Association Between Baseline Affective Disorders and 30-Day Readmission Rates in Patients Undergoing Elective Spine Surgery

The Impact of the Preoperative Mental Health Component Summary (MCS) Score on Short-Term Outcomes After Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study is to characterize the relationship between preoperative MCS and surgical outcomes after lumbar spine surgery including inpatient complications, length of stay, readmissions, and reoperations.

SUMMARY OF BACKGROUND DATA

As the prevalence of mental health disorders in the United States increases, it is important to identify risks associated with poor mental health status in the surgical spine patient. The mental health component summary (MCS) of the Short Form-12 has been used extensively as an indication of a patient's mental health status and psychological well-being.

PATIENTS AND METHODS

Adult patients older than or equal to 18 years who underwent primary one to three level lumbar fusion surgery at our academic medical institution from 2017 to 2021 were retrospectively identified. Preoperative MCS score was used to analyze outcomes in patients based on a cutoff (<45.6). A score >45.6 indicated better preoperative mental health and a score ≤45.6 indicated worse preoperative mental health.

RESULTS

Patients with lower preoperative MCS scores had longer hospital stays (3.86±2.16 vs. 3.55±1.42 d, P =0.010) and were more likely to have inpatient renal complications (3.09% vs. 7.19%, P =0.006). Patients with lower preoperative MCS scores also had lower activity measure for post-acute care (AM-PAC) scores (17.1±2.85 vs. 17.6±2.49, P =0.030). Ninety-day surgical readmissions, medical readmissions, and reoperations were not significantly different between groups ( P >0.05).

CONCLUSION

Our study suggests that patients with lower preoperative mental health scores (MCS ≤45.6) were independently more likely to experience more renal complications and longer length of stay after primary lumbar fusion. In addition, higher MCS scores may correlate with better postoperative mobility and daily activity scores. Nevertheless, long-term outcomes are not significantly different between patients of better or worse preoperative mental health.

LEVEL OF EVIDENCE

Level IV.

90-Day Emergency Department Utilization and Readmission Rate After Full-Endoscopic Spine Surgery: A Multicenter, Retrospective Analysis of 821 Patients

BACKGROUND AND OBJECTIVES

Emergency department (ED) utilization and readmission rates after spine surgery are common quality of care measures. Limited data exist on the evaluation of quality indicators after full-endoscopic spine surgery (FESS). The objective of this study was to detect rates, causes, and risk factors for unplanned postoperative clinic utilization after FESS.

METHODS

This retrospective multicenter analysis assessed ED utilization and clinic readmission rates after FESS performed between 01/2014 and 04/2023 for degenerative spinal pathologies. Outcome measures were ED utilizations, hospital readmissions, and revision surgeries within 90 days postsurgery.

RESULTS

Our cohort includes 821 patients averaging 59 years of age, who underwent FESS. Most procedures targeted the lumbar or sacral spine (85.75%) while a small fraction involved the cervical spine (10.11%). The most common procedures were lumbar unilateral laminotomies for bilateral decompression (40.56%) and lumbar transforaminal discectomies (25.58%). Within 90 days postsurgery, 8.0% of patients revisited the ED for surgical complications. A total of 2.2% of patients were readmitted to a hospital of which 1.9% required revision surgery. Primary reasons for ED visits and clinic readmissions were postoperative pain exacerbation, transient neurogenic bladder dysfunction, and recurrent disk herniations. Our multivariate regression analysis revealed that female patients had a significantly higher likelihood of using the ED ( P = .046; odds ratio: 1.77, 95% CI 1.01-3.1 5.69% vs 10.33%). Factors such as age, American Society of Anesthesiologists class, body mass index, comorbidities, and spanned spinal levels did not significantly predict postoperative ED utilization.

CONCLUSION

This analysis demonstrates the safety of FESS, as evidenced by acceptable rates of ED utilization, clinic readmission, and revision surgery. Future studies are needed to further elucidate the safety profile of FESS in comparison with traditional spinal procedures.

Preoperative Optimization Strategies in Elective Spine Surgery

» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.

Impact of Depression on Postoperative Medical and Surgical Outcomes in Spine Surgeries: A Systematic Review and Meta-Analysis

Introduction: The relationship between psychiatric disorders, including depression, and invasive interventions has been a topic of debate in recent literature. While these conditions can impact the quality of life and subjective perceptions of surgical outcomes, the literature lacks consensus regarding the association between depression and objective perioperative medical and surgical complications, especially in the neurosurgical domain. Methods: MEDLINE (PubMed), EMBASE, PsycINFO, and the Cochrane Library were queried in a comprehensive manner from inception until 10 November 2023, with no language restrictions, for citations investigating the association between depression and length of hospitalization, medical and surgical complications, and objective postoperative outcomes including readmission, reoperation, and non-routine discharge in patients undergoing spine surgery. Results: A total of 26 articles were considered in this systematic review. Upon pooled analysis of the primary outcome, statistically significantly higher rates were observed for several complications, including delirium (OR:1.92), deep vein thrombosis (OR:3.72), fever (OR:6.34), hematoma formation (OR:4.7), hypotension (OR:4.32), pulmonary embolism (OR:3.79), neurological injury (OR:6.02), surgical site infection (OR:1.36), urinary retention (OR:4.63), and urinary tract infection (OR:1.72). While readmission (OR:1.35) and reoperation (OR:2.22) rates, as well as non-routine discharge (OR:1.72) rates, were significantly higher in depressed patients, hospitalization length was comparable to non-depressed controls. Conclusions: The results of this review emphasize the significant increase in complications and suboptimal outcomes noted in patients with depression undergoing spinal surgery. Although a direct causal relationship may not be established, addressing psychiatric aspects in patient care is crucial for providing comprehensive medical attention.

The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis

Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2  = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2  = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2  = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2  = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.

Risk Factors for 30-day Unplanned Readmission following Surgery for Lumbar Degenerative Diseases: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Surgical procedures for lumbar degenerative diseases (LDD), which have emerged in the 21-century, are commonly practiced worldwide. Regarding financial burdens and health costs, readmissions within 30days following surgery are inconvenient. We performed a systematic review to integrate real-world evidence and report the current risk factors associated with 30-day readmission following surgery for LDD.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched from inception to April 2022 to identify relevant studies reporting risk factors for 30-day readmission following surgery for LDD.

RESULTS

Thirty-six studies were included in the review. Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay.

CONCLUSIONS

There are several potential perioperative risk factors associated with unplanned readmission following surgery for LDD. Preoperatively identifying patients that are at increased risk of readmission is critical for achieving the best possible outcomes.

Impact of Affective Disorders on Inpatient Opioid Consumption and Hospital Outcomes Following Open Posterior Spinal Fusion for Adult Spine Deformity

OBJECTIVE

Affective disorders (ADs) are common and have a profound impact on surgical recovery, though few have studied the impact of ADs on inpatient narcotic consumption. The aim of this study was to assess the impact of ADs on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity.

METHODS

A retrospective cohort study was performed using the 2016-2017 Premier Healthcare Database. Adults who underwent adult spinal deformity surgery were identified using International Classification of Disease, Tenth Revision, codes. Patients were grouped based on comorbid diagnosis of an AD. Demographics, comorbidities, intraoperative variables, complications, length of stay, admission costs, and nonroutine discharge rates were assessed. Increased inpatient opioid use was categorized by morphine milligram equivalents consumption greater than the 75th percentile. Multivariate regression analysis was used to identify predictors of increased healthcare recourse utilization.

RESULTS

Of the 1831 study patients, 674 (36.8%) had an AD. A smaller proportion of patients in the AD cohort were 65+ years of age (P = 0.001), while a greater proportion of patients in the AD cohort identified as non-Hispanic White (P < 0.001). A greater proportion of patients in the AD cohort had increased morphine milligram equivalents consumption (P < 0.001). The AD cohort also had a longer mean length of stay (P < 0.001). A greater proportion of patients in the AD cohort had nonroutine discharges (P = 0.039) and unplanned 30-day readmission (P = 0.041). On multivariate analysis, AD was significantly associated with increased cost (odds ratio: 1.61, P < 0.001) and nonroutine discharge (odds ratio: 1.36, P = 0.035).

CONCLUSIONS

ADs may be associated with increased inpatient opioid consumption and healthcare resource utilization.

Factors associated with greater patient satisfaction in outpatient neurosurgical clinics: Recommendation for surgery, older age, cranial chief complaint, and public health insurance

OBJECTIVE

Patient satisfaction has increasingly played a role in determining care quality. Surveys are used to gauge patient experience, satisfaction of care, and likelihood to recommend providers and facilities. The aim of the study is to evaluate whether clinical and demographic data predict greater patient satisfaction with providers in the outpatient neurosurgery clinic.

METHODS

Press-Ganey (Press Ganey Associates, South Bend, IL) evaluations of 1521 patients were reviewed in an academic neurosurgical clinic from January 1, 2019 through February 1, 2021. We analyzed associations between Press-Ganey ratings and patient demographics, chief complaint, psychiatric comorbidities, number of orders placed, medication prescriptions, surgical recommendation, payor status, and referral source. We used univariate logistic regression to assess for associations between independent variables and Press-Ganey ratings. Multivariable logistic regression was used for associated factors.

RESULTS

For the Likelihood to Recommend question, older age (p = 0.003), cranial chief complaint (p = 0.046), and recommendations for surgery (p < 0.001) were significantly associated with "good" ratings. For the rating of Care Received, older age (p = 0.002), cranial chief complaint (p = 0.05), and recommendations for surgery (p = 0.002) were significantly associated with "good" ratings. For Confidence in Care Provider question, recommendations for surgery (p = <0.001) and government insurance type (p = 0.002) were significantly associated with "good" ratings.

CONCLUSIONS

Patients with older age, cranial pathologies, a recommendation for surgery, and government health insurance were significantly associated with favorable patient satisfaction with providers in the outpatient neurosurgery clinic. Prospective studies should target patient populations who are younger, have spinal complaints, have non-surgical needs, and have commercial insurance to improve satisfaction.

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) Comparison Study: Assessing for PROMIS-29 Depression and Anxiety Psychopathologic Cutoff Values Amongst Patients Undergoing Elective Complex Spine Procedures

OBJECTIVE

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) are used to assess patient psychology, pain, and quality of life. As psychological factors, such as depression and anxiety, are associated with poor perioperative outcomes, we aim to translate MMPI-2-RF values to PROMIS-29 scores and establish cutoff values for PROMIS-29 anxiety and depression domains that might warrant attention preoperatively.

METHODS

Seventy adult patients scheduled for an elective spinal surgery between July 2018 and February 2020 who completed both the MMPI-2-RF and PROMIS-29 preoperatively at a single institution were reviewed.

RESULTS

Patients with MMPI-2-RF scores of 65 or greater (the cutoff for psychopathology) in the emotional/internalizing dysfunction scale (4.29%) had an average PROMIS-29 depression score of 14.33, which is significantly higher than the control group's (<65 score) 8.49 score (P = 0.04). Similarly, those demonstrating psychopathology on the demoralization (4.29%) and helplessness/hopelessness (4.29%) scales had average PROMIS-29 depression scores significantly higher than the control group's averages (15.33 vs. 8.45, P = 0.02 and 14.33 vs. 8.49, P = 0.04, respectively). Patients with an MMPI-2-RF score of 65 or greater on the emotional/internalizing dysfunction (4.29%), stress/worry (10.00%), and anxiety (7.14%) scales had average PROMIS-29 anxiety domain scores of 15, 15, and 15, respectively, which were significantly greater than that of the control group's scores (8.94, P = 0.04; 8.75, P = 0.004; and 8.55, P < 0.001, respectively).

CONCLUSIONS

PROMIS-29 scores of 15 or greater on the depression and anxiety domains may have psychopathologies that warrant addressing, given their increased likelihood of having poor outcomes.

The Impact of Social Determinants of Health on 30 and 90-Day Readmission Rates After Spine Surgery

BACKGROUND

Since its 2012 inception, the U.S. Centers for Medicare & Medicaid Services Hospital Readmissions Reduction Program (HRRP) has espoused cost-effective health-care delivery by financially penalizing hospitals with excessive 30-day readmission rates. In this study, we hypothesized that socioeconomic factors impact readmission rates of patients undergoing spine surgery.

METHODS

In this study, 2,830 patients who underwent a spine surgical procedure between 2012 and 2018 were identified retrospectively from our institutional database, with readmission (postoperative day [POD] 0 to 30 and POD 31 to 90) as the outcome of interest. Patients were linked to U.S. Census Tracts and ZIP codes using the Geographic Information Systems (ArcGIS) mapping program. Social determinants of health (SDOH) were obtained from publicly available databases. Patient income was estimated at the Public Use Microdata Area level based on U.S. Census Bureau American Community Survey data. Univariate and multivariable stepwise regression analyses were conducted. Significance was defined as p < 0.05, with Bonferroni corrections as appropriate.

RESULTS

Race had a significant effect on readmission only among patients whose estimated incomes were <$31,650 (χ2 = 13.4, p < 0.001). Based on a multivariable stepwise regression, patients with estimated incomes of <$31,000 experienced greater odds of readmission by POD 30 compared with patients with incomes of >$62,000; the odds ratio (OR) was 11.06 (95% confidence interval [CI], 6.35 to 15.57). There were higher odds of 30-day readmission for patients living in neighborhoods with higher diabetes prevalence (OR, 3.02 [95% CI, 1.60 to 5.49]) and patients living in neighborhoods with limited access to primary care providers (OR, 1.39 [95% CI, 1.10 to 1.70]). Lastly, each decile increase in the Area Deprivation Index of a patient's Census Tract was associated with higher odds of 30-day readmission (OR, 1.40 [95% CI, 1.30 to 1.51]).

CONCLUSIONS

Socioeconomically disadvantaged patients and patients from areas of high social deprivation have a higher risk of readmission following a spine surgical procedure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Differences in Healthcare Resource Utilization After Surgery for Metastatic Spinal Column Tumors in Patients with a Concurrent Affective Disorder in the United States

BACKGROUND

Affective disorders, such as depression and anxiety, are exceedingly common among patients with metastatic cancer. The aim of this study was to investigate the relationship between affective disorders and healthcare resource utilization in patients undergoing surgery for a spinal column metastasis.

METHODS

A retrospective cohort study was performed using the 2016-2018 National Inpatient Sample database. All adult patients (≥18 years) undergoing surgery for a metastatic spinal tumor were identified using the ICD-10-CM coding systems. Patients were categorized into two cohorts: No Affective Disorder (No-AD) and Affective Disorder (AD). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, postoperative adverse events (AEs), LOS, discharge disposition, and total cost of hospital admission were assessed. A multivariate logistic regression analysis was used to identify independent predictors of increased cost, non-routine discharge, and prolonged LOS.

RESULTS

Of the 8,360 patients identified, 1,710 (20.5%) had a diagnosis of AD. While no difference was observed in the rates of postoperative AEs between the cohorts (p=0.912), the AD cohort had a significantly longer mean LOS (No-AD:10.1±8.3 days vs AD:11.6±9.8 days, p=0.012) and greater total cost (No-AD:$53,165±35,512 vs AD:$59,282±36,917, p=0.011). No significant differences in non-routine discharge were observed between the cohorts (p=0.265). On multivariate regression analysis, having an affective disorder was a significant predictor of increased costs [OR:1.45, CI(1.03,2.05), p=0.034] and non-routine discharge [OR:1.40, CI(1.06,1.85), p=0.017], but not prolonged LOS (p=0.067).

CONCLUSIONS

Our study found that affective disorders were significantly associated with greater hospital expenditures and non-routine discharge, but not prolonged LOS, for patients undergoing surgery for spinal metastases.

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients.

BACKGROUND

While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement.

RESULTS

The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change.

CONCLUSIONS

Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery

BACKGROUND

Preoperative depression is a risk factor for poor outcomes after spine surgery.

OBJECTIVE

To understand effects of depression on spine surgery outcomes and healthcare resource utilization.

METHODS

Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use.

RESULTS

Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery.

CONCLUSION

EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.

Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis

OBJECTIVE

To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay.

STUDY DESIGN

Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates.

DATA SOURCES

MEDLINE, EMBASE, PsychINFO, and the Cochrane Library.

DATA SYNTHESIS

Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99).

CONCLUSIONS

Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018080114 (prospective).

Depression Identified on the Mental Component Score of the Short Form-12 Affects Health Related Quality of Life After Lumbar Decompression Surgery

STUDY DESIGN

This was a retrospective comparative study.

OBJECTIVE

The goal of this study was to further elucidate the relationship between preoperative depression and patient-reported outcome measurements (PROMs) following lumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

The impact of preoperative depression on PROMs after lumbar decompression surgery is not well established.

METHODS

Patients undergoing lumbar decompression between 1 and 3 levels were retrospectively identified. Patients were split into 2 groups using a preoperative Mental Component Score (MCS)-12 threshold score of 45.6 or 35.0 to identify those with and without depressive symptoms. In addition, patients were also split based on a pre-existing diagnosis of depression in the medical chart. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared, and a multiple linear regression analysis was performed.

RESULTS

A total of 184 patients were included, with 125 (67.9%) in the MCS-12 >45.6 group and 59 (32.1%) in the MCS-12 ≤45.6 group. The MCS-12 ≤45.6 and MCS<35.0 group had worse baseline Oswestry Disability Index (ODI) (P<0.001 for both) and Visual Analogue Scale Leg (P=0.018 and 0.024, respectively) scores. The MCS ≤45.6 group had greater disability postoperatively in terms of SF-12 Physical Component Score (PCS-12) (39.1 vs. 43.1, P=0.015) and ODI (26.6 vs. 17.8, P=0.006). Using regression analysis, having a baseline MCS-12 scores ≤45.6 before surgical intervention was a significant predictor of worse improvement in terms of PCS-12 [β=-4.548 (-7.567 to -1.530), P=0.003] and ODI [β=8.234 (1.433, 15.035), P=0.010] scores than the MCS-12 >45.6 group.

CONCLUSION

Although all patients showed improved in all PROMs after surgery, those with MCS-12 ≤45.6 showed less improvement in PCS-12 and ODI scores.

Evaluating the Impact of Psychiatric Disorders on Preoperative Pain Ratings, Narcotics Use, and the PROMIS-29 Quality Domains in Spine Surgery Candidates

Objective We aimed to study the relationship between psychiatric Disorders (PD), preoperative pain, and opioid medication intake, as well as the quality of life patient-reported outcome measures using the Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) questionnaire, during the 30-day interval preceding surgery, in a consecutive series of patients who were scheduled to undergo surgical spine procedures. We hypothesized that PD could affect preoperative narcotic use and pain interference in a fashion that was not linearly associated with preoperative pain in spine surgery candidates. Methods The records of consecutive adult patients who underwent elective spinal surgery between October 2016 and August 2017 at a single institution were reviewed. We included patients who underwent preoperative pain assessment within 30 days prior to their planned surgery using the PROMIS-29 questionnaire. Patients with PD were compared to controls. Results A total of 117 patients matched our criteria. The average rating of pain intensity was notably higher in the PD group as compared to controls (p=0.004). The PD group had more patients complaining of high pain levels (>6) as compared to the control group (p=0.026). Controls with high pain levels had a greater incidence of preoperative narcotic use as compared to the low-pain cohort (p=0.029). However, there was no difference in the actual dose of daily narcotic medication taken between the PD and control groups (P=0.099) or between the low- and high pain score groups in the control (p=0.291) and PD (p=0.441) groups, respectively. Patients with PD and higher pain ratings seemed to have a higher incidence of anxiety (p=0.005) and depression (p<0.001). That was not the case for controls. Conclusions PDs may impact the degree of preoperative pain interference and the intake of narcotic medication independently from pain intensity ratings.

Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA).

SUMMARY OF BACKGROUND DATA

For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA.

METHODS

A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R).

RESULTS

There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission.

CONCLUSION

Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures.

LEVEL OF EVIDENCE

Level III.

Effect of change in preoperative depression/anxiety on patient outcomes following lumbar spine surgery

OBJECTIVE

The purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery.

METHODS

This study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery.

RESULTS

Of the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p < 0.01) compared to those who did not experience improvement in depression or anxiety.

CONCLUSION

Depression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BACKGROUND

We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.

METHOD

Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions.

RESULTS

A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.

CONCLUSION

Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

Electronic Communication Patterns Could Reflect Preoperative Anxiety and Serve as an Early Complication Warning in Elective Spine Surgery Patients with Affective Disorders: A Retrospective Analysis of a Cohort of 1199 Elective Spine Patients

OBJECTIVE

The analysis of perioperative electronic patient portal (EPP) communication may provide risk stratification and insight for complication prevention in patients with affective disorders (ADs). We aimed to understand how patterns of EPP communication in patients with AD relate to preoperative narcotic use, surgical outcomes, and readmission rates.

METHODS

The records of adult patients who underwent elective spinal surgery between January 2010 and August 2017 at a single institution were retrospectively reviewed for analysis. Primary outcomes included preoperative narcotic use, the number of perioperative EPP messages sent, rates of perioperative complications, hospital length of stay, emergency department (ED) visits within 6 weeks, and readmissions within 30 days after surgery.

RESULTS

A total of 1199 patients were included in the analysis. Patients with an AD were more likely to take narcotics before surgery (51.69% vs. 41%, P < 0.001) and to have active EPP accounts (75.36% vs. 69.75%, P = 0.014) compared with controls. They were also more likely to send postoperative messages (38.89% vs. 32.75%, P = 0.030) and tended to send more messages (0.67 vs. 0.48, P = 0.034). The AD group had higher rates of postoperative complications (8.21% vs. 3.98%, P = 0.001), ED visits (4.99% vs. 2.43%, P = 0.009), and readmissions postoperatively (2.49% vs. 1.38%, P = 0.049).

CONCLUSIONS

AD patients have specific patterns of perioperative EPP communication. They are at a higher risk of postoperative complications. Addressing these concerns early may prevent more serious morbidity and avoid unnecessary ED visits and readmissions, thus reducing costs and improving patient care.

Use of Patient Health Questionnaire-2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire-2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.

METHODS

Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.

RESULTS

Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.

CONCLUSIONS

A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

Reduced influence of affective disorders on perioperative complication rates, length of hospital stay, and healthcare costs following spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

In the past decade, a gradual transition of health policy to value-based healthcare has brought increased attention to measuring the quality of care delivered. In spine surgery, adolescents with scoliosis are a population particularly at risk for depression, anxious feelings, and impaired quality of life related to back pain and cosmetic appearance of the deformity. With the rising prevalence of mental health ailments, it is necessary to evaluate the impact of concurrent affective disorders on patient care after spinal surgery in adolescents. The aim of this study was to investigate the impact that affective disorders have on perioperative complication rates, length of stay (LOS), and total costs in adolescents undergoing elective posterior spinal fusion (PSF) (≥ 4 levels) for idiopathic scoliosis.

METHODS

A retrospective study of the Kids' Inpatient Database for the year 2012 was performed. Adolescent patients (age range 10-17 years old) with AIS undergoing elective PSF (≥ 4 levels) were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were categorized into 2 groups at discharge: affective disorder or no affective disorder. Patient demographics, comorbidities, complications, LOS, discharge disposition, and total cost were assessed. The primary outcomes were perioperative complication rates, LOS, total cost, and discharge dispositions.

RESULTS

There were 3759 adolescents included in this study, of whom 164 (4.4%) were identified with an affective disorder (no affective disorder: n = 3595). Adolescents with affective disorders were significantly older than adolescents with no affective disorders (affective disorder: 14.4 ± 1.9 years vs no affective disorder: 13.9 ± 1.8 years, p = 0.001), and had significantly different proportions of race (p = 0.005). Aside from hospital region (p = 0.016), no other patient- or hospital-level factors differed between the cohorts. Patient comorbidities did not differ significantly between cohorts. The number of vertebral levels involved was similar between the cohorts, with the majority of patients having 9 or more levels involved (affective disorder: 76.8% vs no affective disorder: 79.5%, p = 0.403). Postoperative complications were similar between the cohorts, with no significant difference in the proportion of patients experiencing a postoperative complication (p = 0.079) or number of complications (p = 0.124). The mean length of stay and mean total cost were similar between the cohorts. Moreover, the routine and nonroutine discharge dispositions were also similar between the cohorts, with the majority of patients having routine discharges (affective disorder: 93.9% vs no affective disorder: 94.9%, p = 0.591).

CONCLUSIONS

This study suggests that affective disorders may not have a significant impact on surgical outcomes in adolescent patients undergoing surgery for scoliosis in comparison with adults. Further studies are necessary to elucidate how affective disorders affect adolescent patients with idiopathic scoliosis, which may improve provider approach in managing these patients perioperatively and at follow-up in hopes to better the overall patient satisfaction and quality of care delivered.

Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes

OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 2

STUDY DESIGN

Structured literature review.

OBJECTIVES

To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery.

METHODS

Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies.

RESULTS

We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications.

CONCLUSION

Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care.

LEVEL OF EVIDENCE

Level II.

Effect of Mental Health Conditions on Complications, Revision Rates, and Readmission Rates Following Femoral Shaft, Tibial Shaft, and Pilon Fracture

OBJECTIVES

To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures.

DESIGN

Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions.

SETTING

National databases of 70 million combined patients from 2007 to 2015.

PATIENTS/PARTICIPANTS

Humana and Medicare insured patients.

INTERVENTION

Surgical treatment of tibial, femoral, and pilon fractures.

MAIN OUTCOME MEASUREMENTS

Ninety-day readmission, 90-day complications, and all-time revision surgical intervention.

RESULTS

The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all).

CONCLUSIONS

Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduced Influence of Affective Disorders on 6-Week and 3-Month Narcotic Refills After Primary Complex Spinal Fusions for Adult Deformity Correction: A Single-Institutional Study

OBJECTIVE

Previous studies have identified the impact of affective disorders on preoperative and postoperative perception of pain. However, there is a scarcity of data identifying the impact of affective disorders on postdischarge narcotic refills. The aim of this study was to determine whether patients with affective disorders have more narcotic refills after complex spinal fusion for deformity correction.

METHODS

The medical records of 121 adult (≥18 years old) spine deformity patients undergoing elective, primary complex spinal fusion (≥5 level) for deformity correction at a major academic institution from 2010 to 2015 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative complication rates, baseline and postoperative patient-reported pain scores, ambulatory status, and narcotic refills were collected for each patient. The primary outcome was the rate of 6-week and 3-month narcotic refills.

RESULTS

Of the 121 patients, 43 (35.5%) had a clinical diagnosis of anxiety or depression (affective disorder) (AD n = 43; No-AD n = 78). Preoperative narcotic use was significantly higher in the AD cohort (AD 65.9% vs. No-AD 37.7%, P = 0.0035). The AD cohort had significantly higher pain scores at baseline (AD 6.5 ± 2.9 vs. No-AD 4.7 ± 3.1, P = 0.004) and at the first postoperative pain score reported (AD 6.7 ± 2.6 vs. No-AD 5.6 ± 2.9, P = 0.049). However, there were no significant differences in narcotic refills at 6 weeks (AD 34.9% vs. No-AD 25.6%, P = 0.283) and 3 months (AD 23.8% vs. No-AD 17.4%, P = 0.411) after discharge between the cohorts.

CONCLUSIONS

Our study suggests that whereas spinal deformity patients with affective disorders may have a higher baseline perception of pain and narcotic use, the impact of affective disorders on narcotic refills at 6 weeks and 3 months may be minimal after complex spinal fusion.

Predictive Model for Medical and Surgical Readmissions Following Elective Lumbar Spine Surgery: A National Study of 33,674 Patients

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here we aim to develop predictive models for 3-month medical and surgical readmission after elective lumbar surgery, based on a multi-institutional, national spine registry.

SUMMARY OF BACKGROUND DATA

Unplanned readmissions place considerable stress on payers, hospitals, and patients. Medicare data reveals a 30-day readmission rate of 7.8% for lumbar-decompressions and 13.0% for lumbar-fusions, and hospitals are now being penalized for excessive 30-day readmission rates by virtue of the Hospital Readmissions Reduction Program.

METHODS

The Quality and Outcomes Database (QOD) was queried for patients undergoing elective lumbar surgery for degenerative diseases. The QOD prospectively captures 3-month readmissions through electronic medical record (EMR) review and self-reported outcome questionnaires. Distinct multivariable logistic regression models were fitted for surgery-related and medical readmissions adjusting for patient and surgery-specific variables.

RESULTS

Of the total 33,674 patients included in this study 2079 (6.15%) reported at least one readmission during the 90-day postoperative period. The odds of medical readmission were significantly higher for older patients, males versus females, African Americans versus Caucasion, those with higher American Society of Anesthesiologists (ASA) grade, diabetes, coronary artery disease, higher numbers of involved levels, anterior only or anterior-posterior versus posterior approach; also, for patients who were unemployed compared with employed patients and those with high baseline Oswestry Disability Index (ODI). The odds of surgery-related readmission were significantly greater for patients with a higher body mass index (BMI), a higher ASA grade, female versus male, and African Americans versus Caucasians; also, for patients with severe depression, more involved spinal levels, anterior-only surgical approaches and higher baseline ODI scores.

CONCLUSION

In this study we present internally validated predictive models for medical and surgical readmission after elective lumbar spine surgery. These findings set the stage for targeted interventions with a potential to reduce unnecessary readmissions, and also suggest that medical and surgical readmissions be treated as distinct clinical events.

LEVEL OF EVIDENCE

3.

Analysis of Risk Factors Associated with Hospital Readmission Within 360 Days After Degenerative Lumbar Spine Surgery in Elderly Patients

OBJECTIVE

There is a paucity of studies on readmission rates in elderly patients over a period of 360 days after spinal surgery.

METHODS

We identified 1248 patients older than 70 years who underwent degenerative lumbar spinal surgery from November 2005 to April 2015. We reviewed the patients who were readmitted within 360 days and compared them by univariate and multivariate analysis with the nonreadmitted patients for each period of 0-30, 30-90, 90-180, and 180-360 days postoperatively to determine risk factors for hospital readmission.

RESULTS

A total of 1248 patients (733 female, 58.7%) were enrolled in the study. The number of readmitted patients was 37 (2.96%), 94 (7.53%), 145 (11.62%), 182 (14.58%), and 213 (17.07%) at 30, 90, 180, 270, and 360 days, respectively. Surgical site-related problems decreased gradually in the first 0-90 days and slightly increased after then. Non-surgical site-related problems gradually increased with time. Logistic multiple regression analysis showed that electrocardiographic abnormalities, male sex, low hemoglobin levels, asthma, heart disease, intensive care unit admission, low alanine aminotransferase level, high body mass index, and high platelet level were risk factors for readmission.

CONCLUSIONS

We found that electrocardiographic abnormalities, male sex, low hemoglobin levels, asthma, heart disease, intensive care unit admission, low aspartate aminotransferase level, high body mass index, and high platelet level were risk factors for readmission. As the postoperative observational period became longer, the reasons for readmission tended to be more related to non-surgical site-related problems than to surgical-related problems.

Impact of Psychiatric Comorbidities on Short-Term Outcomes Following Intervention for Lumbar Degenerative Disc Disease

STUDY DESIGN

Retrospective, observational cohort study.

OBJECTIVE

To investigate the impact of psychiatric diseases on short-term outcomes in patients undergoing fusion surgery for lumbar degenerative disc disease (LDDD).

SUMMARY OF BACKGROUND DATA

Limited literature exists on the prevalence and impact of psychiatric comorbidities on outcomes in patients undergoing surgery for LDDD.

METHODS

Adult patients (>18 yr) registered in the Nationwide Inpatient Sample database (2002-2011) and undergoing an elective spine fusion for LDDD that met inclusion criteria formed the study population. Defined primary outcome measures were discharge disposition, length of stay, hospitalization cost, and short-term postsurgical complications (neurological, respiratory, cardiac, gastrointestinal, wound complication and infections, venous thromboembolism, and acute renal failure). Multivariable regression techniques were used to explore the association of psychiatric comorbidities on short-term outcomes by adjusting for patient demographics, clinical, and hospital characteristics.

RESULTS

Of the 126,044 adult patients undergoing fusion surgery for LDDD (mean age: 54.91 yr, 58% female) approximately 18% had a psychiatric disease. Multivariable regression analysis revealed patients with psychiatric disease undergoing fusion surgery have higher likelihood for unfavorable discharge (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.35-1.47; P < 0.001), length of stay (OR 1.03; 95% CI 1.02-1.04; P < 0001), postsurgery neurologic complications (OR 1.25; 95% CI 1.13-1.37; P < 0.001), venous thromboembolic events (OR 1.38 95% CI 1.26-1.52; P < 0.001), and acute renal failure (OR 1.17; 95% CI 1.01-1.37; P = 0.040). Patients with psychiatric disease were also associated to have higher hospitalization cost (6.3% higher; 95% CI: 5.6%-7.1%; P < 0.001) compared to those without it.

CONCLUSION

Our study quantifies the estimates for presence of concomitant psychiatric comorbid conditions on short outcomes in patients undergoing fusions for LDDD. The data provide supporting evidence for adequate preoperative planning and postsurgical care including consultation for mental health for favorable outcomes.

LEVEL OF EVIDENCE

4.

Influence of racial disparities on patient-reported satisfaction and short- and long-term perception of health status after elective lumbar spine surgery

OBJECTIVE

In spine surgery, racial disparities have been shown to impact various aspects of surgical care. Previous studies have associated racial disparities with inferior surgical outcomes, including increased complication and 30-day readmission rates after spine surgery. Recently, patient-reported outcomes (PROs) and satisfaction measures have been proxies for overall quality of care and hospital reimbursements. However, the influence that racial disparities have on short- and long-term PROs and patient satisfaction after spine surgery is relatively unknown. The aim of this study was to investigate the impact of racial disparities on 3- and 12-month PROs and patient satisfaction after elective lumbar spine surgery.

METHODS

This study was designed as a retrospective analysis of a prospectively maintained database. The medical records of adult (age ≥ 18 years) patients who had undergone elective lumbar spine surgery for spondylolisthesis (grade 1), disc herniation, or stenosis at a major academic institution were included in this study. Patient demographics, comorbidities, postoperative complications, and 30-day readmission rates were collected. Patients had prospectively collected outcome and satisfaction measures. Patient-reported outcome instruments—Oswestry Disability Index (ODI), visual analog scale for back pain (VAS-BP), and VAS for leg pain (VAS-LP)—were completed before surgery and at 3 and 12 months after surgery, as were patient satisfaction measures.

RESULTS

The authors identified 345 medical records for 53 (15.4%) African American (AA) patients and 292 (84.6%) white patients. Baseline patient demographics and comorbidities were similar between the two cohorts, with AA patients having a greater body mass index (33.1 ± 6.6 vs 30.2 ± 6.4 kg/m2, p = 0.005) and a higher prevalence of diabetes (35.9% vs 16.1%, p = 0.0008). Surgical indications, operative variables, and postoperative variables were similar between the cohorts. Baseline and follow-up PRO measures were worse in the AA cohort, with patients having a greater baseline ODI (p < 0.0001), VAS-BP score (p = 0.0002), and VAS-LP score (p = 0.0007). However, mean changes from baseline to 3- and 12-month PROs were similar between the cohorts for all measures except the 3-month VAS-BP score (p = 0.046). Patient-reported satisfaction measures at 3 and 12 months demonstrated a significantly lower proportion of AA patients stating that surgery met their expectations (3 months: 47.2% vs 65.5%, p = 0.01; 12 months: 35.7% vs 62.7%, p = 0.007).

CONCLUSIONS

The study data suggest that there is a significant difference in the perception of health, pain, and disability between AA and white patients at baseline and short- and long-term follow-ups, which may influence overall patient satisfaction. Further research is necessary to identify patient-specific factors associated with racial disparities that may be influencing outcomes to adequately measure and assess overall PROs and satisfaction after elective lumbar spine surgery.

Impact of Depression on Patient-Reported Outcome Measures After Lumbar Spine Decompression

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate the effect depression has on the improvement of patient-reported outcome measures (PROMs) following lumbar decompression.

SUMMARY OF BACKGROUND DATA

Decompression without fusion is a viable treatment option for lumbar spine stenosis. Depression reportedly has a negative impact on PROMs after certain types of spine surgery, though verification of this with new, more precise outcome measures is needed.

METHODS

We included consecutive adult patients who underwent lumbar decompression for lumbar spine stenosis between 2016 and 2017 who had PROM information system (PROMIS) physical function, pain, depression, and Oswestry Disability Index (ODI) questionnaires completed preoperatively and at 6-month follow-up. Patients with a PROMIS depression score >50 or <50 were allocated to the depressed and not depressed groups, respectively. The cohorts were compared using unpaired t tests and repeated-measures two-way analysis of variance (ANOVA) with statistical significance taken at P < 0.05.

RESULTS

The analysis included 55 patients without depression and 56 patients with depression. Depressed patients had worse preoperative PROMIS physical function (30.08 vs. 36.66, P = 0.005), PROMIS pain (69.36 vs. 64.69, P < 0.0001), and ODI scores (51.92 vs. 36.35, P < 0.0001). Similarly, the depressed group had worse postoperative PROMIS physical function (36.29 vs. 40.34, P = 0.005), PROMIS pain (60.16 vs. 54.87, P < 0.0001), and ODI scores (37.01 vs. 23.44, P = 0.0003). We observed a statistically significant interaction between depression status and pre to postoperative improvement in outcome for PROMIS physical function (F[1,109] = 102.5, P < 0.0001) and depression scores (F[1,109] = 15.38, P = 0.0002). No interaction was found for pain and ODI scores.

CONCLUSION

Our results suggest that depressed patients experience a greater magnitude of improvement in PROMIS physical function and depression scores than nondepressed patients. Despite this, depressed patients have worse postoperative outcomes for PROMIS physical function, depression, pain, and ODI. These findings are important for risk stratifying and treating depressed patients before lumbar spine decompression.

LEVEL OF EVIDENCE

3.

Reduced Impact of Smoking Status on 30-Day Complication and Readmission Rates After Elective Spinal Fusion (≥3 Levels) for Adult Spine Deformity: A Single Institutional Study of 839 Patients

BACKGROUND

Smoking status has been shown to affect postoperative outcomes after surgery. The aim of this study was to determine whether patients' smoking status impacts 30-day complication and readmission rates after elective complex spinal fusion (≥3 levels).

METHODS

The medical records of 839 adult spinal deformity patients undergoing elective complex spinal fusion (≥3 levels) at a major academic institution from 2005 to 2015 were reviewed. We identified 124 (14.8%) smokers and 715 (85.2%) nonsmokers. Patient demographics, comorbidities, intraoperative and postoperative complications, and 30-day readmission rates were collected for each patient. The primary outcome investigated in this study was the rate of 30-day postoperative complication and readmission rates.

RESULTS

Patient demographics and comorbidities were similar between both groups, including age, sex, and body mass index. Median [interquartile] number of fusion levels and operative time were similar between the cohorts (smoker: 5 [4-7] vs. nonsmoker: 5 [4-8], P = 0.58) and (smoker: 309.6 ± 157.9 minutes vs. nonsmoker: 287.5 ± 131.7 minutes, P = 0.16), respectively. Both cohorts had similar postoperative complication rates and lengths of hospital stay. There was no significant difference in 30-day readmission between the cohorts (smoker: 12.9% vs. nonsmoker: 10.8%, P = 0.48). There were no observed differences in 30-day complication rates, including pain (P = 0.46), UTI (P = 0.54), hardware failure (P = 0.36), wound dehiscence (P = 0.29), and wound drainage (P = 0.86). Smokers had greater rates of 30-day cellulitis (smoker: 1.6% vs. nonsmoker: 0.3%, P = 0.05) and DVT (smoker: 0.8% vs. nonsmoker: 0.0%, P = 0.02).

CONCLUSIONS

Our study suggests that smoking does not significantly affect 30-day readmission rates after complex spinal surgery requiring ≥3 levels of fusion. Further studies are necessary to corroborate our findings.

Preoperative Nomograms Predict Patient-Specific Cervical Spine Surgery Clinical and Quality of Life Outcomes

BACKGROUND

Clinical and quality of life (QOL) outcomes vary depending on the patient's demographics, comorbidities, presenting symptoms, pathology, and surgical treatment used. While there have been individual predictors identified, no comprehensive method incorporates a patient's complex clinical presentation to predict a specific individual postoperative outcome.

OBJECTIVE

To create tool that predicts patient-specific outcomes among those undergoing cervical spine surgery.

METHODS

A total of 952 patients at a single tertiary care institution who underwent anterior or posterior cervical decompression/fusion between 2007 and 2013 were retrospectively reviewed. Outcomes included postoperative emergency department visit or readmission within 30 d, reoperation within 90 d for infection, and changes in QOL outcomes. Nomograms were modeled based on patient demographics and surgical variables. Bootstrap was used for internal validation.

RESULTS

Bias-corrected c-index for emergency department visits, readmission, and reoperation were 0.63, 0.78, and 0.91, respectively. For the QOL metrics, the bias-corrected adjusted R-squared was EQ-5D (EuroQOL): 0.43, for PHQ-9 (Patient Health Questionnaire-9): 0.35, and for PDQ (Pain/Disability Questionnaire): 0.47. Variables predicting the clinical outcomes varied, but included race and median income, body mass index, comorbidities, presenting symptoms, indication for surgery, surgery type, and levels. For the QOL nomograms, the predictors included similar variables, but were significantly more affected by the preoperative QOL of the patient.

CONCLUSION

These prediction models enable referring physicians and spine surgeons to provide patients with personalized expectations regarding postoperative clinical and QOL outcomes following a cervical spine surgery. After appropriate validation, use of patient-specific prediction tools, such as nomograms, has the potential to lead to superior spine surgery outcomes and more cost effective care.

Impact of Affective Disorders on Recovery of Baseline Function in Patients Undergoing Spinal Surgery: A Single Institution Study of 275 Patients

BACKGROUND

Decompressive spinal surgery patients have high expectations of recovering functionally, both at work and with leisurely activities. Affective disorders, such as depression or anxiety, are increasingly prevalent in this population and are associated with poorer baseline quality-of-life measures and worse postoperative outcomes. The study examined the results of affective disorders on self-reported recovery of baseline function (RBF) following decompressive spinal surgery.

METHODS

Medical records of 275 patients undergoing elective decompressive spinal surgery at a major academic institution were reviewed. There were 101 (36.7%) patients (with diagnosed anxiety or depression) in the affective disorder cohort (ADC) and 174 (63.6%) patients in the control cohort. The main outcome measure was self-reported RBF 3 months after surgery. Multivariate regression analysis was also used to determine whether affective disorders were a risk factor for poor RBF.

RESULTS

Baseline demographics, comorbidities, and perioperative variables between the two cohorts were similar, except for a higher proportion of females, more smokers, and longer length of stay in the ADC. On patient-reported outcome measures, the ADC had significantly decreased baseline scores and decreased improvement in scores over time. On univariate analysis, the ADC had significantly lower rates of RBF at 3 months after surgery. On regression analysis, affective disorders were an independent risk factors for poor RBF.

CONCLUSIONS

This study suggests that affective disorders are an independent risk factor for decreased recovery of baseline functionality after decompressive spinal surgery. Preoperatively identifying these patients could improve management of postoperative expectations and thereby improve surgical outcome.