Outcomes from 871,441 Consecutive Surgical Procedures without Overlap or with Maximally Permissible Non-Concurrent Overlap.

OBJECTIVE: To isolate the impact of subsumed surgery (a shorter procedure completed entirely during overlapping non-critical portions of a longer antecedent procedure) on patient outcomes. SUMMARY BACKGROUND DATA: The American College of Surgeons recently recommended the elimination of "concurrent surgery" with overlap during a procedure's critical portions. Guidelines for non-concurrent overlap have been established, but the safety of subsumed surgery remains to be examined. METHODS: All consecutive procedures from 2013 to 2021 within a multihospital academic medical center were included (n=871,441). Simple logistic regression was performed to compare postoperative events between patients undergoing non-overlap surgery (n=533,032) and completely subsumed surgery (n=11,319). Thereafter, coarsened exact matching was used to match patients with non-overlap and subsumed surgery 1:1 on CPT code, 18 demographic features, baseline health characteristics, and procedural variables (n=7,146). Exact-matched cases were subsequently limited to pairs performed by the same surgeon (n=5,028). Primary outcomes included 30-day readmission, ED visits, and reoperations. RESULTS: Univariate analysis suggested that subsumed surgery had a higher 30-day risk of readmission (OR 1.55, P<0.0001), ED evaluation (OR 1.19, P<0.0001), and reoperation (OR 1.98, P<0.0001). When comparison was limited to the exact same procedure and patients were matched on demographics and health characteristics, there were no outcome differences between patients with subsumed surgery and non-overlapping surgery, even when limiting analyses to the same surgeon. CONCLUSIONS: Similar surgeries for similar patients result in similar outcomes whether there is completely subsumed or no overlap. Individual surgeons performing a specific procedure have no outcome differences with subsumed and non-overlapping cases.

Racial disparities in short-term spinal fusion outcomes across 4263 consecutive patients.

OBJECTIVE: Race plays a salient role in access to surgical care. However, few investigations have assessed the impact of race within surgical populations after care has been delivered. The objective of this study was to employ an exact matching protocol to a homogenous population of spine surgery patients in order to isolate the relationships between race and short-term postoperative outcomes. METHODS: In total, 4263 consecutive patients who underwent single-level, posterior-only lumbar fusion at a single multihospital academic medical center were retrospectively enrolled. Of these patients, 3406 patients self-identified as White and 857 patients self-identified as non-White. Outcomes were initially compared across all patients via logistic regression. Subsequently, White patients and non-White patients were exactly matched on the basis of key demographic and health characteristics (1520 matched patients). Outcome disparities were evaluated between the exact-matched cohorts. Primary outcomes were readmissions, emergency department (ED) visits, reoperations, mortality, intraoperative complications, and discharge disposition. RESULTS: Before matching, non-White patients were less likely to be discharged home and more likely to be readmitted, evaluated in the ED, and undergo reoperation. After matching, non-White patients experienced higher rates of nonhome discharge, readmissions, and ED visits. Non-White patients did not have more surgical complications either before or after matching. CONCLUSIONS: Between otherwise similar cohorts of spinal fusion cases, non-White patients experienced unfavorable discharge disposition and higher risk of multiple adverse postoperative outcomes. However, these findings were not accounted for by differences in surgical complications, suggesting that structural factors underlie the observed disparities.

The Impact of Neighborhood Socioeconomic Disadvantage on Operative Outcomes after Single-Level Lumbar Fusion.

INTRODUCTION: The relationship between socioeconomic status and neurosurgical outcomes has been investigated with respect to insurance status or median household income, but few studies have considered more comprehensive measures of socioeconomic status. This study examines the relationship between Area Deprivation Index (ADI), a comprehensive measure of neighborhood socioeconomic disadvantage, and short-term postoperative outcomes after lumbar fusion surgery. METHODS: 1861 adult patients undergoing single-level, posterior-only lumbar fusion at a single, multihospital academic medical center were retrospectively enrolled. An ADI matching protocol was used to identify each patient's 9-digit zip code and the zip code-associated ADI data. Primary outcomes included 30- and 90-day readmission, emergency department visits, reoperation, and surgical complication. Coarsened exact matching was used to match patients on key demographic and baseline characteristics known to independently affect neurosurgical outcomes. Odds ratios (ORs) were computed to compare patients in the top 10% of ADI versus lowest 40% of ADI. RESULTS: After matching (n = 212), patients in the highest 10% of ADI (compared to the lowest 40% of ADI) had significantly increased odds of 30- and 90-day readmission (OR = 5.00, P < 0.001 and OR = 4.50, P < 0.001), ED visits (OR = 3.00, P = 0.027 and OR = 2.88, P = 0.007), and reoperation (OR = 4.50, P = 0.039 and OR = 5.50, P = 0.013). There was no significant association with surgical complication (OR = 0.50, P = 0.63). CONCLUSIONS: Among otherwise similar patients, neighborhood socioeconomic disadvantage (measured by ADI) was associated with worse short-term outcomes after single-level, posterior-only lumbar fusion. There was no significant association between ADI and surgical complications, suggesting that perioperative complications do not explain the socioeconomic disparities in outcomes.

Relationship Between Comorbidity Burden and Short-Term Outcomes Across 4680 Consecutive Spinal Fusions.

OBJECTIVE: Preoperative management requires the identification and optimization of modifiable medical comorbidities, though few studies isolate comorbid status from related patient-level variables. This study evaluates Charlson Comorbidity Index (CCI)-an easily derived measure of aggregate medical comorbidity-to predict outcomes from spinal fusion surgery. Coarsened exact matching is employed to control for key patient characteristics and isolate CCI. METHODS: We retrospectively assessed 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion at a single academic center. Logistic regression evaluated the univariate relationship between CCI and patient outcomes. Coarsened exact matching generated exact demographic matches between patients with high comorbid status (CCI >6) or no medical comorbidities (matched n = 524). Patients were matched 1:1 on factors associated with surgical outcomes, and outcomes were compared between matched cohorts. Primary outcomes included surgical complications, discharge status, 30- and 90-day risk of readmission, emergency department (ED) visits, reoperation, and mortality. RESULTS: Univariate regression of increasing CCI was significantly associated with non-home discharge, as well as 30- and 90-day readmission, ED visits, and mortality (all P < 0.05). Subsequent isolation of comorbidity between otherwise exact-matched cohorts found comorbid status did not affect readmissions, reoperations, or mortality; high CCI score was significantly associated with non-home discharge (OR = 2.50, P < 0.001) and 30-day (OR = 2.44, P = 0.02) and 90-day (OR = 2.29, P = 0.008) ED evaluation. CONCLUSIONS: Comorbidity, measured by CCI, did not increase the risk of readmission, reoperation, or mortality. Single-level, posterior lumbar fusions may be safe in appropriately selected patients regardless of comorbid status. Future studies should determine whether CCI can guide discharge planning and postoperative optimization.

Varying Degree of Overlap Following the Critical Steps of Lumbar Fusion and Short-term Outcomes.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The present study analyzes the impact of end-overlap on short-term outcomes after single-level, posterior lumbar fusions. SUMMARY OF BACKGROUND DATA: Few studies have evaluated how "end-overlap" (i.e., surgical overlap after the critical elements of spinal procedures, such as during wound closure) influences surgical outcomes. METHODS: Retrospective analysis was performed on 3563 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a 6-year period at a multi-hospital university health system. Exclusion criteria included revision surgery, missing key health information, significantly elevated body mass index (>70), non-elective operations, non-general anesthesia, and unclean wounds. Outcomes included 30-day emergency department visit, readmission, reoperation, morbidity, and mortality. Univariate analysis was carried out on the sample population, then limited to patients with end-overlap. Subsequently, patients with the least end-overlap were exact-matched to patients with the most. Matching was performed based on key demographic variables-including sex and comorbid status-and attending surgeon, and then outcomes were compared between exact-matched cohorts. RESULTS: Among the entire sample population, no significant associations were found between the degree of end-overlap and short-term adverse events. Limited to cases with any end-overlap, increasing overlap was associated with increased 30-day emergency department visits ( P =0.049) but no other adverse outcomes. After controlling for confounding variables in the demographic-matched and demographic/surgeon-matched analyses, no differences in outcomes were observed between exact-matched cohorts. CONCLUSIONS: The degree of overlap after the critical steps of single-level lumbar fusion did not predict adverse short-term outcomes. This suggests that end-overlap is a safe practice within this surgical population.

Postoperative Outcomes and Resource Utilization Following Open vs Endoscopic Far Lateral Lumbar Discectomy.

BACKGROUND: Operative approaches for far lateral disc herniation (FLDH) repair may be classified as open or minimally invasive. The present study aims to compare postoperative outcomes and resource utilization between patients undergoing open and endoscopic (one such minimally invasive approach) FLDH surgeries. METHODS: A total of 144 consecutive adult patients undergoing FLDH repair at a single, university health system over an 8-year period (2013-2020) were retrospectively reviewed. Patients were divided into 2 cohorts: "open" (n = 92) and "endoscopic" (n = 52). Logistic regression was performed to evaluate the impact of procedural type on postoperative outcomes, and resource utilization metrics were compared between cohorts using χ 2 test (for categorical variables) or t test (for continuous variables). Primary postsurgical outcomes included readmissions, reoperations, emergency department visits, and neurosurgery outpatient office visits within 90 days of the index operation. Primary resource utilization outcomes included total direct cost of the procedure and length of stay. Secondary measures included discharge disposition, operative length, and duration of follow-up. RESULTS: No differences were observed in adverse postoperative events. Patients undergoing open FLDH surgery were more likely to attend outpatient visits within 30 days (P = 0.016). Although direct operating room cost was lower (P < 0.001) for open procedures, length of hospital stay was longer (P < 0.001). Patients undergoing open surgery also demonstrated less favorable discharge dispositions, longer operative length, and greater duration of follow-up. CONCLUSIONS: While both procedure types represent viable options for FLDH, endoscopic surgeries appear to achieve comparable clinical outcomes with decreased perioperative resource utilization. CLINICAL RELEVANCE: The present study suggests that endoscopic FLDH repairs do not lead to inferior outcomes but may decrease utilization of perioperative resources.

Neurosurgeons Deliver Similar Quality Care Regardless of First Assistant Type: Resident Physician versus Nonphysician Surgical Assistant.

OBJECTIVE: There are limited data evaluating the outcomes of attending neurosurgeons with different types of first assistants. This study considers a common neurosurgical procedure (single-level, posterior-only lumbar fusion surgery) and examines whether attending surgeons deliver equal patient outcomes, regardless of the type of first assistant (resident physician vs. nonphysician surgical assistant [NPSA]), among otherwise exact-matched patients. METHODS: The authors retrospectively analyzed 3395 adult patients undergoing single-level, posterior-only lumbar fusion at a single academic medical center. Primary outcomes included readmissions, emergency department visits, reoperation, and mortality within 30 and 90 days after surgery. Secondary outcome measures included discharge disposition, length of stay, and length of surgery. Coarsened exact matching was used to match patients on key demographics and baseline characteristics known to independently affect neurosurgical outcomes. RESULTS: Among exact-matched patients (n = 1402), there was no significant difference in adverse postsurgical events (readmission, emergency department visits, reoperation, or mortality) within 30 days or 90 days of the index operation between patients who had resident physicians and those who had NPSAs as first assistants. Patients who had resident physicians as first assistants demonstrated a longer length of stay (mean: 100.0 vs. 87.4 hours, P < 0.001) and a shorter duration of surgery (mean: 187.4 vs. 213.8 minutes, P < 0.001). There was no significant difference between the two groups in the percentage of patients discharged home. CONCLUSIONS: For single-level posterior spinal fusion, in the setting described, there are no differences in short-term patient outcomes delivered by attending surgeons assisted by resident physicians versus NPSAs.

"July Effect" in Spinal Fusions: A Coarsened Exact-Matched Analysis.

BACKGROUND: Few neurosurgical studies examine the July Effect within elective spinal procedures, and none uses an exact-matched protocol to rigorously account for confounders. OBJECTIVE: To evaluate the July Effect in single-level spinal fusions, after coarsened exact matching of the patient cohort on key patient characteristics (including race and comorbid status) known to independently affect neurosurgical outcomes. METHODS: Two thousand three hundred thirty-eight adult patients who underwent single-level, posterior-only lumbar fusion at a single, multicenter university hospital system were retrospectively enrolled. Primary outcomes included readmissions, emergency department visits, reoperation, surgical complications, and mortality within 30 days of surgery. Logistic regression was used to analyze month as an ordinal variable. Subsequently, outcomes were compared between patients with surgery at the beginning vs end of the academic year (ie, July vs April-June), before and after coarsened exact matching on key characteristics. After exact matching, 99 exactly matched pairs of patients (total n = 198) were included for analysis. RESULTS: Among all patients, operative month was not associated with adverse postoperative events within 30 days of the index operation. Furthermore, patients with surgeries in July had no significant difference in adverse outcomes. Similarly, between exact-matched cohorts, patients in July were observed to have noninferior adverse postoperative events. CONCLUSION: There was no evidence suggestive of a July Effect after single-level, posterior approach spinal fusions in our cohort. These findings align with the previous literature to imply that teaching hospitals provide adequate patient care throughout the academic year, regardless of how long individual resident physician assistants have been in their particular role.

Household income is associated with return to surgery following discectomy for far lateral disc herniation.

BACKGROUND: Numerous studies have demonstrated that household income is independently predictive of postsurgical morbidity and mortality, but few studies have elucidated this relationship in a purely spine surgery population. This study aims to correlate household income with adverse events after discectomy for far lateral disc herniation (FLDH). METHODS: All adult patients (N.=144) who underwent FLDH surgery at a single, multihospital, 1659-bed university health system (2013-2020) were retrospectively analyzed. Univariate logistic regression was used to evaluate the relationship between household income and adverse postsurgical events, including unplanned hospital readmissions, ED visits, and reoperations. RESULTS: Mean age of the population was 61.72±11.55 years. Mean household income was $78,283±26,996; 69 (47.9%) were female; and 126 (87.5%) were non-Hispanic white. Ninety-two patients underwent open and fifty-two underwent endoscopic FLDH surgery. Each additional dollar decrease in household income was significantly associated with increased risk of reoperation of any kind within 90-days, but not 30-days, after the index admission. However, household income did not predict risk of readmission or ED visit within either 30-days or 30-90-days postsurgery. CONCLUSIONS: These findings suggest that household income may predict reoperation following FLDH surgery. Additional research is warranted into the relationship between household income and adverse neurosurgical outcomes.

Impact of the 2016 American College of Surgeons Guideline Revision on Overlapping Lumbar Fusion Cases at a Large Academic Medical Center.

OBJECTIVE: The American College of Surgeons (ACS) updated its guidelines on overlapping surgery in 2016. The objective was to examine differences in postoperative outcomes after overlapping surgery either pre-ACS guideline revision or post-guideline revision, in a coarsened exact matching sample. METHODS: A total of 3327 consecutive adult patients undergoing single-level posterior lumbar fusion from 2013 to 2019 were retrospectively analyzed. Patients were separated into a pre-ACS guideline revision cohort (surgery before April 2016) or a post-guideline revision cohort (surgery after October 2016) for comparison. The primary outcomes were proportion of cases performed with any degree of overlap, and adverse events including 30-day and 90-day rates of readmission, reoperation, emergency department visit, morbidity, and mortality. Subsequently, coarsened exact matching was used among overlapping surgery patients only to assess the impact of the ACS guideline revision on overlapping outcomes, and controlling for attending surgeon and key patient characteristics known to affect surgical outcomes. RESULTS: After the implementation of the ACS guidelines, fewer cases were performed with overlap (22.0% vs. 53.7%; P < 0.001). Patients in the post-ACS guideline revision cohort experienced improved rates of readmission and reoperation within 30 and 90 days. However, when limited to overlapping cases only, no differences were observed in overlap outcomes pre-ACS versus post-ACS guideline revision. Similarly, when exact matched on risk-associated patient characteristics and attending surgeon, overlapping surgery patients pre-ACS and post-ACS guideline revision experienced similar rates of 30-day and 90-day outcomes. CONCLUSIONS: After the ACS guideline revision, no discernable impact was observed on postoperative outcomes after lumbar fusion performed with overlap.

Resident assistant training level is not associated with patient spinal fusion outcomes.

OBJECTIVE: A hallmark of surgical training is resident involvement in operative procedures. While resident-assisted surgeries have been deemed generally safe, few studies have rigorously isolated the impact of resident post-graduate year (PGY) level on post-operative outcomes in a neurosurgical patient population. The objective of this study is to evaluate the relationship between resident training level and outcomes following single-level, posterior-only lumbar fusion, after matching on key patient demographic/clinical characteristics and attending surgeon. PATIENTS AND METHODS: This coarsened-exact matching (CEM) study analyzed 2338 consecutive adult patients who underwent single-level lumbar fusion with a resident assistant surgeon at a multi-hospital university health system from 2013 to 2019. Primary outcomes were 30-day and 90-day readmissions, Emergency Department (ED) visits, reoperations, surgical complications, and mortality. First, univariate logistic regression examined the relationship between PGY level and outcomes. Then, CEM was used to control for key patient characteristics - such as race and comorbid status - and supervising attending surgeon, between the most junior (PGY-2)-assisted cases and the most senior (PGY-7)-assisted cases, thereby isolating the relationship between training level and outcomes. RESULTS: Among all patients, resident training level was not associated with risk of adverse post-surgical outcomes. Similarly, between exact-matched cohorts of PGY-2- and PGY-7-assisted cases, no significant differences in adverse events or discharge disposition were observed. Patients with the most senior resident assistant surgeons demonstrated longer length of stay (mean 100.5 vs. 93.8 h, p = 0.022) and longer duration of surgery (mean 173.5 vs. 159.8 min, p = 0.036). CONCLUSION: Training level of the resident assistant surgeon did not impact adverse outcomes provided to patients in the setting of single-level, posterior-only lumbar fusion. These findings suggest that attending surgeons appropriately manage cases with resident surgeons at different levels of training.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection.

Objectives The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design This is a retrospective regression analysis. Setting This study was done at a single, multihospital, urban academic medical center. Participants Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p = 0.015) and reoperation after index admission ( p = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p = 0.045) and decreasing but not significant reoperation after index admission ( p = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Socioeconomic Status Predicts Short-Term Emergency Department Utilization Following Supratentorial Meningioma Resection.

Introduction By identifying drivers of healthcare disparities, providers can better support high-risk patients and develop risk-mitigation strategies. Household income is a social determinant of health known to contribute to healthcare disparities. The present study evaluates the impact of household income on short-term morbidity and mortality following supratentorial meningioma resection. Methods A total of 349 consecutive patients undergoing supratentorial meningioma resection over a six-year period (2013-2019) were analyzed retrospectively. Primary outcomes were unplanned hospital readmission, reoperations, emergency department (ED) visits, return to the operating room, and all-cause mortality within 30 days of the index operation. Standardized univariate regression was performed across the entire sample to assess the impact of household income on outcomes. Subsequently, outcomes were compared between the lowest (household income ≤ $51,780) and highest (household income ≥ $87,958) income quartiles. Finally, stepwise regression was executed to identify potential confounding variables. Results Across all supratentorial meningioma resection patients, lower household income was correlated with a significantly increased rate of 30-day ED visits (p = 0.002). Comparing the lowest and highest income quartiles, the lowest quartile was similarly observed to have a significantly higher rate of 30-day ED evaluation (p = 0.033). Stepwise regression revealed that the observed association between household income and 30-day ED visits was not affected by confounding variables. Conclusion This study suggests that household income plays a role in short-term ED evaluation following supratentorial meningioma resection.

Increasing Nonconcurrent Overlapping Surgery Is Not Associated With Outcome Changes in Lumbar Fusion.

BACKGROUND: There remains a paucity of literature on the impact of overlap on neurosurgical patient outcomes. The purpose of the present study was to correlate increasing duration of surgical overlap with short-term patient outcomes following lumbar fusion. METHODS: The present study retrospectively analyzed 1302 adult patients undergoing overlapping, single-level, posterior-only lumbar fusion within a single, multicenter, academic health system. Recorded outcomes included 30-day emergency department visits, readmission, reoperation, mortality, overall morbidity, and overall morbidity/surgical complications. The amount of overlap was calculated as a percentage of total overlap time. Comparison was made between patients with the most (top 10%) and least (bottom 40%) amount of overlap. Patients were then exact matched on key demographic factors but not by the attending surgeons. Subsequently, patients were exact matched by both demographic data and the attending surgeons. Univariate analysis was first carried out prior to matching and then on both the demographic-matched and surgeon-matched cohorts. Significance for all analyses was set at a P value of <0.05. RESULTS: Within the whole population, increasing duration of overlap was not correlated with any short-term outcome (P = 0.41-0.91). After exact matching, patients with the most and least durations of overlap did not have significant differences with respect to any short-term outcomes (P = 0.34-1.00). CONCLUSION: Increased amount of overlap is not associated with adverse short-term outcomes for single-level, posterior-only lumbar fusions. CLINICAL RELEVANCE: The present results suggest that increasing the duration of overlap during lumbar fusion surgery does not lead to inferior outcomes.

Matched analysis of patient gender and meningioma resection outcomes.

PURPOSE: Gender is a known social determinant of health (SDOH) that has been linked to neurosurgical outcome disparities. To improve quality of care, there exists a need to investigate the impact of gender on procedure-specific outcomes. The objective of this study was to assess the role of gender on short- and long-term outcomes following resection of meningiomas - the most common benign brain neoplasm of adulthood - between exact matched patient cohorts. MATERIAL AND METHODS: All consecutive patients undergoing supratentorial meningioma resection (n = 349) at a single, university-wide health system over a 6-year period were analyzed retrospectively. Coarsened exact matching was employed to match patients on numerous key characteristics related to outcomes. Primary outcomes included readmission, ED visit, reoperation, and mortality within 30 and 90 days of surgery. Mortality and reoperation were also assessed during the entire follow-up period. Outcomes were compared between matched female and male cohorts. RESULTS: Between matched cohorts, no significant difference was observed in morbidity or mortality at 30 days (p = 0.42-0.75), 90-days (p = 0.23-0.69), or throughout the follow-up period (p = 0.22-0.45). Differences in short-term mortality could not be assessed due to the low number of mortality events. CONCLUSIONS: After matching on characteristics known to impact outcomes and when isolated from other SDOHs, gender does not independently affect morbidity and mortality following meningioma resection. Further research on the role of other SDOHs in this population is merited to better understand underlying drivers of disparity.

Matched Analysis of the Risk Assessment and Prediction Tool for Discharge Planning Following Single-Level Posterior Lumbar Fusion.

OBJECTIVES: Predicting patient needs for extended care after spinal fusion remains challenging. The Risk Assessment and Prediction Tool (RAPT) was externally developed to predict discharge disposition after nonspine orthopedic surgery but remains scarcely used in neurosurgery. The present study is the first to use coarsened exact matching-which incorporated patient characteristics known to independently affect outcomes-for 1:1 matching across a large population of single-level, posterior lumbar fusions, to isolate the predictive value of preoperative RAPT score on postoperative discharge disposition. METHODS: Preoperative RAPT scores were prospectively calculated for 1066 patients undergoing consecutive single-level, posterior-only lumbar fusion within a single, university healthcare system. The primary outcome was discharge disposition. Logistic regression was executed across all patients, evaluating the RAPT score as a continuous variable to predict home discharge. Subsequently, patients were retrospectively clustered into predicted risk cohorts-validated within prior orthopedic joint research-based on the RAPT score (Lowest, Intermediate, and Highest Risk). Coarsened exact matching was performed among predicted risk cohorts, and outcomes were compared between exact-matched groups. RESULTS: Among all patients, single-point increases in the RAPT score (i.e., decrease in predicted risk) were associated a 75% increased odds of home discharge (P < 0.001). Exact-matched analysis demonstrated increased odds of home discharge by 400% when comparing the Lowest versus Highest Risk cohorts (P = 0.004), by 750% when comparing the Intermediate versus Highest Risk cohorts (P < 0.001), and by 200% when comparing the Lowest versus Intermediate Risk cohorts (P < 0.001). CONCLUSIONS: The RAPT score, captured in preoperative evaluations, can be highly predictive of discharge disposition following single-level, posterior lumbar fusion.

The impact of gender on long-term outcomes following supratentorial brain tumor resection.

PURPOSE: Gender is a known social determinant of health which has been linked disparities in medical care. This study intends to assess the impact of gender on 90-day and long-term morbidity and mortality outcomes following supratentorial brain tumor resection in a coarsened-exact matched population. MATERIALS AND METHODS: A total of 1970 consecutive patients at a single, university-wide health system undergoing supratentorial brain tumor resection over a six-year period (09 June 2013 to 26 April 2019) were analyzed retrospectively. Coarsened Exact Matching was employed to match patients on key demographic factors including history of prior surgery, smoking status, median household income, American Society of Anesthesiologists (ASA) grade, and Charlson Comorbidity Index (CCI), amongst others. Primary outcomes assessed included readmission, ED visit, unplanned reoperation, and mortality within 90 days of surgery. Long-term outcomes such as mortality and unplanned return to surgery during the entire follow-up period were also recorded. RESULTS: Whole-population regression demonstrated significantly increased mortality throughout the entire follow-up period for the male cohort (p = 0.004, OR = 1.32, 95% CI = 1.09 - 1.59); however, no significant difference was found after coarsened exact matching was performed (p = 0.08). In both the whole-population regression and matched-cohort analysis, no significant difference was observed between gender and readmission, ED visit, unplanned reoperation, or mortality in the 90-day post-operative window, in addition to return to surgery after throughout the entire follow-up period. CONCLUSION: After controlling for confounding variables, female birth gender did not significantly predict any difference in morbidity and mortality outcomes following supratentorial brain tumor resection. Difference between mortality outcomes in the pre-matched population versus the matched cohort suggests the need to better manage the underlying health conditions of male patients in order to prevent future disparities.

The role of socioeconomic status on outcomes following cerebellopontine angle tumor resection.

PURPOSE: It is well documented that the interaction between many social factors can affect clinical outcomes. However, the independent effects of economics on outcomes following surgery are not well understood. The goal of this study is to investigate the role socioeconomic status has on postoperative outcomes in a cerebellopontine angle (CPA) tumor resection population. MATERIALS AND METHODS: Over 6 years (07 June 2013 to 24 April 2019), 277 consecutive CPA tumor cases were reviewed at a single, multihospital academic medical center. Patient characteristics obtained included median household income, Charlson Comorbidity Index (CCI), race, BMI, tobacco use, amongst 23 others. Outcomes studied included readmission, ED evaluation, unplanned return to surgery (during and after index admission), return to surgery after index admission, and mortality within 90 days, in addition to reoperation and mortality throughout the entire follow-up period. Univariate analysis was conducted amongst the entire population with significance set at a p value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p value <0.05. Stepwise regression was conducted to determine the correlations amongst study variables and identify confounding factors. RESULTS: Regression analysis of 273 patients did not find household income to be associated with any of the long-term outcomes assessed. Similarly, a Q1 vs Q4 comparison did not yield significantly different odds of outcomes assessed. CONCLUSION: Although not statistically significant, the odds ratios suggest socioeconomic status may have a clinically significant effect on postsurgical outcomes. Further studies in larger, matched populations are necessary to validate these findings.

Postoperative outcomes and the association with overlap before or after the critical step of lumbar fusion.

OBJECTIVE: This study assesses how degree of overlap, either before or after the critical operative portion, affects lumbar fusion outcomes. METHODS: The authors retrospectively studied 3799 consecutive patients undergoing single-level, posterior-only lumbar fusion over 6 years (2013-2019) at a university health system. Outcomes recorded within 30-90 and 0-90 postoperative days included emergency department (ED) visit, readmission, reoperation, overall morbidity, and mortality. Furthermore, morbidity and mortality were recorded for the duration of follow-up. The amount of overlap that occurred before or after the critical portion of surgery was calculated as a percentage of total beginning or end operative time. Subsequent to initial whole-population analysis, coarsened exact-matched cohorts of patients were created with the least and most amounts of either beginning or end overlap. Univariate analysis was performed on both beginning and end overlap exact-matched cohorts, with significance set at p < 0.05. RESULTS: Equivalent outcomes were observed when comparing exact-matched patients. Among the whole population, the degree of beginning overlap was correlated with reduced ED visits within 30-90 and 0-90 days (p = 0.007, p = 0.009; respectively), and less 0-90 day morbidity (p = 0.037). Degree of end overlap was correlated with fewer 30-90 day ED visits (p = 0.015). When comparing only patients with overlap, degree of beginning overlap was correlated with fewer 0-90 day reoperations (p = 0.022), and no outcomes were correlated with degree of end overlap. CONCLUSIONS: The degree of overlap before or after the critical step of surgery does not lead to worse outcomes after lumbar fusion.

Use of the LACE+ index to predict readmissions after single-level lumbar fusion.

OBJECTIVE: Spinal fusion is one of the most common neurosurgical procedures. The LACE (length of stay, acuity of admission, Charlson Comorbidity Index [CCI] score, and emergency department [ED] visits within the previous 6 months) index was developed to predict readmission but has not been tested in a large, homogeneous spinal fusion population. The present study evaluated use of the LACE+ score for outcome prediction after lumbar fusion. METHODS: LACE+ scores were calculated for all patients (n = 1598) with complete information who underwent single-level, posterior-only lumbar fusion at a single university medical system. Logistic regression was performed to assess the ability of the LACE+ score as a continuous variable to predict hospital readmissions within 30 days (30D), 30-90 days (30-90D), and 90 days (90D) of the index operation. Secondary outcome measures included ED visits and reoperations. Subsequently, patients with LACE+ scores in the bottom decile were exact matched to the patients with scores in the top 4 deciles to control for sociodemographic and procedural variables. RESULTS: Among all patients, increased LACE+ score significantly predicted higher rates of readmissions in the 30D (p < 0.001), 30-90D (p = 0.001), and 90D (p < 0.001) postoperative windows. LACE+ score also predicted risk of ED visits at all 3 time points and reoperations at 30-90D and 90D. When patients with LACE+ scores in the bottom decile were compared with patients with scores in the top 4 deciles, higher LACE+ score predicted higher risk of readmissions at 30D (p = 0.009) and 90D (p = 0.005). No significant difference in hospital readmissions was observed between the exact-matched cohorts. CONCLUSIONS: The present results suggest that the LACE+ score demonstrates utility in predicting readmissions within 30 and 90 days after single-level lumbar fusion. Future research is warranted that utilizes the LACE+ index to identify strategies to support high-risk patients in a prospective population.