90-day Readmission in Elective Primary Lumbar Spine Surgery in the Inpatient Setting: A Nationwide Readmissions Database Sample Analysis

Risk Factors of 90-Day Unplanned Readmission After Lumbar Spine Surgery for Degenerative Lumbar Disk Disease: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

With the increasing aging population, the number of patients undergoing lumbar spinal surgery for degenerative changes is rising. In the United States, spinal fusion surgery ranked sixth in operating room procedures, accounting for 3.2% of all such procedures, with an aggregate cost for stays amounting to $14.1 billion, making it the most expensive operating room procedure in 2018. The aim of this study was to identify valid risk factors of 90-day unplanned readmissions after lumbar spine surgery through a meta-analysis, with the goal of saving insurance finances and improving patient clinical outcomes.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library databases using the search terms "90-day readmission" and "lumbar spine surgery." Eleven eligible studies were included. Characteristic differences between readmitted and nonreadmitted patients were identified and analyzed using Review Manager software.

RESULTS

This meta-analysis included 11 studies with a total of 648 415 patients; 50 047 were readmitted unplanned after lumbar spine surgery. The incidence of unplanned readmission after lumbar spine surgery was 7.72%. Among demographic risk factors, older age and higher body mass index were significantly associated with unplanned readmission after lumbar spine surgery. Patient characteristics, such as depression, diabetes mellitus, hypertension, renal failure, and an American Society of Anesthesiologists grade greater than 2 were also significantly associated with unplanned readmission after lumbar spine surgery.

CONCLUSION

The meta-analysis revealed a 7.72% incidence of unplanned readmission after lumbar spine surgery. These findings suggest the need for enhanced preoperative optimization and careful patient selection for lumbar spine surgery, particularly in elderly patients and those with multiple comorbidities. Implementation of targeted preventive strategies for high-risk patients may help reduce unplanned readmissions and improve healthcare resource utilization.

Preoperative Emergency Department Usage is a Sentinel Marker of Worsened Posterior Lumbar Interbody Fusion Outcome

BACKGROUND

Utilization of the emergency department (ED) is associated with medical and social comorbidities. These factors may also be associated with medical complications after complex surgeries. This study investigated how preoperative ED use increases risk of posterior lumbar interbody fusion (PLIF) complications.

METHODS

We identified adult PLIF patients treated between 2016 and 2019 in the PearlDiver Claims Database. Clinical variables including preoperative ED use within 180 days were collected using International Classification of Disease (ICD-10) codes. Risk difference was calculated, and multivariable regression was performed.

RESULTS

This study included 13,010 (21.1%) patients who went to the ED before surgery and 48,065 (78.9%) who did not. Having a preoperative ED visit significantly increased risk of a postoperative ED visit by 28.7 percentage points, 90-day readmission by 3.8 percentage points, and 30-day major-medical complications by 3.4 percentage points. Risk of these outcomes increased in a dose-dependent fashion. Compared with patients with zero preoperative ED visits, patients who had 6 or more preoperative ED visits had an 82.0 percentage point increase in risk for a postoperative ED visit, a 46.5 percentage point increase for six or more ED visits, a 6.1 percentage point increase for major medical complications, and 10.6% increase for readmission.

CONCLUSIONS

Patients with any preoperative ED visit had an increased risk for postoperative ED use, readmission, and medical complications. The risk difference increased with each additional preoperative visit. Patient counseling and protocols that reduce preventable ED visit in the preoperative period may reduce a patient's risk for costly postoperative complications.

Spine surgery and readmission: Risk factors in lumbar corpectomy patients

Background

A corpectomy of the lumbar spine is a widely performed surgical procedure with numerous indications. Previous research predominantly focused on various surgical techniques and their outcomes, lacking a general and comprehensive analysis of factors affecting this procedure. With this study, we aimed to assess the all-cause 90-day readmission rate and identify risk factors for adverse events following a lumbar corpectomy.

Methods

Utilizing the 2020 Nationwide Readmissions Database adults (>18 years) were selected by ICD-10 procedure category codes for lumbar corpectomy. Patients with adult deformity or degenerative conditions were excluded due to coding inconsistencies. Demographic information and clinical data, including comorbidities, was extracted. Patients were categorized by their readmission status. The primary outcome was readmission, with multivariable logistic regression analysis used to identify independent risk factors.

Results

A total of 3,238 patients were included, with 20.8% readmitted. The readmission group was significantly older and had higher comorbidity burdens. Malignancy had the greatest odds of readmission (OR 3.172, p=.002), with spondylodiscitis also showing significant association (OR 2.177, p=.030). Fractures were significantly more frequent in the single admission group and not associated with readmission (OR 1.235, p=.551). Medical comorbidities differed significantly between the groups with a variety of them being identified as risk factors.

Conclusions

We established an all-cause 90-day readmission rate of 20.8%, which is in range of other procedures in spine surgery but underscores the severity of lumbar corpectomy. Underlying pathologies have a greater impact on the readmission rate compared to medical comorbidities. These findings highlight the importance of preoperative patient selection, especially when performing more invasive procedures. However, the study's limitations may limit the generalizability of the findings.

The economic burden of diabetes in spinal fusion surgery: a systematic review and meta-analysis

PURPOSE

This study aimed at comparing the costs of spinal fusion surgery between patients with and without diabetes.

METHODS

Following PRISMA guidelines, a systematic search of four databases was conducted. A meta-analysis was performed on comparative studies examining diabetic versus non-diabetic adults undergoing cervical/lumbar fusion in terms of cost. Heterogeneity was assessed using the I2 test. Standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model in the presence of heterogeneity.

RESULTS

Twenty-two studies were included in this meta-analysis. Standardized costs were significantly higher in the diabetic group (SMD 0.02, 95% CI 0.01 to 0.03, p < 0.05). The excess cost per diabetic patient undergoing spinal fusion surgery was estimated to be $2,492 (95% CI: $1,620 to $3,363). The length of stay (LOS) was significantly longer in the diabetes group (MD 0.42, 95% CI 0.24 to 0.60, p < 0.001). No significant difference was observed in intensive care unit admission between the groups (OR 4.15, 95% CI 0.55 to 31.40, p > 0.05). Reoperation showed no significant differences between the groups (OR 1.14, 95% CI 0.96 to 1.35, p > 0.05). However, 30-day and 90-day readmissions were significantly higher in the diabetes group: (OR 1.42, 95% CI 1.24 to 1.62, p < 0.05) and (OR 1.39, 95% CI 1.15 to 1.68, p < 0.001), respectively. Non-routine or non-home discharge was also significantly higher in the diabetes group (OR 1.89, 95% CI 1.67 to 2.13, p < 0.001).

CONCLUSION

Patients with diabetes undergoing spinal fusion surgery had increased costs, prolonged LOS, increased 30-day/90-day readmission rates, and more frequent non-routine discharges.

Incidence and predictors of readmission following hospitalization for thoracic disc herniation

OBJECTIVE

Symptomatic thoracic disc herniations (TDH) are relatively rare and can be discovered incidentally on neuroimaging. Surgical interventions for TDH represent only 4 % of all surgeries performed for intervertebral disc pathologies, which are most commonly indicated for myelopathy and radiculopathy. Given the absence of publications on rates of readmissions following hospitalization for TDH, we aim to establish baseline metrics for the 90-day all-cause readmission rates and pertinent risk factors.

METHODS

The 2020 Nationwide Readmissions Database was used to screen for patients with a primary diagnosis of TDH and disc degeneration within the first 9 months of the year. Demographic information, admission details, clinical data, comorbidities, and surgical treatment were extracted. Patients were divided into two groups based on readmission status. A sub-analysis was performed by treatment.

RESULTS

Overall, 970 patients met our inclusion criteria. Of these, 183 patients (18.9 %) were readmitted within a mean of 34.58 days. The readmission group was significantly older and more likely to have been admitted non-electively. Surgical treatment was associated with a lower readmission rate. Eight comorbidities differed significantly between the groups. Independent risk factors for readmission included non-surgical treatment, Medicare insurance, hypertension, and depression.

CONCLUSION

We established a 90-day all-cause readmission rate of 18.9 % for TDH. There was no difference in readmission based on patients' initial neurological presentation. Non-surgical treatment was identified as an independent risk factor for readmission, suggesting that timely surgical interventions may reduce the risk of readmission. Medicare insurance, hypertension and depression were also identified as independent risk factors.

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.

Malnutrition in spondylodiscitis: an overlooked risk factor

OBJECTIVE

Spondylodiscitis presents a significant diagnostic and treatment challenge to healthcare providers, with various risk factors and treatment outcomes having been identified. Malnutrition, a multifactorial condition defined by imbalance or deficiency of nutrients, is a known risk factor for various adverse events such as postoperative infection and readmissions in spine surgery. However, its impact in SD has not yet been explored. The study aims to assess the prevalence of malnutrition and hypoalbuminemia in SD patients and their impact on the 90-day-all-cause readmission and in-hospital mortality rates.

METHODS

Using the 2020 Nationwide Readmission Database, adult patients were selected by primary ICD-10 diagnosis for SD (M46.2x, M46.3x and M46.4x). Demographic information and clinical data were extracted. Readmissions were identified by VisitLink. Patients were categorized into 2 groups: those with malnutrition and/or hypoalbuminemia and those without. Descriptive and comparative analysis, with multivariate regression models to assess for independent risk factors of mortality and readmission were performed.

METHODS

Using the 2020 Nationwide Readmission Database, adult patients were selected by primary ICD-10 diagnosis for SD (M46.2x, M46.3x and M46.4x). Demographic information and clinical data were extracted. Readmissions were identified by VisitLink. Patients were categorized into 2 groups: those with malnutrition and/or hypoalbuminemia and those without. Descriptive and comparative analysis, with multivariate regression models to assess for independent risk factors of mortality and readmission were performed.

CONCLUSION

Malnutrition and hypoalbuminemia are relatively common in SD patients and are significant risk factors for both in-hospital mortality and readmission. Early identification, including screening for hypoalbuminemia and management of malnutrition, may be beneficial in SD treatment.

Nomogram for predicting early complications after distal gastrectomy

BACKGROUND

Reducing or preventing postoperative morbidity in patients with gastric cancer (GC) is particularly important in perioperative treatment plans.

AIM

To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model.

METHODS

This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023. The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis. Based on the results obtained, a predictive nomogram was established. The nomogram was validated using internal and external (n = 45) datasets. Its sensitivity and specificity were established by receiver operating characteristic curve analysis. Decision curve (DCA) analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability.

RESULTS

Multivariate logistic regression analysis showed that hypertension, diabetes, history of abdominal surgery, and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy. The modeling and validation sets showed that the area under the curve was 0.843 [95% confidence interval (CI): 0.746-0.940] and 0.877 (95%CI: 0.719-1.000), the sensitivity was 0.762 and 0.778, respectively, and the specificity was 0.809 and 0.944, respectively, indicating that the model had good sensitivity and specificity. The C-indexes of the modeling and validation datasets were 0.843 (95%CI: 0.746-0.940) and 0.877 (95%CI: 0.719-1.000), respectively. The calibration curve (Hosmer Lemeshow test: χ2 = 7.33) showed that the model had good consistency. The results of the DCA analysis indicated that this model offered good clinical benefits. The accuracy of 10-fold cross-validation was 0.878, indicating that the model had good accuracy and stability.

CONCLUSION

The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.

Preoperative medical assessment for adult spinal deformity surgery: a state-of-the-art review

INTRODUCTION

The purpose of this study is to provide a state-of-the-art review regarding risk factors for perioperative complications in adult spinal deformity (ASD) surgery. The review includes levels of evidence for risk factors associated with complications in ASD surgery.

METHODS

Using the PubMed database, we searched for complications, risk factors, and adult spinal deformity. The included publications were assessed for level of evidence as described in clinical practice guidelines published by the North American Spine Society, with summary statements generated for each risk factor (Bono et al. in Spine J 9:1046-1051, 2009).

RESULTS

Frailty had good evidence (Grade A) as a risk for complications in ASD patients. Fair evidence (Grade B) was assigned for bone quality, smoking, hyperglycemia and diabetes, nutritional status, immunosuppression/steroid use, cardiovascular disease, pulmonary disease, and renal disease. Indeterminate evidence (Grade I) was assigned for pre-operative cognitive function, mental health, social support, and opioid utilization.

CONCLUSIONS

Identification of risk factors for perioperative complications in ASD surgery is a priority for empowering informed choices for patients and surgeons and managing patient expectations. Risk factors with grade A and B evidence should be identified prior to elective surgery and modified to reduce the risk of perioperative complications.

Readmission and Associated Factors in Surgical Versus Non-Surgical Management of Spinal Epidural Abscess: A Nationwide Readmissions Database Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Spinal epidural abscess (SEA) is a rare but potentially life-threatening infection treated with antimicrobials and, in most cases, immediate surgical decompression. Previous studies comparing medical and surgical management of SEA are low powered and limited to a single institution. As such, the present study compares readmission in surgical and non-surgical management using a large national dataset.

METHODS

We identified all hospital admissions for SEA using the Nationwide Readmissions Database (NRD), which is the largest collection of hospital admissions data. Patients were grouped into surgically and non-surgically managed cohorts using ICD-10 coding and compared using information retrieved from the NRD such as demographics, comorbidities, length of stay and cost of admission.

RESULTS

We identified 350 surgically managed and 350 non-surgically managed patients. The 90-day readmission rates for surgical and non-surgical management were 26.0% and 35.1%, respectively (P < .05). Expectedly, surgical management was associated with a significantly higher charge and length of stay at index hospital admission. Surgically managed patients had a significantly lower risk of readmission for osteomyelitis (P < .05). Finally, in patients with a low comorbidity burden, we observed a significantly lower 90-day readmission rate for surgically managed patients (surgical: 23.0%, non-surgical: 33.8%, P < .05).

CONCLUSION

In patients with a low comorbidity burden, we observed a significantly lower readmission rate for surgically managed patients than non-surgically managed patients. The results of this study suggest a lower readmission rate as an advantage to surgical management of SEA and emphasize the importance of SEA as a not-to-miss diagnosis.

Early Readmission and Reoperation After Percutaneous Transforaminal Endoscopic Decompression for Degenerative Lumbar Spinal Stenosis: Incidence and Risk Factors

PURPOSE

To identify the incidence rates and risk factors for early readmission and reoperation after percutaneous transforaminal endoscopic decompression (PTED) for degenerative lumbar spinal stenosis (DLSS).

PATIENTS AND METHODS

A total of 1011 DLSS patients who underwent PTED were retrospectively evaluated. Of them, 58 were readmitted, and 31 underwent reoperation. The patients were matched with 174 control patients to perform case-control analyses. The clinical and preoperative imaging data of each patient were recorded. Univariate analyses were performed using independent sample t-tests and Fisher's exact tests. Furthermore, the risk factors for early readmission and reoperation were analyzed using multivariate logistic regression analyses.

RESULTS

The incidence rates of readmission and reoperation within 90 days after PTED were 5.7% and 3.1%, respectively. Age (odds ratio [OR]=1.054, p=0.001), BMI (OR=1.104, p=0.041), a history of lumbar surgery (OR=3.260, p=0.014), and the number of levels with radiological lumbar foraminal stenosis (LFS, OR=2.533, p<0.001) were independent risk factors for early readmission. The number of levels with radiological LFS (OR=5.049, p<0.001), the grade of surgical-level facet joint degeneration (OR=2.010, p=0.023), and a history of lumbar surgery (OR=10.091, p<0.001) were independent risk factors for early reoperation.

CONCLUSION

This study confirmed that aging, a higher BMI, a history of lumbar surgery, and more levels with radiological LFS were associated with a higher risk of early readmission. More levels with radiological LFS, a higher grade of surgical-level facet joint degeneration, and a history of lumbar surgery were predictors of early reoperation. These results are helpful in patient counseling and perioperative evaluation of PTED.

Risk Factors for 30-day and 90-day Readmission After Lumbar Decompression

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess readmission rates and risk factors for 30-day and 90-day readmission after elective lumbar decompression at a single institution.

SUMMARY OF BACKGROUND DATA

Hospital readmission is an undesirable aspect of interventional treatment. Studies evaluating readmissions after elective lumbar decompression typically analyze national databases, and therefore have several drawbacks inherent to their macroscopic nature that limit their clinical utility.

METHODS

Patients undergoing primary one- to four-level lumbar decompression surgery were retrospectively identified. Demographic, surgical, and readmission data within "30-days" (0-30 days) and "90-days" (31-90 days) postoperatively were extracted from electronic medical records. Patients were categorized into four groups: (1) no readmission, (2) readmission during the 30-day or 90-day postoperative period, (3) complication related to surgery, and (4) Emergency Department (ED)/Observational (OBs)/Urgent (UC) care.

RESULTS

A total of 2635 patients were included. Seventy-six (2.9%) were readmitted at some point within the 30- (2.3%) or 90-day (0.3%) postoperative periods. Patients in the pooled readmitted group were older (63.1 yr, P  < 0.001), had a higher American Society of Anesthesiologists (ASA) grade (31.2% with ASA of 3, P = 0.03), and more often had liver disease (8.1%, P = 0.004) or rheumatoid arthritis (12.0%, P = 0.02) than other cohorts. A greater proportion of 90-day readmissions and complications had surgical-related diagnoses or a diagnosis of recurrent disc herniation than 30-day readmissions and complications (66.7% vs. 44.5%, P = 0.04 and 33.3% vs. 5.5%, P < 0.001, respectively). Age (Odds ratio [OR]: 1.02, P = 0.01), current smoking status (OR: 2.38, P < 0.001), longer length of stay (OR: 1.14, P < 0.001), and a history of renal failure (OR: 2.59, P = 0.03) were independently associated with readmission or complication.

CONCLUSION

Increased age, current smoking status, hospital length of stay, and a history of renal failure were found to be significant independent predictors of inpatient readmission or complication after lumbar decompression.

Rates and risk factors associated with 30- and 90-day readmissions and reoperations after spinal fusions for adult lumbar degenerative pathology and spinal deformity

PURPOSE

Analyze state databases to determine variables associated with of short-term readmissions and reoperations following thoracolumbar spine fusions for degenerative pathology and spinal deformity.

METHODS

Retrospective study of State Inpatient Database (2005-13, CA, NE, NY, FL, NC, UT).

INCLUSION CRITERIA

age > 45 years, diagnosis of degenerative spinal deformity, ≥ 3 level posterolateral lumbar spine fusion.

EXCLUSION CRITERIA

revision surgery, cervical fusions, trauma, and cancer. Univariate and step-wise multivariate logistic regression analyses were performed to identify independent variables associated with of 30- and 90-day readmissions and reoperations.

RESULTS

12,641 patients were included. All-cause 30- and 90-day readmission rates were 14.6% and 21.1%, respectively. 90-day readmissions were associated with: age > 80 (OR: 1.42), 8 + level fusions (OR: 1.19), hospital length of stay (LOS) > 7 days (OR: 1.43), obesity (OR: 1.29), morbid obesity (OR: 1.66), academic hospital (OR: 1.13), cancer history (OR:1.21), drug abuse (OR: 1.31), increased Charlson Comorbidity index (OR: 1.12), and depression (OR: 1.20). Private insurance (OR: 0.64) and lumbar-only fusions (OR: 0.87) were not associated with 90-day readmissions. All-cause 30- and 90-day reoperation rates were 1.8% and 4.2%, respectively. Variables associated with 90-day reoperations were 8 + level fusions (OR: 1.28), LOS > 7 days (OR: 1.43), drug abuse (OR: 1.68), osteoporosis (OR: 1.26), and depression (OR: 1.23). Circumferential fusion (OR: 0.58) and lumbar-only fusions (OR: 0.68) were not associated with 90-day reoperations.

CONCLUSIONS

30- and 90-day readmission and reoperation rates in thoracolumbar fusions for adult degenerative pathology and spinal deformity may have been underreported in previously published smaller studies. Identification of modifiable risk factors is important for improving quality of care through preoperative optimization.

Diabetes Is Predictive of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The present study analyzes complication rates and episode-based costs for patients with and without diabetes mellitus (DM) following posterior lumbar fusion (PLF).

METHODS

PLF cases at a single institution from 2008 to 2016 were queried (n = 3226), and demographic and perioperative data were analyzed. Patients with and without the diagnosis of DM were compared using chi-square, Student's t test, and multivariable regression modeling.

RESULTS

Patients with diabetes were older (63.10 vs 56.48 years, P < .001) and possessed a greater number of preoperative comorbidities (47.84% of patients had Elixhauser Comorbidity Index >0 vs 42.24%, P < .001) than did patients without diabetes. When controlling for preexisting differences, diabetes remained a significant risk factor for prolonged length of stay (OR = 1.59, 95% CI 1.26-2.01, P < .001), intensive care unit stay (OR = 1.52, 95% CI 1.07-2.17, P = .021), nonhome discharge (OR = 1.86, 95% CI 1.46-2.37, P < .001), 30-day readmission (OR = 2.15, 95% CI 1.28-3.60, P = .004), 90-day readmission (OR = 1.65, 95% CI 1.05-2.59, P = .031), 30-day emergency room visit (OR = 2.15, 95% CI 1.27-3.63, P = .004), and 90-day emergency room visit (OR = 2.27, 95% CI 1.41-3.65, P < .001). Cost modeling controlling for overall comorbidity burden demonstrated that diabetes was associated with a $1709 increase in PLF costs (CI $344-$3074, P = .014).

CONCLUSIONS

The present findings indicate a correlation between diabetes and a multitude of postoperative adverse outcomes and increased costs, thus illustrating the substantial medical and financial burdens of diabetes for PLF patients. Future studies should explore preventive measures that may mitigate these downstream effects.

Natural language processing for prediction of readmission in posterior lumbar fusion patients: which free-text notes have the most utility?

BACKGROUND CONTEXT

The increasing volume of free-text notes available in electronic health records has created an opportunity for natural language processing (NLP) algorithms to mine this unstructured data in order to detect and predict adverse outcomes. Given the volume and diversity of documentation available in spine surgery, it remains unclear which types of documentation offer the greatest value for prediction of adverse outcomes.

STUDY DESIGN/SETTING

Retrospective review of medical records at two academic and three community hospitals.

PURPOSE

The purpose of this study was to conduct an exploratory analysis in order to examine the utility of free-text notes generated during the index hospitalization for lumbar spine fusion for prediction of 90-day unplanned readmission.

PATIENT SAMPLE

Adult patients 18 years or older undergoing lumbar spine fusion for lumbar spondylolisthesis or lumbar spinal stenosis between January 1, 2016 and December 31, 2020.

OUTCOME MEASURES

The primary outcome was inpatient admission within 90-days of discharge from the index hospitalization.

METHODS

The predictive performance of NLP algorithms developed by using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, medical doctor (MD) (resident or attending), and allied practice professional (APP) (nurse practitioner or physician assistant) notes were assessed by discrimination, calibration, overall performance.

RESULTS

Overall, 708 patients were included in the study and 83 (11.7%) had 90-day inpatient readmission. In the independent testing set of patients (n=141) not used for model development, the area under the receiver operating curve of NLP algorithms for prediction of 90-day readmission using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, MD/APP notes was 0.70, 0.57, 0.57, 0.60, 0.60, and 0.49 respectively.

CONCLUSION

In this exploratory analysis, discharge summary, physical therapy, and case management notes had the most utility and daily MD/APP progress notes had the least utility for prediction of 90-day inpatient readmission in lumbar fusion patients among the free-text documentation generated during the index hospitalization.

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.

Early Outcomes of Elective Anterior Cervical Diskectomy and Fusion for Degenerative Spine Disease Correlate With the Specialty of the Surgeon Performing the Procedure

BACKGROUND

Comparative effectiveness research has a vital role in recent health reform and policies. Specialty training is one of these provider-side variables, and surgeons who were trained in different specialties may have different outcomes on performing the same procedure.

OBJECTIVE

To investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective anterior cervical diskectomy and fusion (ACDF) for degenerative spine diseases.

METHODS

This was a retrospective, 1:1 propensity score-matched cohort study. In total, 21 211 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were performed.

RESULTS

In both groups (single-level/multilevel ACDF), patients operated on by neurosurgeons had longer operation time (133 vs 104 min/164 vs 138 min), shorter total hospital stay (24 vs 41 h/25 vs 46 h), and lower rates of return to operating room (0.7% vs 2.1%/0.6% vs 2.4%), nonhome discharge (1.2% vs 4.6%/1.0% vs 4.9%), discharge after postoperative day 1 (6.7% vs 11.9%/10.1% vs 18.9%), perioperative blood transfusion (0.4% vs 2.1%/0.6% vs 3.1%), and sepsis (0.2% vs 0.7%/0.1% vs 0.7%; P < .05). In the single-level ACDF group, patients operated on by neurosurgeons had lower readmission (1.9% vs 4.1%) and unplanned intubation rates (0.1% vs 1.1%; P < .05). Other outcome measures and mortality rates were similar among the 2 cohorts in both groups.

CONCLUSION

Our analysis found significant differences in early perioperative outcomes of patients undergoing ACDF by neurosurgeons and orthopedic surgeons. These differences might have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

Disparities in the Surgical Treatment of Adult Spine Diseases: A Systematic Review

BACKGROUND

Our goal was to systematically review the literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement.

METHODS

We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES).

RESULTS

Of 2679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 studies were analyzed. Forty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. After discharge, white patients reported better outcomes than did black patients. Thirty-three studies (55%) reported no disparities within at least 1 examined metric.

CONCLUSIONS

This comprehensive systematic review underscores ongoing potential for health care disparities among adult patients in spinal surgery. We show a need for continued efforts to promote equity and cultural competency within neurologic surgery.

Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes?

BACKGROUND

Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases.

METHODS

In a retrospective, 1:1 propensity score-matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used.

RESULTS

In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty.

CONCLUSIONS

Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

Risk Factors Associated with 90-day Readmissions Following Odontoid Fractures: A Nationwide Readmissions Database Study

STUDY DESIGN

Nationwide Readmissions Database Study.

OBJECTIVE

The aim of this study was to investigate readmission rates and factors related to readmission after surgical and nonsurgical management of odontoid fractures.

SUMMARY OF BACKGROUND DATA

Management of odontoid fractures, which are the most common isolated spine fracture in the elderly, continues to be debated. The choice between surgical or nonsurgical treatment has been reported to impact mortality and might influence readmission rates. Hospital readmissions represent a large financial burden upon our healthcare system. Factors surrounding hospital readmissions would benefit from a better understanding of their associated causes to lower health care costs.

METHODS

A retrospective study was performed using the 2016 Healthcare Utilization Project (HCUP) Nationwide Readmission Database (NRD). Demographic information and factors associated with readmission were collected. Readmission rates, complications, length of hospital stay were collected. Patients treated operatively, nonoperatively, and patients who were readmitted or not readmitted were compared. Statistical analysis was performed using open source software SciPy (Python v1.3.0) for all analyses.

RESULTS

We identified 2921 patients who presented with Type II dens fractures from January 1, 2016 to September 30, 2016, 555 of which underwent surgical intervention. The readmission rate in patients who underwent surgery was 16.4% (91/555) and 29.4% (696/2366) in the nonoperative group. Hospital costs for readmitted and nonreadmitted patients were $353,704 and $174,922, and $197,099 and $80,715 for nonoperatively managed patients, respectively. Medicaid and Medicare patients had the highest readmission rate in both groups. Charlson and Elixhauser comorbidity indices were significantly higher in patients who were readmitted (P < 0.0001).

CONCLUSION

We report an overall 90-day readmission rate of 16.4% and 29.4%, in operative and nonoperative management of type II odontoid fractures, respectively. In the face of a rising incidence of this fracture in the elderly population, an understanding of the comorbidities and age-related demographics associated with 90-day readmissions following both surgical and nonsurgical treatment are critical.Level of Evidence: 3.

Risk Factors for 30- and 90-Day Readmissions Due To Surgical Site Infection Following Posterior Lumbar Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

Identify the independent risk factors for 30- and 90-day readmission because of surgical site infection (SSI) in patients undergoing elective posterior lumbar fusion (PLF).

SUMMARY OF BACKGROUND DATA

SSI is a significant cause of morbidity in the 30- and 90-day windows after hospital discharge. There remains a gap in the literature on independent risk factors for readmission because of SSI after PLF procedures. In addition, readmission for SSI after spine surgery beyond the 30-day postoperative period has not been well studied.

METHODS

A retrospective analysis was performed on data from the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. The authors identified 65,121 patients who underwent PLF. There were 191 patients (0.30%) readmitted with a diagnosis of SSI in the 30-day readmission window, and 283 (0.43%) patients readmitted with a diagnosis of SSI in the 90-day window. Baseline patient demographics and medical comorbidities were assessed. Bivariate and multivariate analyses were performed to examine the independent risk factors for readmission because of SSI.

RESULTS

In the 30-day window after discharge, this study identified patients with liver disease, uncomplicated diabetes, deficiency anemia, depression, psychosis, renal failure, obesity, and Medicaid or Medicare insurance as higher risk patients for unplanned readmission with a diagnosis of SSI. The study identified the same risk factors in the 90-day window with the addition of diabetes with chronic complications, chronic pulmonary disease, and pulmonary circulation disease.

CONCLUSIONS

Independent risk factors for readmission because of SSI included liver disease, uncomplicated diabetes, obesity, and Medicaid insurance status. These findings suggest that additional intervention in the perioperative workup for patients with these risk factors may be necessary to lower unplanned readmission because of SSI after PLF surgery.

Do PEEK Rods for Posterior Instrumented Fusion in the Lumbar Spine Reduce the Risk of Adjacent Segment Disease?

BACKGROUND

Polyetheretherketone (PEEK) rods were clinically introduced in the mid-2000s as an alternative to titanium (Ti) rods for posterior instrumented lumbar spine fusion, theorized to reduce the risk of adjacent segment disease (ASD). However, few studies have follow-up beyond 2 years. Consequently, we conducted a matched cohort study using data from Kaiser Permanente's spine registry to compare the 2 rod systems and risk for outcomes.

METHODS

Patients aged ≥18 undergoing first posterior lumbar fusion for a degenerative diagnosis from 2009 to 2018 using either a PEEK or a Ti rod were identified. Fusions using Ti rods were 2:1 propensity score matched to PEEK rods on the following factors: patient age, body mass index, smoking, American Society of Anesthesiologists classification, diagnosis, interbody use, bone morphogenic protein use, number of levels fused, fusion levels, and operative year. The matched sample included 154 PEEK and 308 Ti fusions. We used Cox regression to evaluate ASD and nonunion, and logistic regression to evaluate 90-day emergency department (ED) visit, readmission, and complication.

RESULTS

We did not observe a difference in risk for ASD (hazard ratio = 1.02, 95% confidence interval [CI] = 0.66-1.59) or ED visit (odds ratio [OR] = 0.88, 95% CI = 0.48-1.59). A lower likelihood of readmission (OR = 0.34, 95% CI = 0.13-0.94) was observed following PEEK fusion compared with Ti. No nonunions or 90-day complications were observed for the PEEK group; 5 (2-year cumulative incidence = 0.7%) nonunions and 4 (1.3%) complications were observed for the Ti group.

CONCLUSIONS

Our multicenter study did not support the hypothesis that PEEK rods are associated with a lower ASD risk. Reasons for readmission need to be identified to better understand the differences observed here. Further study of patients with TLIF using Ti and PEEK rods and posterolateral fusion with Ti and PEEK rods is needed.

CLINICAL RELEVANCE

The present study adds to the literature supporting their midterm effectiveness of PEEK rods compared with Ti rods for both their safety and their effectiveness at the 5-7-year follow-up.

LEVEL OF EVIDENCE

3.

Economic analysis of 90-day return to the emergency room and readmission after elective lumbar spine surgery: a single-center analysis of 5444 patients

OBJECTIVE

In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity and/or use a proxy for actual cost. The purpose of this study was to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions after elective lumbar spine surgery.

METHODS

A prospective, multisurgeon, single-center electronic medical record was queried for elective lumbar spine fusion surgeries from 2013 to 2017. Predictive models were created for 90-day ER visits and readmissions.

RESULTS

Of 5444 patients, 729 (13%) returned to the ER, most often for pain (n = 213, 29%). Predictors of an ER visit were prior ER visit (OR 2.5), underserved zip code (OR 1.4), and number of chronic medical conditions (OR 1.4). In total, 421 (8%) patients were readmitted, most frequently for wound infection (n = 123, 2%), exacerbation of chronic obstructive pulmonary disease (n = 24, 0.4%), and sepsis (n = 23, 0.4%). Predictors for readmission were prior ER visit (OR 1.96), multiple chronic conditions (OR 1.69), obesity (nonobese, OR 0.49), race (African American, OR 1.43), admission status (ER admission, OR 2.29), and elevated hemoglobin A1c (OR 1.80). The mean direct hospital cost for an ER visit was $1971, with 75% of visits costing less than $1890, and the average readmission cost was $7347, with 75% of readmissions costing less than $8820. Over the 5-year study period, the cost to the institution for 90-day return ER visits was $5.1 million.

CONCLUSIONS

Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient counseling, appropriate postoperative pain management, and optimization of modifiable risk factors prior to surgery are areas to focus future efforts to lower 90-day ER visits and readmissions and reduce healthcare costs.

Risk Factors Associated with 90-Day Readmissions Following Occipitocervical Fusion-A Nationwide Readmissions Database Study

BACKGROUND

Occipitocervical fusion (OCF) procedures are increasing due to an aging population and the prevalence of trauma, rheumatoid arthritis, and tumors. Reoperation rates and readmission risk factors for cervical fusions have been established, but in relation to OCF they have not been explored. This study investigates the patterns of readmissions and complications following OCF using a national database.

METHODS

The 2016 U.S. Nationwide Readmissions Database was used for sample collection. Adults (>18 years) who underwent OCF were identified using the 2016 ICD-10 coding system, and we examined the readmission rates (30-day and 90-day) and reoperation rates.

RESULTS

Between January and September 2016, a total of 477 patients underwent OCF; the 30-day and 90-day readmission rates were 10.4% and 22.4%, respectively. The 90-day reoperation rate related to the index surgery was 5.7%. Mean age (68.58 years) was significantly greater in the readmitted group versus nonreadmitted group (61.76 years) (P < 0.001). The readmitted group had a significantly higher Charlson Comorbidity Index and Elixhauser Comorbidity Index (5.00 and 2.41, respectively) than the nonreadmitted group (3.25 and 1.15, respectively; P < 0.001). Nonelective OCF showed a higher readmission rate (29.18%) versus elective OCF (12.23%) (P < 0.001). Medicare and Medicaid patients showed the highest rates of readmission (27.27% and 20.41%, respectively). Readmitted patients had higher total health care costs.

CONCLUSIONS

Nonelective OCF was found to have a readmission rate of almost 2½× that of elective OCF. Understanding risk factors associated with OCF will help with operative planning and patient optimization.

Institutional databases may underestimate the risk factors for 30-day unplanned readmissions compared to national databases

OBJECTIVE

The National Surgical Quality Improvement Program (NSQIP) and National Readmissions Database (NRD) are two widely used databases for research studies. However, they may not provide generalizable information in regard to individual institutions. Therefore, the objective of the present study was to evaluate 30-day readmissions following anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) procedures by using these two national databases and an institutional cohort.

METHODS

The NSQIP and NRD were queried for patients undergoing elective ACDF and PLF, with the addition of an institutional cohort. The outcome of interest was 30-day readmissions following ACDF and PLF, which were unplanned and related to the index procedure. Subsequently, univariable and multivariable analyses were conducted to determine the predictors of 30-day readmissions by using both databases and the institutional cohort.

RESULTS

Among all identified risk factors, only hypertension was found to be a common risk factor between NRD and the institutional cohort following ACDF. NSQIP and the institutional cohort both showed length of hospital stay to be a significant predictor for 30-day related readmission following PLF. There were no overlapping variables among all 3 cohorts for either ACDF or PLF. Additionally, the national databases identified a greater number of risk factors for 30-day related readmissions than did the institutional cohort for both procedures.

CONCLUSIONS

Overall, significant differences were seen among all 3 cohorts with regard to top predictors of 30-day unplanned readmissions following ACDF and PLF. The higher quantity of significant predictors found in the national databases may suggest that looking at single-institution series for such analyses may result in underestimation of important variables affecting patient outcomes, and that big data may be helpful in addressing this concern.

90-day Readmission Rates for Single Level Anterior Lumbosacral Interbody Fusion: A Nationwide Readmissions Database Analysis

STUDY DESIGN

Nationwide Readmissions Database Study.

OBJECTIVE

To investigate the patterns of readmissions and complications following hospitalization for elective single level anterior lumbobsacral interbody fusion.

SUMMARY OF BACKGROUND DATA

Lumbar interbody spine fusions for degenerative disease have increased annually in the United States, including associated hospital costs. Anterior lumbar interbody fusions (ALIFs) have become popularized secondary to higher rates of fusion compared with posterior procedures, and preservation of posterior elements. Prior national databases have sought to study readmission rates with some limitations due to older diagnosis and procedure codes. The newer 2016 International Classification of Diseases Tenth Revision, Clinical Modification (ICD-10 CM) includes more specification of the surgical site.

METHODS

We utilized the 2016 United States Nationwide Readmissions Database (NRD), this nationally representative, all-payer database that includes weighted probability sample of inpatient hospitalizations for all ages. We identified all adults (≥ 18 yrs) using the 2016 ICD-10 coding system who underwent elective primary L5-S1 ALIF and examined rates of readmissions within 90 days of discharge.

RESULTS

Between January and September 2016, a total of 7029 patients underwent elective stand-alone L5-S1 ALIF who were identified from NRD of whom 497 (7.07%) were readmitted within 90 days of their procedure. No differences in sex were appreciated. Medicare patients had statistically significant higher readmission rates (47.69%) among all payer types. With respect to intraoperative complications, vascular complications had statistically significant increased odds of readmission (OR, 3.225, 95% CI, 0.59 -1.75; P = 0.0001). Readmitted patients had higher total healthcare costs.

CONCLUSION

The 90-day readmission rate following stand-alone single level lumbosacral (L5-S1) ALIF was 7.07%. ALIF procedures have increased in frequency, and an understanding of the comorbidities, age-related demographics, and costs associated with 90-day readmissions are critical. Surgeons should consider these risk factors in preoperative planning and optimization.

LEVEL OF EVIDENCE

3.

Long-Term Effect of Diabetes on Reoperation After Lumbar Spinal Surgery: A Nationwide Population-Based Sample Cohort Study

BACKGROUND

Diabetes mellitus (DM) is associated with poor postoperative outcomes and increased morbidity after surgeries. Some previous studies have addressed the close association between DM and those leading to reoperations, whereas others have rejected this theory. This study aimed to evaluate the long-term effect of DM on lumbar spinal surgery using data from a nationwide sample cohort.

METHODS

A population-based cohort comprised one million people, which is a 2.1% representative sample of the Korean population. The present study included adult patients with lumbar degenerative diseases (e.g., lumbar spinal stenosis and spondylolisthesis), who underwent their first lumbar surgery in 2006. The cumulative incidence function for reoperation was calculated and multivariate analysis was performed to define correlation between reoperation and independent factors.

RESULTS

A total of 2020 patients were enrolled and followed up for 10 years. Nondiabetic patients, patients with DM without complication (DwoC), and patients with DM with complication (DwC) accounted for 79.5%, 9.36%, and 11.14% of all patients, respectively. Reoperation incidence stratified by DM was 12.7% for nondiabetic patients, 22.2% for patients with DwoC, and 20.0% for patients with DwC in 10 years of follow-up. During the same period, death, a competing event of reoperation, occurred in 7.8% of nondiabetic patients, in 13.2% of patients with DwoC, and in 20.9% of patients with DwC.

CONCLUSIONS

DM increased 1.65 times the overall cumulative incidences of reoperation after lumbar spinal surgeries for 10 years of follow-up. The reoperation incidence for DwC may be lower than that for DwoC because of a high incidence of death as a competing event of reoperation.