ya-Wen Chen
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ruijia Niu
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, USA
| | - David H Kim
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, USA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raymond W Hwang
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts, USA
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Young S, Osman B, Shapiro FE. Safety considerations with the current ambulatory trends: more complicated procedures and more complicated patients. Korean J Anesthesiol 2023; 76:400-412. [PMID: 36912006 PMCID: PMC10562071 DOI: 10.4097/kja.23078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
In the last quarter of a century, the backdrop of appropriate ambulatory and office-based surgeries has changed dramatically. Procedures that were traditionally done in hospitals or patients being admitted after surgery are migrating to the outpatient setting and being discharged on the same day, respectively, at a remarkable rate. In the face of this exponential growth, anesthesiologists are constantly being challenged to maintain patient safety by understanding the appropriate patient selection, procedure, and surgical location. Recently published literature supports the trend of higher, more medically complex patients, and more complicated procedures shifting towards the outpatient arena. Several reasons that may account for this include cost incentives, advancement in anesthesia techniques, enhanced recovery after surgery (ERAS) protocols, and increased patient satisfaction. Anesthesiologists must understand that there is a lack of standardized state regulations regarding ambulatory surgery centers (ASCs) and office-based surgery (OBS) centers. Current and recently graduated anesthesiologists should be aware of the safety concerns related to the various non-hospital-based locations, the sustained growth and demand for anesthesia in the office, and the expansion of mobile anesthesia practices in the US in order to keep up and practice safely with the professional trends. Continuing procedural ambulatory shifts will require ongoing outcomes research, likely prospective in nature, on these novel outpatient procedures, in order to develop risk stratification and prediction models for the selection of the proper patient, procedure, and surgery location.
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Affiliation(s)
- Steven Young
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Brian Osman
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Fred E. Shapiro
- Department of Anesthesiology, 1Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Federico VP, Zavras AG, Butler A, Nolte MT, Munim MA, Lopez GD, DeWald C, An HS, Colman MW, Phillips FM. Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion. J Am Acad Orthop Surg 2023; 31:923-930. [PMID: 37192412 DOI: 10.5435/jaaos-d-22-00800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. METHODS Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. RESULTS A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. CONCLUSION SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.
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Affiliation(s)
- Vincent P Federico
- From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Soliman MAR, Aguirre AO, Kuo CC, Ruggiero N, Khan A, Ghannam MM, Rho K, Jowdy PK, Mullin JP, Pollina J. A Novel Cervical Vertebral Bone Quality Score Independently Predicts Cage Subsidence After Anterior Cervical Diskectomy and Fusion. Neurosurgery 2023; 92:779-786. [PMID: 36729684 DOI: 10.1227/neu.0000000000002269] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Surgeons can preoperatively assess bone quality using dual-energy X-ray absorptiometry or computed tomography; however, this is not feasible for all patients. Recently, a MRI-based scoring system was used to evaluate the lumbar spine's vertebral bone quality. OBJECTIVE To create a similar MRI-based scoring system for the cervical spine (C-VBQ), correlate C-VBQ scores with computed tomography-Hounsfield units (HU), and evaluate the utility of this scoring system to independently predict cage subsidence after single-level anterior cervical diskectomy and fusion (ACDF). METHODS Demographic, procedure-related, and radiographic data were collected for patients. Pearson correlation test was used to determine the correlation between C-VBQ and HU. Cage subsidence was defined as ≥3 mm loss of fusion segmental height. A multivariate logistic regression model was built to determine the correlation between potential risk factors for subsidence. RESULTS Of 59 patients who underwent single-level ACDF, subsidence was found in 17 (28.8%). Mean C-VBQ scores were 2.22 ± 0.36 for no subsidence levels and 2.83 ± 0.38 ( P < .001) for subsidence levels. On multivariate analysis, a higher C-VBQ score was significantly associated with subsidence (odds ratio = 1.85, 95% CI = 1.39-2.46, P < .001) and was the only significant independent predictor of subsidence after ACDF. There was a significant negative correlation between HU and C-VBQ (r 2 = -0.49, P < .001). CONCLUSION We found that a higher C-VBQ score was significantly associated with cage subsidence after ACDF. Furthermore, there was a significant negative correlation between C-VBQ and HU. The C-VBQ score may be a valuable tool for assessing preoperative bone quality and independently predicting cage subsidence after ACDF.
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Affiliation(s)
- Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Moleca M Ghannam
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Kyungduk Rho
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Patrick K Jowdy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA
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Zelenty WD, Paek S, Dodo Y, Sarin M, Shue J, Soffin E, Lebl DR, Cammisa FP, Girardi FP, Sokunbi G, Sama AA, Hughes AP. Utilization Trends of Intraoperative Neuromonitoring for Anterior Cervical Discectomy and Fusion in New York State. Spine (Phila Pa 1976) 2023; 48:492-500. [PMID: 36576864 DOI: 10.1097/brs.0000000000004569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/04/2022] [Indexed: 12/29/2022]
Abstract
STUDY DESIGN Retrospective cohort analysis. OBJECTIVE To elucidate trends in the utilization of intraoperative neuromonitoring (IONM) during anterior cervical discectomy and fusion (ACDF) procedures in NY state using the Statewide Planning and Research Cooperative System and to determine if utilization of IONM resulted in a reduction in postoperative neurological deficits. SUMMARY OF BACKGROUND DATA IONM has been available to spinal surgeons for several decades. It has become increasingly prevalent in all facets of spinal surgery including elective ACDF procedures. The utility of IONM for preventing a neurological deficit in elective spine procedures has recently been called into question. MATERIALS AND METHODS The Statewide Planning and Research Cooperative System database were accessed to perform a retrospective cohort study comparing monitored versus unmonitored ACDF procedures between 2007 and 2018 as defined by the International Classification of Disease-9 and 10 Procedural Coding System (ICD-9 PCS, ICD-10 PCS) codes. Patient demographics, medical history, surgical intervention, pertinent in-hospital events, and urban versus rural medical centers (as defined by the United States Office of Management and Budget) were recorded. Propensity-score-matched comparisons were used to identify factors related to the utilization of IONM and risk factors for neurological deficits after elective ACDF. RESULTS A total of 70,838 [15,092 monitored (21.3%) and 55,746 (78.7%) unmonitored] patients' data were extracted. The utilization of IONM since 2007 has increased in a linear manner from 0.9% of cases in 2007 to 36.7% by 2018. Overall, baseline characteristics of patients who were monitored during cases differed significantly from unmonitored patients in age, race/ethnicity, insurance type, presence of myelopathy or radiculopathy, and Charlson Comorbidity Index; however, only race/ethnicity was statistically significant when analyzed using propensity-score-matched. When comparing urban and rural medical centers, there is a significant lag in the adoption of the technology with no monitored cases in rural centers until 2012 with significant fluctuations in utilization compared with steadily increasing utilization among urban centers. From 2017 to 2018, reporting of neurological deficits after surgery resembled literature-established norms. Pooled analysis of these years revealed that the incidence of neurological complications occurred more frequently in monitored cases than in unmonitored (3.0% vs. 1.4%, P < 0.001). CONCLUSIONS The utility of IONM for elective ACDF remains uncertain; however, it continues to gain popularity for routine cases. For medical centers that lack similar resources to centers in more densely populated regions of NY state, reliable access to this technology is not a certainty. In our analysis of intraoperative neurological complications, it seems that IONM is not protective against neurological injury.
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Affiliation(s)
- William D Zelenty
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Samuel Paek
- Geisinger Commonwealth School of Medicine, Scranton, PA
| | - Yusuke Dodo
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
- Department of Orthopedic Surgery, School of Medicine, Showa University Hospital, Tokyo, Japan
| | - Michele Sarin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Jennifer Shue
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Ellen Soffin
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Darren R Lebl
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Frank P Cammisa
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Federico P Girardi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Gbolabo Sokunbi
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Andrew A Sama
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
| | - Alexander P Hughes
- Orthopaedic Surgery, Spine Care Institute, Hospital for Special Surgery, New York, NY
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10
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Badin D, Ortiz-Babilonia C, Musharbash FN, Jain A. Disparities in Elective Spine Surgery for Medicaid Beneficiaries: A Systematic Review. Global Spine J 2023; 13:534-546. [PMID: 35658589 PMCID: PMC9972279 DOI: 10.1177/21925682221103530] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regards to 2 types of elective spine surgery, lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF). METHODS Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regards to rates of LF and ACDF, costs/reimbursement, and health outcomes. RESULTS A total of 573 articles were assessed. Twenty-five articles were included in the analysis. We found that the literature is consistent with regards to Medicaid disparities. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes (such as higher rates of readmission and emergency department utilization) compared to other insurance categories. CONCLUSIONS In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regards to access to care and health outcomes. Efforts should focus on identifying causes and interventions for such disparities in this vulnerable population.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | | | - Farah N. Musharbash
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins
University, Baltimore, MD, USA,Amit Jain, MD, Department of Orthopaedic
Surgery, Johns Hopkins University, 601 N Caroline St, JHOC 5230 Baltimore, MD
21287, USA.
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11
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Geng EA, Gal JS, Kim JS, Martini ML, Markowitz J, Neifert SN, Tang JE, Shah KC, White CA, Dominy CL, Valliani AA, Duey AH, Li G, Zaidat B, Bueno B, Caridi JM, Cho SK. Robust prediction of nonhome discharge following elective anterior cervical discectomy and fusion using explainable machine learning. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07621-8. [PMID: 36854862 DOI: 10.1007/s00586-023-07621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/25/2023] [Accepted: 02/19/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. METHODS 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model's decision making. RESULTS The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. CONCLUSION We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model's "thinking" aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.
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Affiliation(s)
- Eric A Geng
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan S Gal
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - Michael L Martini
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Sean N Neifert
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, United States of America
| | - Justin E Tang
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Kush C Shah
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Christopher A White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Calista L Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Aly A Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Akiro H Duey
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Gavin Li
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Bashar Zaidat
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Brian Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - John M Caridi
- Department of Neurosurgery, McGovern Medical School at University of Texas Health, Houston, United States of America
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
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12
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Hersh AM, Dedrickson T, Gong JH, Jimenez AE, Materi J, Veeravagu A, Ratliff JK, Azad TD. Neurosurgical Utilization, Charges, and Reimbursement After the Affordable Care Act: Trends From 2011 to 2019. Neurosurgery 2023; 92:963-970. [PMID: 36700751 DOI: 10.1227/neu.0000000000002306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND An estimated 50 million Americans receive Medicare health care coverage. Prior studies have established a downward trend in Medicare reimbursement for commonly billed surgical procedures, but it is unclear whether these trends hold true across all neurosurgical procedures. OBJECTIVE To assess trends in utilization, charges, and reimbursement by Medicare for neurosurgical procedures after passage of the Affordable Care Act in 2010. METHODS We review yearly Physician/Supplier Procedure Summary datasets from the Centers for Medicare and Medicaid Services for all procedures billed by neurosurgeons to Medicare Part B between 2011 and 2019. Procedural coding was categorized into cranial, spine, vascular, peripheral nerve, and radiosurgery cases. Weighted averages for charges and reimbursements adjusted for inflation were calculated. The ratio of the weighted mean reimbursement to weighted mean charge was calculated as the reimbursement-to-charge ratio, representing the proportion of charges reimbursed by Medicare. RESULTS Overall enrollment-adjusted utilization decreased by 12.1%. Utilization decreased by 24.0% in the inpatient setting but increased by 639% at ambulatory surgery centers and 80.2% in the outpatient setting. Inflation-adjusted, weighted mean charges decreased by 4.0% while reimbursement decreased by 4.6%. Procedure groups that saw increases in reimbursement included cervical spine surgery, cranial functional and epilepsy procedures, cranial pain procedures, and endovascular procedures. Ambulatory surgery centers saw the greatest increase in charges and reimbursements. CONCLUSION Although overall reimbursement declined across the study period, substantial differences emerged across procedural categories. We further find a notable shift in utilization and reimbursement for neurosurgical procedures done in non-inpatient care settings.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tara Dedrickson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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Hébert JJ, Adams T, Cunningham E, El-Mughayyar D, Manson N, Abraham E, Wedderkopp N, Bigney E, Richardson E, Vandewint A, Small C, Kolyvas G, Roux AL, Robichaud A, Weber MH, Fisher C, Dea N, Plessis SD, Charest-Morin R, Christie SD, Bailey CS, Rampersaud YR, Johnson MG, Paquet J, Nataraj A, LaRue B, Hall H, Attabib N. Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy. J Neurosurg Spine 2023; 38:56-65. [PMID: 36115059 DOI: 10.3171/2022.7.spine22592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/22/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.
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Affiliation(s)
- Jeffrey J Hébert
- 1Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada
- 2School of Psychology and Exercise Science, Murdoch University, Murdoch, Western Australia, Australia
| | - Tyler Adams
- 1Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Erin Cunningham
- 1Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada
| | | | - Neil Manson
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 4Division of Orthopaedic Surgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Edward Abraham
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 4Division of Orthopaedic Surgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Niels Wedderkopp
- 6Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- 7The Orthopedic Department, Hospital of Southwestern Jutland, Esbjerg, Denmark
| | - Erin Bigney
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 8Research Services, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Eden Richardson
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 8Research Services, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Amanda Vandewint
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 8Research Services, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Chris Small
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 4Division of Orthopaedic Surgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - George Kolyvas
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andre le Roux
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- 9Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Aaron Robichaud
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- 9Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Michael H Weber
- 10Department of Neurology and Neurosurgery, McGill University, Montréal, Québec, Canada
- 21Department of Surgery, Montréal General Hospital, McGill University, Montréal, Québec, Canada
| | - Charles Fisher
- 11Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- 11Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Raphaele Charest-Morin
- 11Combined Neurosurgical and Orthopaedic Spine Program, Department of Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean D Christie
- 13Division of Neurosurgery, Halifax Infirmary, Halifax, Nova Scotia, Canada
| | - Christopher S Bailey
- 14Department of Orthopaedic Surgery, London Health Science Centre, Western University, London, Ontario, Canada
| | - Y Raja Rampersaud
- 15Division of Orthopaedic Surgery, Department of Surgery, University Health Network, University of Toronto, Ontario, Canada
| | - Michael G Johnson
- 16Department of Orthopaedics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerome Paquet
- 17Centre de Recherche CHU de Québec, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Andrew Nataraj
- 18Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Bernard LaRue
- 19Département de Chirurgie, Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, Québec, Canada
| | - Hamilton Hall
- 20Department of Surgery, University of Toronto, Ontario, Canada; and
| | - Najmedden Attabib
- 3Canada East Spine Centre, Saint John, New Brunswick, Canada
- 5Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- 9Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, New Brunswick, Canada
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14
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Gowd AK, Agarwalla A, Beck EC, Derman PB, Yasmeh S, Albert TJ, Liu JN. Prediction of Admission Costs Following Anterior Cervical Discectomy and Fusion Utilizing Machine Learning. Spine (Phila Pa 1976) 2022; 47:1549-1557. [PMID: 36301923 DOI: 10.1097/brs.0000000000004436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/09/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE Predict cost following anterior cervical discectomy and fusion (ACDF) within the 90-day global period using machine learning models. BACKGROUND The incidence of ACDF has been increasing with a disproportionate decrease in reimbursement. As bundled payment models become common, it is imperative to identify factors that impact the cost of care. MATERIALS AND METHODS The Nationwide Readmissions Database (NRD) was accessed in 2018 for all primary ACDFs by the International Classification of Diseases 10th Revision (ICD-10) procedure codes. Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics, such as volume of procedures performed and wage index, were also queried. Readmissions within 90 days were identified, and cost of readmissions was added to the total admission cost to represent the 90-day healthcare cost. Machine learning algorithms were used to predict patients with 90-day admission costs >1 SD from the mean. RESULTS There were 42,485 procedures included in this investigation with an average age of 57.7±12.3 years with 50.6% males. The average cost of the operative admission was $24,874±25,610, the average cost of readmission was $25,371±11,476, and the average total cost was $26,977±28,947 including readmissions costs. There were 10,624 patients who were categorized as high cost. Wage index, hospital volume, age, and diagnosis-related group severity were most correlated with the total cost of care. Gradient boosting trees algorithm was most predictive of the total cost of care (area under the curve=0.86). CONCLUSIONS Bundled payment models utilize wage index and diagnosis-related groups to determine reimbursement of ACDF. However, machine learning algorithms identified additional variables, such as hospital volume, readmission, and patient age, that are also important for determining the cost of care. Machine learning can improve cost-effectiveness and reduce the financial burden placed upon physicians and hospitals by implementing patient-specific reimbursement.
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Affiliation(s)
- Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY
| | - Edward C Beck
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC
| | | | - Siamak Yasmeh
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Todd J Albert
- Department of Orthopedic Surgery, Weill Cornell Medical College, Hospital for Special Surgery, New York, NY
| | - Joseph N Liu
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA
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15
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Gordon AM, Golub IJ, Ng MK, Lam AW, Houten JK, Saleh A. Primary and Revision Cervical Disc Arthroplasty from 2010–2020: Patient Demographics, Utilization Trends, and Health Care Reimbursements. World Neurosurg 2022; 168:e344-e349. [DOI: 10.1016/j.wneu.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
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16
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Toci GR, Lambrechts MJ, Issa TZ, Karamian BA, Syal A, Parson JP, Canseco JA, Woods BI, Rihn JA, Hilibrand AS, Schroeder GD, Kepler CK, Vaccaro AR, Kaye ID. Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion? World Neurosurg 2022; 166:e495-e503. [PMID: 35843583 DOI: 10.1016/j.wneu.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion. METHODS Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05. RESULTS A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = -4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM < 65. CONCLUSIONS Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.
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Affiliation(s)
- Gregory R Toci
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Mark J Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA.
| | - Tariq Z Issa
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Amit Syal
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Jory P Parson
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Barrett I Woods
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Christopher K Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
| | - I David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia Pennsylvania, USA
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17
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Chatterjee A, Rbil N, Yancey M, Geiselmann MT, Pesante B, Khormaee S. Increase in surgeons performing outpatient anterior cervical spine surgery leads to a shift in case volumes over time. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 11:100132. [PMID: 35783006 PMCID: PMC9243295 DOI: 10.1016/j.xnsj.2022.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Nada Rbil
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Michael Yancey
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
| | - Matthew T. Geiselmann
- New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, NY, United States
| | - Benjamin Pesante
- The University of Connecticut School of Medicine, Farmington, CT, United States
| | - Sariah Khormaee
- Weill Cornell Medical College, New York, NY, United States
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
- Corresponding author: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, United States
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18
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Thomas G, Bornstein S, Cho K, Rao RD. Industry payments to spine surgeons from 2014 to 2019: trends and comparison of payments to spine surgeons versus all physicians. Spine J 2022; 22:910-920. [PMID: 35038572 DOI: 10.1016/j.spinee.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/28/2021] [Accepted: 01/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The ethics of industry payments to physicians and the potential impact on healthcare costs and research outcomes have long been topics of debate. Industry payments to spine surgeons are frequently scrutinized. Transparency of industry relationships with physicians provides insight into their possible impact on clinical decision-making and utilization of care. PURPOSE To analyze trends in medical industry payments to spine surgeons and all physicians from 2014 to 2019, and further evaluate whether specific payments to spine surgeons vary based on company size. STUDY DESIGN/SETTING Cross-sectional investigation of publicly reported Center for Medicare and Medicaid Services (CMS) Open Payments Database (OPD) POPULATION SAMPLE: All US providers listed as receiving industry payments with further evaluation of payments to neurosurgeons and orthopedic spine surgeons. OUTCOME MEASURES Main measures were the magnitude and trends of industry general and research payments and subcategories of general payments, such as royalty/license and consulting fees, to spine surgeons and comparison to all physicians over the six-year period. Variations in payment patterns among spine device manufacturers with the highest reported level of spine surgeon payments in 2019. METHODS From 2014 to 2019 publicly reported general and research industry payments in the CMS OPD were analyzed. Trends in payments to all physicians were compared to trends in payments to neurosurgeons and orthopedic spine surgeons. Trends in payment patterns among spine device manufacturers with the highest payments in 2019 were determined. Linear regression analysis was completed to find statistically significant outcomes. RESULTS Our investigation found an aggregate of $42,710,365,196 general and research payments reported to all physicians over the 6-year period, 2.6% ($1,112,936,203) of which went to spine surgeons. Industry general and research payments to spine surgeons decreased by 17.5% ($195,571,109, 2014; $161,283,683, 2019), while increasing by 8.7% ($6,706,208,391, 2014; $7,288,003,832, 2019) to all physicians. Industry research payments to spine surgeons were notably low each year and decreased to only 0.5% of research payments made to all physicians in 2019. Median payment received by spine surgeons as well as the overall distribution of payments to the 75th and 95th percentile significantly increased over the six-year period in comparison to the stable distribution of payments to all physicians. Top eight spine device manufactures with the highest level of spine surgeon payments accounted for 72.9% payments in 2014 but decreased payments by 17.6% to 2019 ($120,409,083.75, 2014; $99,283,264.49, 2019). CONCLUSIONS Industry general and research payments to all physicians increased from 2014 to 2019 but decreased to spine surgeons, largely due to decreasing payments from eight device manufacturers with the highest level of surgeon payments. A small subset of spine surgeons continues to receive increasing payments. The implications of decreasing investments in research by industry and of large payments made to a small group of spine surgeons bears cautious oversight, both for the future of the specialty and any impact on patient care outcomes.
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Affiliation(s)
- George Thomas
- George Washington School of Medicine and Health Sciences, Washington, DC 20052, USA.
| | - Sydney Bornstein
- George Washington School of Medicine and Health Sciences, Washington, DC 20052, USA.
| | - Kevin Cho
- George Washington School of Medicine and Health Sciences, Washington, DC 20052, USA.
| | - Raj D Rao
- West Palm Beach VA Healthcare System, West Palm Beach, FL 33410, USA.
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19
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Rajan PV, Emara AK, Ng M, Grits D, Pelle DW, Savage JW. Longer operative time associated with prolonged length of stay, non-home discharge and transfusion requirement after anterior cervical discectomy and fusion: an analysis of 24,593 cases. Spine J 2021; 21:1718-1728. [PMID: 33971323 DOI: 10.1016/j.spinee.2021.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/17/2021] [Accepted: 04/28/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prolonged operative time of single-level ACDF has been associated with adverse postoperative outcomes. The current literature does not contain a comprehensive quantitative description of these associations PURPOSE: This study characterized the associations between single-level anterior cervical discectomy and fusion(ACDF) operative time and (1)30-day postoperative healthcare utilization, and (2)the incidence of local wound complications, need for transfusion and mechanical ventilation. DESIGN/SETTING Retrospective database analysis PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP) database was queried for single-level ACDF cases(2012-2018) using current procedural terminology codes. A total of 24,593 cases were included. OUTCOME MEASURES Primary outcomes included healthcare utilization(lengths of stay[LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative time category. The secondary outcome was the incidence of wound complications, blood transfusion and need for ventilation per operative time category. METHODS Multivariate regression determined operative time categories associated with increased risk while adjusting for patient demographics and comorbidities. Predictive spline regression models visualized the associations. RESULTS Compared to the reference operative time of 81-100-minutes, the 101-120-minute category was associated with higher odds of LOS >2 days(OR:1.36,95%CI(1.18-1.568);p<.001) and non-home discharge(OR:1.341,95%CI(1.081-1.664);p=.008). Three-times greater odds of LOS >2 days(OR:3.367,95%CI(2.719-4.169); p<.001) and twice the odds of non-home discharge(OR:2.174,95%CI(1.563-3.022);p<.001) were detected at 181-200-minutes. The highest operative time category(≥221 minutes) was associated with the highest odds of LOS>2 days(OR:4.838,95%CI(4.032-5.804);p<.001), non-home discharge(OR:2.687,95%CI(2.045-3.531);p<.001) and reoperation(OR:1.794,95%CI(1.094-2.943);p=.021). Patients within the 201-220 and the ≥221-minute categories exhibited a significant association with greater odds of transfusion(OR:8.57,95%CI(2.321-31.639);p<.001, and OR:11.699, 95%CI(4.179-32.749);p=.001, respectively). Spline regression demonstrated that the odds of LOS >2 days, non-home discharge disposition, reoperation and bleeding requiring transfusion events began to rise, starting at 94, 91.6, 91.6, and 93.3 minutes of operative time, respectively. CONCLUSION This study demonstrated that prolonged operative time is associated with increased odds of healthcare utilization and transfusion after single-level ACDF. Operative times greater than 91 minutes may carry higher odds of postoperative complications.
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Affiliation(s)
- Prashant V Rajan
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA; Center for Spine Health, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA.
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Mitchell Ng
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Daniel Grits
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Dominic W Pelle
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA; Center for Spine Health, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
| | - Jason W Savage
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA; Center for Spine Health, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, USA
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