Cannabis Use Disorder Trends and Health Care Utilization After Cervical and Lumbar Spine Fusions.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To identify differences in complication rates after cervical and lumbar fusion over the first postoperative year between those with and without cannabis use disorder (CUD) and to assess how CUD affects opioid prescription patterns. SUMMARY OF BACKGROUND DATA: Cannabis is legal for medical purposes in 36 states and for recreational use in 18 states. Cannabis has multisystem effects and may contribute to transient vasoconstrictive, prothrombotic, and inflammatory effects. METHODS: The IBM MarketScan Database (2009-2019) was used to identify patients who underwent cervical or lumbar fusions, with or without CUD. Exact match hospitalization and postdischarge outcomes were analyzed at index, six, and 12 months. RESULTS: Of 72,024 cervical fusion (2.0% with CUD) and 105,612 lumbar fusion patients (1.5% with CUD), individuals with CUD were more likely to be young males with higher Elixhauser index. The cervical CUD group had increased neurological complications (3% vs. 2%) and sepsis (1% vs. 0%) during the index hospitalization and neurological (7% vs. 5%) and wound complications (5% vs. 3%) at 12 months. The lumbar CUD group had increased wound (8% vs. 5%) and myocardial infarction (MI) (2% vs. 1%) complications at six months and at 12 months. For those with cervical myelopathy, increased risk of pulmonary complications was observed with CUD at index hospitalization and 12-month follow-up. For those with lumbar stenosis, cardiac complications and MI were associated with CUD at index hospitalization and 12 months. CUD was associated with opiate use disorder, decreasing postoperatively. CONCLUSIONS: No differences in reoperation rates were observed for CUD groups undergoing cervical or lumbar fusion. CUD was associated with an increased risk of stroke for the cervical fusion cohort and cardiac (including MI) and pulmonary complications for lumbar fusion at index hospitalization and six and 12 months postoperatively. Opiate use disorder and decreased opiate dependence after surgery also correlated with CUD.

Risk of developing glioblastoma following non-CNS primary cancer: a SEER analysis between 2000 and 2018.

BACKGROUND: Patients with a prior malignancy are at elevated risk of developing subsequent primary malignancies (SPMs). However, the risk of developing subsequent primary glioblastoma (SPGBM) in patients with a prior cancer history is poorly understood. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER) database and identified patients diagnosed with non-CNS malignancy between 2000 and 2018. We calculated a modified standardized incidence ratio (M-SIR), defined as the ratio of the incidence of SPGBM among patients with initial non-CNS malignancy to the incidence of GBM in the general population, stratified by sex latency, and initial tumor location. RESULTS: Of the 5,326,172 patients diagnosed with a primary non-CNS malignancy, 3559 patients developed SPGBM (0.07%). Among patients with SPGBM, 2312 (65.0%) were men, compared to 2,706,933 (50.8%) men in the total primary non-CNS malignancy cohort. The median age at diagnosis of SPGBM was 65 years. The mean latency between a prior non-CNS malignancy and developing a SPGBM was 67.3 months (interquartile range [IQR] 27-100). Overall, patients with a primary non-CNS malignancy had a significantly elevated M-SIR (1.13, 95% CI 1.09-1.16), with a 13% increased incidence of SPGBM when compared to the incidence of developing GBM in the age-matched general population. When stratified by non-CNS tumor location, patients diagnosed with primary melanoma, lymphoma, prostate, breast, renal, or endocrine malignancies had a higher M-SIR (M-SIR ranges: 1.09-2.15). Patients with lung cancers (M-SIR 0.82, 95% CI 0.68-0.99), or stomach cancers (M-SIR 0.47, 95% CI 0.24-0.82) demonstrated a lower M-SIR. CONCLUSION: Patients with a history of prior non-CNS malignancy are at an overall increased risk of developing SPGBM relative to the incidence of developing GBM in the general population. However, the incidence of SPGBM after prior non-CNS malignancy varies by primary tumor location, with some non-CNS malignancies demonstrating either increased or decreased predisposition for SPGBM depending on tumor origin. These findings merit future investigation into whether these relationships represent treatment effects or a previously unknown shared predisposition for glioblastoma and non-CNS malignancy.

Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note.

Background: Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES. Methods: This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2-3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively. Results: Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again. Conclusion: scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES's role in SCI patients.

Trends and Impact of Treatment Modalities (Surgery and Radiation Therapy) on Health Care Utilization in Patients With Glomus Jugulare Tumors (GJTs): An Inverse Probability of Treatment Weight Analysis.

OBJECTIVES: The trend of practice pattern and impact on health care utilization for surgery and radiation therapy (RT) in patients with glomus jugulare tumors (GJTs) is not well defined. METHODS: The IBM (Armonk, NY) MarketScan database was queried using the ICD-9/10 and CPT 4th edition, 2000-2020. We included patients ≥18 years of age who underwent either surgery or RT with at-least 1-year follow-up. We compared the health care utilization at 3-month, 6-month, and 1-year follow up using the inverse probability of treatment weight technique. RESULTS: A cohort of 333 patients was identified. Of these, 72.7% (n = 242) underwent RT and 27.3% (n = 91) underwent surgery. RT use increased from 2002-2004 (50%) to 2017-2019 (91%). Patients in the surgery cohort were younger (median age 49 vs. 56 years, P < 0.0001) and had a higher 3+ comorbidity index (34% vs. 30%, P = 0.43) compared with patients in the RT cohort. Patients who underwent surgery had higher complications at index hospitalization (22% vs. 6%, P < 0.0001) and at 30 days (14% vs. 5%, P = 0.0042). No difference in combined index and 6- or 12-month payments were noted (6-months: surgery, $66m108, RT: $43m509, P = 0.1034; 12-months: surgery, $73,259, RT: $51,576, P = 0.1817). Only 4% of patients who had initial RT underwent RT and none underwent surgery at 12 months, whereas 6% of patients who had initial surgery underwent RT and 2% underwent surgery at 12 months. CONCLUSIONS: RT plays an increasingly important role in the treatment for patients with GJTs, with fewer complications and a comparable health care utilization at 1 year.

Intraoperative MRI use in transsphenoidal surgery for pituitary tumors: Trends and healthcare utilization.

BACKGROUND: Intraoperative magnetic resonance imaging (iMRI) use in transsphenoidal approach (TSA) for pituitary tumors (PTs) has been reported to improve the extent of resection (EOR). The aim of this study is to report the trends and the impact of iMRI on healthcare utilization in patients who underwent TSA for PTs. MATERIALS AND METHODS: MarketScan database were queried using the ICD-9/10 and CPT-4, from 2004 to 2020. We included patients ≥ 18 years of age PTs with > 1 year follow-up. Outcomes were length of stay (LOS), discharge disposition, hospital/emergency room (ER) re-admissions, outpatient services, medication refills and corresponding payments. RESULTS: A cohort of 10,192 patients were identified from the database, of these 141 patients (1.4%) had iMRI used during the procedure. Use of iMRI for PTs remained stable (2004-2007: 0.85%; 2008-2011: 1.6%; 2012-2015:1.4% and 2016-2019: 1.46%). No differences in LOS (median 3 days each), discharge to home (93% vs. 94%), complication rates (7% vs. 13%) and payments ($34604 vs. $33050) at index hospitalization were noted. Post-discharge payments were not significantly different without and with iMRI use at 6-months ($8315 vs. $ 7577, p = 0.7) and 1-year ($13,654 vs. $ 14,054, p = 0.70), following the index procedure. CONCLUSION: iMRI use during TSA for PTs remained stable with no impact on LOS, complications, discharge disposition and index payments. Also, there was no difference in combined index payments at 6-months, and 1-year after the index procedure in patients with and without iMRI use for PTs.

Trends of Different Surgical Approaches in Patients With Single-Level Lumbar Isthmic Spondylolisthesis: A National Registry Analysis.

BACKGROUND: A variety of surgical approaches (anterior vs. posterior vs. anterior and posterior) are available for Isthmic Spondylolisthesis (IS). The aim of our study was to analyze the pattern and 30-day outcomes in patients undergoing different surgical approaches for single-level IS. MATERIALS AND METHODS: National Surgical Quality Improvement Program (NSQIP) database was queried using the ICD-9/10 and CPT 4th edition, from 2012 to 2020. We included patients 18-65 years of age who underwent spine fusions for IS. Outcomes were a length of stay (LOS), discharge disposition, 30-day complications, hospital readmission, and complication rates. RESULTS: Of 1036 patients who underwent spine fusions for IS, 838 patients (80.8%) underwent posterior only, 115 patients (11.1%) underwent anterior-only fusions and the rest (8%) underwent combined anterior and posterior procedures. 60% of patients in the posterior-only cohort had at least one comorbidity compared to 54% of patients in anterior only and 55% of patients in the combined cohort. No statistically significant differences in terms of LOS (3 days each) and discharge to home (96% vs. 93% vs. 94%) were noted among the anterior-only, posterior-only and combined cohorts, p> 0.05. In terms of 30-day complication rates, combined procedures had slightly higher rates (13%) compared to anterior (10%) or posterior-only (9%) procedures. CONCLUSION: Posterior-only fusions were performed in 80% of patients with IS. No differences in terms of LOS, discharge disposition to home, 30-day complications, hospital readmission and reoperation rates were noted across the cohorts.

Impact of Management Strategies on New-Onset Mental Health Disorders and Associated Health Care Utilization in Patients with Vestibular Schwannoma.

OBJECTIVE: To compare the impact of different management strategies on diagnosis of new-onset mental health disorders (MHDs) in patients with vestibular schwannoma (VS) and health care utilization at 1-year follow-up. METHODS: MarketScan databases were queried using the International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Terminology, Fourth Edition, 2000-2020. We included patients ≥18 years old with a diagnosis of VS who underwent clinical observation, surgery, or stereotactic radiosurgery (SRS) with at least 1 year of follow-up. We looked at health care outcomes and MHDs at 3-month, 6-month, and 1-year follow-up. RESULTS: The database search identified 23,376 patients. Of these, 94.2% (n = 22,041) were managed conservatively with clinical observation at the initial diagnosis, and 2% (n = 466) underwent surgery. The surgery cohort had the highest incidence of new-onset MHDs followed by SRS and clinical observation cohorts at 3 months (surgery: 17%; SRS: 12%; clinical observation: 7%), 6 months (surgery: 20%; SRS: 16%; clinical observation: 10%), and 12 months (surgery: 27%; SRS: 23%; clinical observation: 16%) (P < 0.0001). The median difference in combined payments between patients with and without MHDs was highest in the surgery cohort followed by SRS and clinical observation cohorts at all time points (12 months: surgery: $14,469; SRS: $10,557; clinical observation: $6439; P = 0.0002). CONCLUSIONS: Compared with clinical observation only, patients who underwent surgery for VS were 2 times more likely and patients who underwent SRS were 1.5 times more likely to develop MHDs with corresponding increase in health care utilization at 1-year follow-up.

Neuroanatomical mapping of the lumbosacral spinal cord in individuals with chronic spinal cord injury.

With emerging applications of spinal cord electrical stimulation in restoring autonomic and motor function after spinal cord injury, understanding the neuroanatomical substrates of the human spinal cord after spinal cord injury using neuroimaging techniques can play a critical role in optimizing the outcomes of these stimulation-based interventions. In this study, we have introduced a neuroimaging acquisition and analysis protocol of the spinal cord in order to identify: (i) spinal cord levels at the lumbosacral enlargement using nerve root tracing; (ii) variability in the neuroanatomical characteristics of the spinal cord among individuals; (iii) location of the epidural stimulation paddle electrode and contacts with respect to the spinal cord levels at lumbosacral enlargement; and (iv) the links between the anatomical levels of stimulation and the corresponding neurophysiological motor responses. Twelve individuals with chronic, motor complete spinal cord injury implanted with a spinal cord epidural stimulator were included in the study (age: 34 ± 10.9 years, sex: 10 males, 2 females, time since injury: 8.2 ± 9.9 years, American Spinal Injury Association Impairment Scale: 6 A, 6 B). High-resolution MRI scans of the spinal cord were recorded pre-implant. An analysis of neuroanatomical substrates indicates that the length of the spinal column and spinal cord, location of the conus tip and the relationship between the spinal cord levels and vertebral levels, particularly at the lumbosacral enlargement, are variable across individuals. There is no statistically significant correlation between the length of the spinal column and the length of the spinal cord. The percentage of volumetric coverage of the lumbosacral spinal cord by the epidural stimulation paddle electrode ranges from 33.4 to 90.4% across participants. The location of the spinal cord levels with respect to the electrode contacts varies across individuals and impacts the recruitment patterns of neurophysiological responses. Finally, MRI-based spinal cord modelling can be used as a guide for the prediction and preplanning of optimum epidural stimulation paddle placement prior to the implant surgery to ensure maximizing functional outcomes. These findings highlight the crucial role that the neuroanatomical characteristics of the spinal cord specific to each individual play in achieving maximum functional benefits with spinal cord electrical stimulation.

Machine learning in clinical diagnosis, prognostication, and management of acute traumatic spinal cord injury (SCI): A systematic review.

Background: Machine learning has been applied to improve diagnosis and prognostication of acute traumatic spinal cord injury. We investigate potential for clinical integration of machine learning in this patient population to navigate variability in injury and recovery. Materials and methods: We performed a systematic review using PRISMA guidelines through PubMed database to identify studies that use machine learning algorithms for clinical application toward improvements in diagnosis, management, and predictive modeling. Results: Of the 132 records identified, a total of 13 articles met inclusion criteria and were included in final analysis. Of the 13 articles, 5 focused on diagnostic accuracy and 8 were related to prognostication or management of traumatic spinal cord injury. Across studies, 1983 patients with spinal cord injury were evaluated with most classifying as ASIA C or D. Retrospective designs were used in 10 of 13 studies and 3 were prospective. Studies focused on MRI evaluation and segmentation for diagnostic accuracy and prognostication, investigation of mean arterial pressure in acute care and intraoperative settings, prediction of ambulatory and functional ability, chronic complication prevention, and psychological quality of life assessments. Decision tree, random forests (RF), support vector machines (SVM), hierarchical cluster tree analysis (HCTA), artificial neural networks (ANN), convolutional neural networks (CNN) machine learning subtypes were used. Conclusions: Machine learning represents a platform technology with clinical application in traumatic spinal cord injury diagnosis, prognostication, management, rehabilitation, and risk prevention of chronic complications and mental illness. SVM models showed improved accuracy when compared to other ML subtypes surveyed. Inherent variability across patients with SCI offers unique opportunity for ML and personalized medicine to drive desired outcomes and assess risks in this patient population.

Is intraoperative MRI use in malignant brain tumor surgery a health care burden? A matched analysis of MarketScan Database.

BACKGROUND: Intraoperative magnetic resonance imaging (iMRI) is a useful adjunct for resection of primary malignant brain tumors (MBTs). The aim of our study is to investigate the impact of iMRI on health care utilization in patients who underwent craniotomy for resection of MBTs. MATERIALS AND METHODS: MarketScan database were queried using the ICD-9/10 and CPT 4th edition, from 2008 to 2020. We included patients ≥ 18 years of age who underwent a craniotomy with at-least one year follow-up. Outcomes were length of stay (LOS), discharge disposition, hospital/emergency room (ER) re-admissions, outpatient services, medication refills and corresponding payments. RESULTS: Of 6,640 patients who underwent craniotomy for MBTs, 465 patients (7%) had iMRI used during the procedure with 0.7% per year increase in iMRI use during the study period. Patients without iMRI use had higher complications at index hospitalization compared to those with iMRI use (19% vs. 14%, p = 0.04). There was no difference in the ER admission rates among the patients who underwent surgery with and without iMRI use at 6-months and 1-year after the index procedure. In terms of post-discharge payments, no significant differences were noted among the patients without and with iMRI use at 6-months ($81,107 vs. $ 81,458, p = 0.26) and 1-year ($132,657 vs. $ 118,113, p = 0.12). CONCLUSION: iMRI use during craniotomy for MBT gradually increased during the study period. iMRI did not result in higher payments at index hospitalization, 6-months, and 1-year after the index procedure.

90-Day Bundled Payment Simulation, Health Care Utilization, and Complications following Craniopharyngioma Resection in Adult Patients.

Context Bundled payment and health care utilization models inform cost optimization and surgical outcomes. Economic analysis of payment plans for craniopharyngioma resection is unknown. Objective This study aimed to identify impact of endocrine and nonendocrine complications (EC and NEC, respectively) on health care utilization and bundled payments following craniopharyngioma resection. Design This study is presented as a retrospective cohort analysis (2000-2016) with 2 years of follow-up. Setting The study included national inpatient hospitalization and outpatient visits. Patients Patients undergoing craniopharyngioma resection were divided into the following four groups: group 1, no complications (NC); group 2, only EC; group 3, NEC; and group 4, both endocrine and nonendocrine complications (ENEC). Interventions This study investigated transphenoidal or subfrontal approach for tumor resection. Main Outcome Hospital readmission, health care utilization up to 24 months following discharge, and 90-day bundled payment performances are primary outcomes of this study. Results Median index hospitalization payments were significantly lower for patients in NC cohort ($28,672) compared with those in EC ($32,847), NEC ($36,259), and ENEC ($32,596; p < 0.0001). Patients in ENEC incurred higher outpatient services and overall median payments at 6 months (NC: 38,268; EC: 49,844; NEC: 68,237; and ENEC: 81,053), 1 year (NC: 46,878; EC: 58,210; NEC: 81,043; and ENEC: 94,768), and 2 years (NC: 58,391; EC: 70,418; NEC: 98,838; and ENEC: 1,11,841; p < 0.0001). The 90-day median bundled payment was significantly different among the cohorts with the highest in ENEC ($60,728) and lowest in the NC ($33,089; p < 0.0001). Conclusion ENEC following surgery incurred almost two times the overall median payments at 90 days, 6 months, 1 year. and 2 years compared with those without complications. Bundled payment model may not be a feasible option in this patient population. Type of complications and readmission rates should be considered to optimize payment model prediction following craniopharyngioma resection.

Trends and outcomes of early and late palliative care consultation for adult patients with glioblastoma: A SEER-Medicare retrospective study.

Background: Glioblastoma (GBM) carries a poor prognosis despite standard of care. Early palliative care (PC) has been shown to enhance survival and quality of life while reducing healthcare costs for other cancers. This study investigates differences in PC timing on outcomes for patients with GBM. Methods: This study used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1997 to 2016. Based on ICD codes, three groups were defined: (1) early PC within 10 weeks of diagnosis, (2) late PC, and (3) no PC. Outcomes were compared between the three groups. Results: Out of 10 812 patients with GBM, 1648 (15.24%) patients had PC consultation with an overall positive trend over time. There were no significant differences in patient characteristics. The late PC group had significantly higher number of hospice claims (1.06 ± 0.69) compared to those without PC, in the last month of life. There were significant differences in survival among the three groups (P < .0001), with late PC patients with the longest mean time to death from diagnosis (11.72 ± 13.20 months). Conclusion: We present the first investigation of PC consultation prevalence and outcomes, stratified by early versus late timing, for adult GBM patients. Despite an overall increase in PC consultations, only a minority of GBM patients receive PC. Patients with late PC had the longest survival times and had greater hospice use in the last month of life compared to other subgroups. Prospective studies can provide additional valuable information about this unique population of patients with GBM.

The Phenotypes of Anxiety and Depression: Analysis of Combined Comorbidity and Treatment in Patients Undergoing Spinal Fusion.

BACKGROUND: Anxiety and depression are associated with suboptimal outcomes, higher complications, and cost of care after elective spine surgery. The effect of combined anxiety-depression and preoperative antidepressant treatment in spinal fusion patients is not known. OBJECTIVE: To study the burden of combined anxiety-depression and its impact on healthcare utilization and costs in patients undergoing spinal fusion and to study the prevalence and impact of antidepressant treatment preoperatively. METHODS: This is a retrospective cohort study from the IBM MarketScan Research Database (2000-2018). Patients were studied in 7 different "phenotypes" of anxiety and depression based on combination of diagnoses and treatment. Outcome measures included healthcare utilization and costs from 1 year preoperatively to 2 years postoperatively. Bivariate and multivariable analyses have been reported. RESULTS: We studied 75 087 patients with a median age of 57 years. Patients with combined anxiety-depression were associated with higher preoperative and postoperative healthcare utilization and costs, as compared with anxiety or depression alone. The presence of depression in patients with and without anxiety disorder was a risk factor for postoperative opioid use and 2-year reoperation rates, as compared with anxiety alone. Patients with anxiety and/or depression on antidepressants are associated with significantly higher healthcare costs and opioid use. The adjusted 2-year reoperation rate was not significantly different between treated and untreated cohorts. CONCLUSION: Spine surgeons should use appropriate measures/questionnaires to screen depressed patients for anxiety and vice versa because the presence of both adds significant risk of higher healthcare utilization and costs over patients with 1 diagnosis, especially anxiety alone.

Simulated Bundled Payments for 4 Common Surgical Approaches to Treat Degenerative Cervical Myelopathy: A Consideration to Break the Clinical Equipoise.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare 90-day and 2-year reimbursements for ≥2-level anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior laminectomy and fusion (LF) and laminoplasty (LP) done for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: In DCM pathologies where there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes over posterior approaches. In the era of value and bundled payments initiatives, cost profile of various approaches will form an important consideration for decision making. MATERIALS AND METHODS: IBM MarketScan Research Database (2005-2018) was used to study beneficiaries (30-75 y) who underwent surgery (mACDF, ACCF, LF, LP) for DCM. Index hospital stay (operating room, surgeon, hospital services) and postdischarge inpatient, outpatient and prescription medication payments have been used to simulate 90-day and 2-year bundled payment amounts, along with their distribution for each procedure. RESULTS: A total of 10,834 patients with median age of 54 years were included. The median 90-day payment was $46,094 (interquartile range: $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital was 62.4% (operating room: 46.6) and surgeon payments were 17.5% of the average 90-day bundle. There was significant difference in the index, 90-day and 2-year reimbursements and their distribution among procedures. CONCLUSION: In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate, and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value as it is on an average 70% less expensive than LF over 90 days.

Health Care Utilization in Patients Undergoing Repeat Stereotactic Radiosurgery for Vestibular Schwannoma with 5-Year Follow-up: A National Database Analysis.

Background Stereotactic radiosurgery (SRS) has been used as an alternative to microsurgery in patients with small vestibular schwannoma (VS). We compare health care utilization metrics in patients undergoing repeat-SRS (re-SRS) and no repeat SRS (nr-SRS) at long-term follow-up. Materials and Methods We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had diagnosis of VS and treatment with SRS with at least 5 years of continuous enrollment after the procedure. Outcomes were hospital admissions, outpatient services, and medication refills. Results Of 1,047 patients, 5.1% ( n = 53) had repeat SRS. Majority of re-SRS (74%, n = 39) were done within 2 years of index procedure and 51% were within 1-year of initial procedure. Patients who required re-SRS incurred higher hospital readmission rate, outpatient services, and had higher payments compared with those who did not require re-SRS at 6 months, 1 year, and 2 years following the initial procedures. Re-SRS received 3.0- and 3.1-times higher payments at 1 and 2 years compared with nr-SRS cohort. At 5 years following SRS, median combined payments for re-SRS cohort was $105286 (interquartile range [IQR] $70999, $156569) compared with $44172 (IQR $22956, $84840) for nr-SRS cohort. Conclusion More than half of the re-SRS procedures were noted within first year of initial SRS for VS. Overall payments at 5 years for repeat SRS was more than double that for nr-SRS. Repeat SRS was also associated with more re-admissions and outpatient services at annual follow-up time points.

Simulated bundled payments for four common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise.

OBJECTIVE: In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM. METHODS: The IBM MarketScan research database (2005-2018) was used to study beneficiaries 30-75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1-Q3) and were adjusted to 2018 US dollars. RESULTS: A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences in the index, 90-day, and 2-year reimbursements and their distribution among procedures. CONCLUSIONS: In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value because it is 70% less expensive on average than LF over 90 days.

Incidence of repeat procedures and healthcare utilization following surgery, radiosurgery, and percutaneous procedures in elderly patients with trigeminal neuralgia.

OBJECTIVE: Management of trigeminal neuralgia (TN) in elderly patients poses significant challenges. The impact of different treatment modalities (surgery, radiosurgery [RS], and percutaneous techniques [PTs]) on healthcare utilization is not well defined in the management of TN in elderly patients. The aim of this study was to compare the long-term healthcare utilization metrics of different interventions in the management of elderly patients with TN. METHODS: The MarketScan database was queried using the International Classification of Diseases, Ninth Revision and Current Procedural Terminology, from 2000 to 2016. TN patients ≥ 65 years of age managed using surgery, RS, and PTs with at least 5 years of follow-up after the index procedure were included. Outcomes analyzed were hospital admissions, outpatient services, and medication refills. RESULTS: Of 993 patients, 43% (n = 430) underwent RS, 44% (n = 432) had PTs, and only 13% (n = 131) underwent surgery for TN. Overall, the median age of patients was 74 years old, 64% were females, 90% had Medicare insurance, and 17% had an Elixhauser index ≥ 3. Patients in the surgery group were younger (median age 71 years) with a higher comorbidity index (≥ 3; 24%) compared with patients undergoing RS and PTs (13% and 17%, respectively). At 1, 2, and 5 years after the index procedure, 41%, 48%, and 57% of patients in the PT cohort underwent any repeat procedure compared with 11%, 18%, and 29% for the RS cohort, and 6%, 9%, and 11% for the surgical cohort, respectively. Also, patients in the PT cohort incurred 1.8, 1.9, and 2.0 times the combined payment at 1, 2, and 5 years, respectively, compared with the surgery cohort. Similarly, patients who underwent RS for TN incurred 1.4, 1.5, and 1.5 times the combined payment at 1, 2, and 5 years, respectively, compared with the surgery cohort. At 5 years after the index procedure, combined payments for the PT cohort were $79,753 (IQR $46,013, $144,064) compared with $61,016 (IQR $27,114, $117,097) for the RS cohort and $41,074 (IQR $25,392, $87,952) for the surgery cohort (p < 0.0001). CONCLUSIONS: PTs followed by RS were the common procedures used in the majority of elderly patients with TN. However, surgery for TN resulted in durable control with the least need for reoperations up to 5 years after the index procedure, followed by RS and PTs. PTs for TN resulted in the highest utilization of healthcare resources and need for reoperations at all time points. These findings should be considered in clinical decision-making when selecting appropriate treatment modalities in elderly patients with TN.

Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population. METHODS: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments. RESULTS: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), P = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, P = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, P = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, P = .5946. CONCLUSIONS: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.

Impact of age on mortality and complications in patients with Ankylosing Spondylitis spine fractures.

OBJECTIVE: The aim of this retrospective cohort study was to study the impact of age on in-hospital complications and mortality following surgery for Ankylosing Spondylitis (AS) associated spine fractures. METHODS: We extracted data from the Nationwide Inpatient Sample (NIS) database (1998-2018) using ICD-9/10 codes. Patients with a primary diagnosis of AS associated spine fractures who underwent fusion surgery were included. Complications and in-hospital mortality were analyzed. RESULTS: A total cohort of 8526 patients was identified. Overall, the median age of the cohort was 69 years. AS associated fractures were equally distributed among cervical and thoracolumbar regions. Overall, complications were noted in 48% of patients and pulmonary complications were the most common (32%) followed by renal (13%) and infection (12%). Complications were seen in 57.3% of patients ≥ 70 years of age compared to 38.4% of patients < 70 years of age (p < .0001). Also, 9.9 % of patients ≥ 70 years of age had in-hospital mortality compared to 3.1 % of patients < 70 years of age (p < .0001). Based on surgical approaches, elderly patients (≥70 years) who underwent anterior, posterior, and anterior + posterior approaches had 19.8%, 7.4% and 16.4% in-hospital mortality compared to 5.3%, 2.2% and 7.4% respectively for patients < 70 years. CONCLUSIONS: Elderly patients (≥70 years of age) were 3.2 times more likely to have in-hospital mortality and higher complications compared to younger patients (57% vs. 38%). Cervical compared to thoracolumbar fractures and anterior compared to posterior surgical approaches were associated with higher complications and in-hospital mortality.

Impact of preoperative treatment of osteoporosis on re-operations, complications and health care utilization in patients undergoing thoraco-lumbar spine fusions. A 5-year national database analysis.

OBJECTIVE: Identify the impact of preoperative treatment of Osteoporosis (OP) on reoperation rates, complications and healthcare utilization following thoraco-lumbar (TL) spine fusions. MATERIALS AND METHODS: We used ICD9/10 and CPT codes to extract data from MarketScan (2000-2018). Patients were divided into two groups based on preoperative treatment of OP within one year prior to the index spinal fusion: medication (m-OP) cohort and non-medication (nm-OP) cohort. Outcomes (re-operation rates, re-admission, complications, healthcare utilization) were analyzed at 1-, 12-, 24- and 60-months. RESULTS: Of 3606 patients, 65% (n = 2330) of patients did not receive OP medications (nm-OP). At index hospitalization, there were no difference in LOS (median nm-OP: 3 days vs. m-OP:4 days), discharge to home (nm-OP 80% vs. m-OP 75%) and complications (nm-OP 13% vs. m-OP 12%). Reoperation rates were not different among the cohorts at 1- (nm-OP 5.7% vs. m-OP 4.2%), 2- (nm-OP 9.4% vs. m-OP 7.8) and 5 years (nm-OP 16.9% vs. m-OP 14.8%). Patients in m-OP cohort incurred higher overall median payments at 1 year ($17,866 vs. $ 16,010), 2 years ($38,634 vs. $34,454) and 5 years ($94,797 vs. $91,072) compared to nm-OP cohort. CONCLUSION: Preoperative treatment of OP had no impact on complications, LOS, discharge disposition following TL fusions at index hospitalization. Similarly, no impact of preoperative treatment was noted in terms of reoperation rates at 12-, 24- and 60 months following the index spine fusion. Patients who received preoperative treatment for OP incurred higher health care utilization at 12-, 24- and 60 months following surgery.