Predictive factors of symptomatic lumbar pseudoarthrosis following multilevel primary lumbar fusion.

Background: Lumbar spinal fusion surgery is a well-established treatment for various spinal disorders. However, one of its complications, pseudoarthrosis, poses a significant concern. This study aims to explore the incidence, time and predictive factors contributing to pseudoarthrosis in patients who have undergone lumbar fusion surgery over a 10-year period. Methods: Data for this research was sourced from the PearlDiver database where insurance claims of patients who underwent multilevel lumbar spinal fusion between 01/01/2010 and 10/31/2022 were examined for claims of pseudoarthrosis within the 10 years of their index procedure. A variety of demographic, comorbid, and surgical factors were assessed, including age, gender, Elixhauser Comorbidity Index (ECI), surgical approach, substance use disorders and history of spinal disorders. Statistical analyses, including chi-squared tests, multivariate analysis, and cox survival analysis were employed to determine significant associations. Results: Among the 76,337 patients included in this retrospective study, 2.70% were diagnosed with symptomatic lumbar pseudoarthrosis at an average of 7.38 years in a 10-year follow-up. Multivariate and Cox hazard analyses revealed that significant predictors of symptomatic pseudoarthrosis development following multilevel primary lumbar fusion include vitamin D deficiency, osteoarthritis, opioid and NSAID use, tobacco use, and a prior history of congenital spine disorders. Conclusions: In summary, this study revealed a 2.70% incidence of symptomatic lumbar pseudoarthrosis within 10 years of the index procedure. It highlighted several potential predictive factors, including comorbidities, surgical approaches, and substance use disorders, associated with the development of symptomatic pseudoarthrosis. Future research should focus on refining our understanding of these factors to improve patient outcomes and optimize healthcare resource allocation.

Interspecialty Variation in Perioperative Health Care Resource Usage for Carpal Tunnel Release.

BACKGROUND: We investigated whether any interspecialty variation exists, regarding perioperative health care resource usage, in carpal tunnel releases (CTRs). METHODS: The 2010 to 2021 PearlDiver Mariner Database, an all-payer claims database, was queried to identify patients undergoing primary CTRs. Physician specialty IDs were used to identify the specialty of the surgeon-orthopedic versus plastic versus general surgery versus neurosurgery. Multivariate logistic regression analysis was used to identify whether there was any interspecialty variation between the use of health care resources. RESULTS: A total of 908 671 patients undergoing CTRs were included, of which 556 339 (61.2%) were by orthopedic surgeons, 297 047 (32.7%) by plastic surgeons, 44 118 (4.9%) by neurosurgeons, and 11 257 (1.2%) by general surgeons. In comparison with orthopedic surgeons, patients treated by plastic surgeons were less likely to have received opioids, nonsteroidal anti-inflammatory drugs, oral steroids, and preoperative antibiotic prophylaxis but were more likely to have received steroid injections and electrodiagnostic studies (EDSs) preoperatively. Patients treated by neurosurgeons were more likely to have received preoperative opioids, gabapentin, oral steroids, preoperative antibiotic prophylaxis, EDSs, and formal preoperative physical/occupational therapy and less likely to have received steroid injections. Patients treated by general surgeons were less likely to receive oral steroids, steroid injections, EDSs, preoperative formal physical therapy, and preoperative antibiotic prophylaxis, but were more likely to be prescribed gabapentin. CONCLUSIONS: There exists significant variation in perioperative health care resource usage for CTRs between specialties. Understanding reasons behind such variation would be paramount in minimizing differences in how care is practiced for elective hand procedures.

Preserving privacy in big data research: the role of federated learning in spine surgery.

PURPOSE: Integrating machine learning models into electronic medical record systems can greatly enhance decision-making, patient outcomes, and value-based care in healthcare systems. Challenges related to data accessibility, privacy, and sharing can impede the development and deployment of effective predictive models in spine surgery. Federated learning (FL) offers a decentralized approach to machine learning that allows local model training while preserving data privacy, making it well-suited for healthcare settings. Our objective was to describe federated learning solutions for enhanced predictive modeling in spine surgery. METHODS: The authors reviewed the literature. RESULTS: FL has promising applications in spine surgery, including telesurgery, AI-based prediction models, and medical image segmentation. Implementing FL requires careful consideration of infrastructure, data quality, and standardization, but it holds the potential to revolutionize orthopedic surgery while ensuring patient privacy and data control. CONCLUSIONS: Federated learning shows great promise in revolutionizing predictive modeling in spine surgery by addressing the challenges of data privacy, accessibility, and sharing. The applications of FL in telesurgery, AI-based predictive models, and medical image segmentation have demonstrated their potential to enhance patient outcomes and value-based care.

Exploring the incidence and risk factors of reoperation for symptomatic adjacent segment disease following cervical decompression and fusion.

Background: Patients with long-term follow-up after cervical decompression and fusion have often been noted to have development of adjacent segment degeneration with a smaller subset of these patients progressing to adjacent segment disease (ASD), which results in the development of new symptomatic radiculopathy or myelopathy referable to a site either directly above or below a prior fused segment. The cause of ASD is multifactorial often involving natural age-related progression of spondylosis, accelerated progression following cervical decompression and fusion, operative technique, and patient-related factors. The effect of age at the time of index cervical decompression and fusion on the need for reoperation for ASD is not fully understood. This study aims to establish underlying risk factors for the development of symptomatic cervical ASD following cervical decompression and fusion requiring reoperation in patients of various age groups. Methods: A retrospective database review of patients aged 20 or greater with insurance claims of primary cervical decompression and fusion over the course of 11 years and 10 months (January 01, 2010-October 31, 2022) was conducted using an insurance claims database. The primary outcome was to evaluate the incidence of cervical ASD requiring reoperation amongst patients stratified by age at the time of their primary procedure. Secondary outcomes included an evaluation of various risk factors for ASD following cervical decompression and fusion including surgeon-controlled factors such as the number of levels fused and approach taken, patient cervical pathology including cervical disc disorder and cervical spondylosis, and underlying patient medical comorbidities including osteoporosis and vitamin D deficiency, and substance use. Results: A total of 60,292 patient records were analyzed, where the overall reoperation incidence for symptomatic ASD was 6.57%, peaking at 8.12% among those aged 30 to 39 and decreasing with age. Regression analysis revealed ages lower than 50 years as more predictive for the development of symptomatic ASD requiring reoperation. Multivariate regression analysis identified predictive factors for reoperation, including age, Elixhauser Comorbidity Index (ECI), multiple-level surgery, cervical spondylosis, cervical disc disorder, osteoporosis, and vitamin D deficiency. Notably, these factors had a variable impact across various age groups, as revealed by subgroup analysis. Conclusions: The incidence of reoperation secondary to symptomatic ASD is 6.57%, highest in those aged 30 to 39. The surgical approach had no significant impact on the need for reoperation, but multiple-level fusions posed a consistent risk in the development of symptomatic ASD requiring reoperation. Patient factors like degenerative disc disease, spondylosis, osteoporosis, and vitamin D deficiency were associated, urging further age-specific risk assessment and nonoperative intervention exploration.

Osteobiologics and Value-Based Care: Challenges and Opportunities.

BACKGROUND: Autologous bone grafts, sourced from the iliac crest, are the gold standard for bone substitution in spine surgery. However, harvesting autografts increases the risk of postoperative complications. Bone allografts are another popular source of graft material, but their use is rapidly surpassing their availability. There has been considerable interest in manufactured bone graft substitutes, commonly referred to as osteobiologics, which mimic the properties of autologous bone and may be osteoconductive, osteoinductive, osteogenic, or a combination. OBJECTIVE: Osteobiologics have been developed to mimic the properties of autologous bone, but their high cost and variable effectiveness raise questions about their value. This article explores the challenges and opportunities associated with the use of osteobiologics used to aid in bone healing in spinal fusion surgery within a value-based care framework. Spinal fusion treatments such as bone morphogenetic proteins, platelet-rich plasma, autologous conditioned serum, demineralized bone matrix, biomaterial scaffolds, stem cells, and cellular bone matrices are compared. SUMMARY: Bone morphogenetic proteins are highly effective but often associated with serious risks; platelet-rich plasma shows promising results but lacks standardization in research protocols. Autologous conditioned serum is inconclusive and cost-effective, while demineralized bone matrix has variable effectiveness and limited data to use in anterior spinal fusions. Biomaterial scaffolds have limited application in the anterior spine but demonstrate high efficacy when it comes to spinal fusion. Stem cells demonstrate improved postsurgical outcomes but have low yield from bone marrow and potential risks associated with genetic engineering and cell therapy. Cellular bone matrices show promising results and have high fusion rates, yet there is currently no US Food and Drug Adminstration requirement for preclinical or clinical data before commercial usage. Although osteobiologics have considerable potential, their high price and uncertain efficiency raise questions concerning their usefulness in spinal fusion surgery. To ensure better patient outcomes, extensive research is needed to explore their utilization within a value-based care framework.

Care-seeking pathways and diagnostic delays in extrapulmonary TB patients.

SETTING: This study was conducted at a private tertiary hospital engaged with the TB control programme in the city of Lahore, Pakistan. OBJECTIVE: To assess the healthcare-seeking pathways, different delays and factors associated with delays among the patients who presented in the outpatient department with tuberculous lymphadenitis and pleuritis, the most common manifestations of extrapulmonary TB. DESIGN: This cross-sectional study was conducted prospectively from April 2016 to August 2017. RESULTS: The median age of the 339 patients analysed was 22 years (IQR 17-30); tuberculous lymphadenitis was predominant in females (63%), while pleuritis affected more males (64%). Overall, 62% reported seeking care from healthcare providers before diagnosis, of whom 62% sought care from private facilities, 32% visited facilities >2 times and 8% visited traditional healers. Diagnostic delay was associated with tuberculous lymphadenitis, age 15-44 years, poor socio-economic status and poor TB knowledge. CONCLUSION: There was considerable delay in the management of extrapulmonary TB patients, and the health-system delay was the major contributor, leading to increased patient suffering. Efforts towards minimising health-system delay need to be prioritised for patient screening and diagnosis, with a feasible algorithm that is workable in resource-limited settings.

CONTEXTE: Cette étude a été menée dans un hôpital tertiaire privé participant au programme de lutte contre la TB dans la ville de Lahore, au Pakistan. OBJECTIF: Évaluer les parcours de recherche de soins, les différents délais et les facteurs associés aux délais parmi les patients qui se sont présentés au service des consultations externes avec une lymphadénite et une pleurite tuberculeuses, les manifestations les plus courantes de la TB extrapulmonaire. MÉTHODE: Cette étude transversale a été menée prospectivement d'avril 2016 à août 2017. RÉSULTATS: L'âge médian des 339 patients analysés était de 22 ans (IQR 17­30) ; la lymphadénite tuberculeuse prédominait chez les femmes (63%), tandis que la pleurite touchait davantage les hommes (64%). Dans l'ensemble, 62% des patients ont déclaré avoir eu recours à des prestataires de soins de santé avant le diagnostic, dont 62% dans des établissements privés, 32% ont visité des établissements >2 fois et 8% ont consulté des guérisseurs traditionnels. Le retard de diagnostic était associé à la lymphadénite tuberculeuse, à l'âge de 15 à 44 ans, à un statut socio-économique défavorable et à un manque de connaissances sur la TB. CONCLUSION: La prise en charge des patients atteints de TB extrapulmonaire accuse un retard considérable, dont le système de santé est le principal responsable, ce qui accroît les souffrances des patients. Les efforts visant à minimiser le retard du système de santé doivent être priorisés pour le dépistage et le diagnostic des patients, avec un algorithme réalisable dans des environnements aux ressources limitées.

Incidence of subsequent surgical decompression following minimally invasive approaches to treat lumbar spinal stenosis: A retrospective review.

BACKGROUND CONTEXT: Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression. PURPOSE: To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years. OUTCOME MEASURES: The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery. METHODS: Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors. RESULTS: A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively. CONCLUSIONS: Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

VENUM (Vascular Education iN Undergraduate Medicine): a multicentre evaluation of undergraduate vascular education in the UK.

INTRODUCTION: Vascular surgery is a recognised surgical subspecialty covering an array of circulatory conditions predominately affecting geriatric and diabetic patients. As such, a wide breadth of clinicians will see patients with vascular pathologies, but it is unclear how detailed their knowledge base is. Key to this is the education of medical students, which has been poorly documented during undergraduate training in the UK. VENUM aimed to establish students' perceptions of vascular surgery and their confidence in performing vascular objective structured clinical examination (OCSE) skills. METHODS: During the academic year of 2022/2023, final-year medical students were invited to complete a JISC survey (collaborative authorship). Seventy-seven research leads were recruited to disseminate the survey. Quantitative and thematic analysis was used to assess the data. RESULTS: In total, 240 final-year medical students completed the survey (54% female; 26 medical schools represented). Forty-five per cent of students reported never having had a vascular placement, 24% had never completed a vascular-focused clinical examination and 26% reported low confidence in performing ankle brachial pressure index measurement. An assessment of peripheral arterial disease morbidity was answered correctly in 17% of respondents compared with 92% for angina (chi-square test p<0.001). Students perceived the specialty to be non-inclusive and that early exposure to vascular surgery was required for better engagement with the specialty. CONCLUSION: Students have experienced little exposure to vascular surgery. This may affect future recruitment to vascular surgery and overall knowledge of vascular conditions in UK-trained doctors, which may affect long-term patient management.

Variation in partial direct costs of treating clinical mastitis among 37 Wisconsin dairy farms.

The objective of this observational study was to describe variations in partial direct costs of clinical mastitis (CM) treatments among 37 dairy herds using data obtained from herd management records. Animal health and drug purchase records were retrospectively collected from 37 Wisconsin dairy herds for a period of 1 yr. Each farm was visited to verify case definitions, recording accuracy, and detection criteria of CM cases. Descriptive statistics were used to summarize cost of drugs and milk discard. Differences in costs among protocols, intramammary (IMM) products, parities, days in milk, and recurrence were analyzed using ANOVA. Of 20,625 cases of CM, 31% did not receive antimicrobial treatment. The average cost of drugs and milk discard (including cases that were not treated) was $192.36 ± 8.90 (mean ± SE) per case and ranged among farms from $118.13 to $337.25. For CM cases treated only with IMM antimicrobials, milk discard accounted for 87% of total costs and was highly influenced by duration of therapy. Differences in costs were observed among parities, recurrence, and stage of lactation at case detection. Eight different treatment protocols were observed, but 64% of cases were treated using only IMM antimicrobials. Treatment costs varied among protocols; however, cases treated using both IMM and injectable antimicrobials as well as supportive therapy had the greatest costs as they were also treated for the longest duration. Ceftiofur was used for 82% of cases that received IMM antimicrobials while ampicillin was used for 51% of cases treated using injectable antimicrobials. With the exception of ceftiofur and pirlimycin IMM products, many IMM products were given for durations that exceeded the maximum labeled duration. For cases treated using only IMM therapy, as compared with observed costs, we estimated that partial direct costs could be reduced by $65.20 per case if the minimum labeled durations were used. Overall, partial direct costs per case varied among herds, cow factors, and treatment protocols and were highly influenced by the duration of therapy.

Applications of Augmented Reality in Orthopaedic Spine Surgery.

The application of augmented reality (AR) in surgical settings has primarily been as a navigation tool in the operating room because of its ease of use and minimal effect on surgical procedures. The surgeon can directly face the surgical field while viewing 3D anatomy virtually, thus reducing the need to look at an external display, such as a navigation system. Applications of AR are being explored in spine surgery. The basic principles of AR include data preparation, registration, tracking, and visualization. Current literature provides sufficient preclinical and clinical data evidence for the use of AR technology in spine surgery. AR systems are efficient assistive devices, providing greater accuracy for insertion points, more comfort for surgeons, and reduced operating time. AR technology also has beneficial applications in surgical training, education, and telementorship for spine surgery. However, costs associated with specially designed imaging equipment and physicians' comfort in using this technology continue to remain barriers to its adoption. As this technology evolves to a more widespread use, future applications will be directed by the cost-effectiveness of AR-assisted surgeries.

Cognitive dissonance increases spine loading in the neck and low back.

Cognitive dissonance refers to a state where two psychologically inconsistent thoughts, behaviours, or attitudes are held at the same time. The objective of this study was to explore the potential role of cognitive dissonance in biomechanical loading in the low back and neck. Seventeen participants underwent a laboratory experiment involving a precision lowering task. To establish a cognitive dissonance state (CDS), study participants were provided negative feedback on their performance running counter to a pre-established expectation that their performance was excellent. Dependent measures of interest were spinal loads in the cervical and lumbar spines, calculated via two electromyography-driven models. The CDS was associated with increases to peak spinal loads in the neck (11.1%, p < .05) and low back (2.2%, p < .05). A greater CDS magnitude was also associated with a greater spinal loading increase. Therefore, cognitive dissonance may represent a risk factor for low back/neck pain that has not been previously identified.Practitioner summary: Upon establishing a cognitive dissonance state in a group of participants, spinal loading in the cervical and lumbar spines were increased proportional to the magnitude of the cognitive dissonance reported. Therefore, cognitive dissonance may represent a risk factor for low back and neck pain that has not been previously identified.

Declining Trend in Anti-osteoporotic Treatment, Despite a Rise in DEXA Screening Following "Sentinel" Distal Radius Fractures.

PURPOSE: To understand national trends and costs associated with the utilization of anti-osteoporotic medication and DEXA screening within the year following a sentinel/primary distal radius fracture. METHODS: The 2008-2015Q1 Humana Administrative Claims database was queried to identify patients aged ≥50 years, with a "sentinel" occurrence of a primary closed distal radius fracture. Linear regression models were used to report and assess for significant trends in utilization of anti-osteoporotic medication and DEXA screenings within the year following the fracture. Multivariate logistic regression analyses were used to assess for factors associated with receiving or not receiving anti-osteoporotic medication. RESULTS: A total of 14 526 sentinel distal radius fractures were included in the study. Only 7.2% (n = 1046) of patients received anti-osteoporosis medication in the year following the distal radius fracture. Treatment with medication for osteoporosis declined from 8.2% in 2008 to 5.9% in 2015, whereas the rate of DEXA screening increased from 14.8% in 2008 to 23.6% in 2015. The most common prescribed treatment was alendronate sodium (n = 835; 79.8%-$49/patient). Factors associated with increased odds of receiving anti-osteoporotic medication were age 70 to 79 years (odds ratio [OR], 1.45; P = .014), age 80 to 89 years (OR, 1.66; P = .001), Asian (OR, 2.95; P = .002) or Hispanic (OR, 1.77; P = .006) ethnicity, belonging to South (OR, 1.19; P = .029) or West (OR, 1.37; P = .010), and having an Elixhauser Comorbidity Index score of 3 (OR, 2.14; P = .024) or > 3 (OR, 2.05; P = .022). CONCLUSIONS: Despite a rising utilization of DEXA screening following "sentinel" distal radius fractures, the proportion of individuals who receive anti-osteoporotic treatment is decreasing over time.

Firework Injuries to the Hand in the United States: An Epidemiological and Cost Analysis.

Although prior literature has evaluated firework injuries broadly, there are no focused investigations examining trends, etiology, and costs associated with firework injuries to the hand. The 2006 to 2014 National Emergency Department Sample (NEDS) was used. International Classification of Diseases, Ninth Revision (ICD-9) codes identified patients presenting to the emergency department with a firework-related injury of the hand that resulted in a burn, open wound, fracture, blood vessel injury, or traumatic amputation. A linear regression model was used to identify significant changes over time, with a significance threshold of P<.05. A total of 19,473 patients with a firework-related injury to the hand were included, with no significant change in the incidence from 2006 to 2014 (7.5 per 1,000,000 population). The greatest number of injuries occurred in July (57.1%), January (7.4%), and December (3.7%). Age groups affected were young adults (18-35 years; 43.6%), older adults (36-55 years; 19.2%), adolescents (12-17 years; 18.6%), and children (0-11 years; 16.1%). Nearly 74% of the injuries resulted in burns, 24.5% resulted in open wounds, 8.0% resulted in fracture, 7.6% resulted in traumatic amputation, and 1.4% resulted in blood vessel injury. Of 14,320 burn injuries, 15.2% had first-degree burns, 69.9% had second-degree burns, and 5.1% had third-degree burns involving the skin. The median emergency department charge was $914 and the median hospitalization charge (for inpatient admittance) was $30,743. Incidence of firework-related injuries to the hand has not changed over time. There is a need for better dissemination of safety information to mitigate the occurrences of these avoidable accidents. [Orthopedics. 2023;46(3):180-184.].

Evaluation of daily environmental cleaning and disinfection practices in veterans affairs acute and long-term care facilities: A mixed methods study.

OBJECTIVES: To describe daily environmental cleaning and disinfection practices and their associations with cleaning rates while exploring contextual factors experienced by healthcare workers involved in the cleaning process. METHODS: A convergent mixed methods approach using quantitative observations (ie, direct observation of environmental service staff performing environmental cleaning using a standardized observation form) and qualitative interviews (ie, semistructured interviews of key healthcare workers) across 3 Veterans Affairs acute and long-term care facilities. RESULTS: Between December 2018 and May 2019 a total of sixty-two room observations (N = 3602 surfaces) were conducted. The average observed surface cleaning rate during daily cleaning in patient rooms was 33.6% for all environmental surfaces and 60.0% for high-touch surfaces (HTS). Higher cleaning rates were observed with bathroom surfaces (Odds Ratio OR = 3.23), HTSs (OR = 1.57), and reusable medical equipment (RME) (OR = 1.40). Lower cleaning rates were observed when cleaning semiprivate rooms (OR = 0.71) and rooms in AC (OR = 0.56). In analysis stratified by patient presence (ie, present, or absent) in the room during cleaning, patient absence was associated with higher cleaning rates for HTSs (OR = 1.71). In addition, the odds that bathroom surfaces being cleaned more frequently than bedroom surfaces decreased (OR = 1.97) as well as the odds that private rooms being cleaned more frequently than semi-private rooms also decreased (OR = 0.26; 0.07-0.93). Between January and June 2019 eighteen qualitative interviews were conducted and found key themes (ie, patient presence and semiprivate rooms) as potential barriers to cleaning; this supports findings from the quantitative analysis. CONCLUSION: Overall observed rates of daily cleaning of environmental surfaces in both acute and long-term care was low. Standardized environmental cleaning practices to address known barriers, specifically cleaning practices when patients are present in rooms and semi-private rooms are needed to achieve improvements in cleaning rates.

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model.

STUDY DESIGN/SETTING: Retrospective. OBJECTIVE: To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. SUMMARY OF BACKGROUND DATA: Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. METHODS: The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. RESULTS: A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. CONCLUSIONS: Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

Is Outpatient Anterior Lumbar Fusion (ALIF) Safe? An Analysis of 30-day Outcomes.

STUDY DESIGN: Review of publicly available database. OBJECTIVE: To compare 30-day outcomes of single-level ALIF procedures performed in outpatient and inpatient settings. SUMMARY OF BACKGROUND DATA: Despite a growing interest in performing standalone anterior lumbar interbody fusions (ALIFs) as an outpatient procedure, no study has evaluated the safety or efficacy of this procedure outside an inpatient setting. METHODS: The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was queried using CPT code 22558 to identify patients undergoing a single-level ALIF. Patients receiving concurrent posterior lumbar surgery/fusion/instrumentation, pelvic fixation, or surgery due to tumor, trauma and/or deformity were excluded to capture an isolated cohort of patients receiving single-level standalone ALIFs. A total of 3728 single-level standalone ALIFs were included in the study. Multivariate regression analyses were used to compare 30-day adverse events and readmissions while controlling for baseline clinical characteristics. RESULTS: Out of a total of 3728 ALIFs, 149 (4.0%) were performed as outpatient procedure. Following adjustment, outpatient ALIFs versus inpatient ALIFs had lower odds of experiencing any 30-day adverse event (2.0% vs. 9.2%, OR 0.24 [95% CI 0.08-0.76]; P =0.015). No significant differences were noted with regard to severe adverse events 9p=0.261), minor adverse events 9p=0.995), and readmission rates ( P =0.95). CONCLUSION: On the basis of the results of the study, it appears that ALIFs may be carried out safely in an outpatient setting in an appropriately selected patient population.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units.

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

The Potential Relationship Between a Cognitive Dissonance State and Musculoskeletal Injury: A Systematic Review.

OBJECTIVE: The objective of this systematic review was to investigate the potential link between cognitive dissonance or its related constructs (emotional dissonance, emotional labor) and musculoskeletal disorders. BACKGROUND: The etiology of musculoskeletal disorders is complex, as pain arises from complex interactions among physical, social, and psychological stressors. It is possible that the psychological factor of cognitive dissonance may contribute to the etiology and/or maintenance of musculoskeletal disorders. METHOD: MEDLINE, APA PsycInfo, and CINAHL Plus databases were searched for studies investigating cognitive dissonance or its related constructs as exposure(s) of interest and outcomes related to physical health (including, but not limited to, musculoskeletal pain). Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies (AXIS) tool. RESULTS: The literature search yielded 7 studies eligible for inclusion. None of the included studies investigated cognitive dissonance directly but instead investigated dissonance-related constructs of emotional dissonance and emotional labor, in which a mismatch between required and felt emotions might elicit a psychological response consistent with the cognitive dissonance state. Moderate effect sizes between dissonance-related constructs and musculoskeletal disorders were noted (OR 1.25-2.22). CONCLUSION: There is likely a relationship between the two factors studied. However, as the included studies were cross-sectional in nature, a causal relationship between cognitive dissonance-related constructs and musculoskeletal disorders cannot be inferred. Therefore, future study proposing and validating a causal pathway between these variables is warranted. APPLICATION: Cognitive dissonance and its related constructs may serve as risk factors for musculoskeletal disorders that have not been considered previously.

Implementing 3HP vs. IPT as TB preventive treatment in Pakistan.

BACKGROUND: We assessed treatment uptake and completion for 6 months of isoniazid (6H) and 3 months of isoniazid plus rifapentine weekly (3HP) in a programmatic setting in Pakistan.METHODS: All household contacts were clinically evaluated to rule out TB disease. 6H was used for TB preventive treatment (TPT) from October 2016 to April 2017; from May to September 2017, 3HP was used for contacts aged ≥2 years. We compared clinical evaluation, TPT uptake and completion rates between contacts aged ≥2 years in the 6H period and in the 3HP period.RESULTS: We identified 3,442 contacts for the 6H regimen. After clinical evaluation, 744/1,036 (72%) started treatment, while 46% completed treatment. In contrast, 3,722 contacts were identified for 3HP. After clinical evaluation, 990/1,366 (72%) started treatment, while 67% completed treatment. Uptake of TPT did not differ significantly between the 6H and 3HP groups (OR 1.03, 95%CI 0.86-1.24). However, people who initiated 3HP had 2.3 times greater odds (95% CI 1.9-2.8) of completing treatment than those who initiated 6H after adjusting for age and sex.CONCLUSION: In programmatic settings in a high-burden country, household contacts of all ages were more likely to complete TPT with shorter weekly regimens, although treatment uptake rate for the two regimens was similar.