Adaptive Health Technology Assessment: A Scoping Review of Methods.

OBJECTIVES: Health technology assessment (HTA) is an established mechanism for explicit priority setting to support universal health coverage. However, full HTA requires significant time, data, and capacity for each intervention, which limits the number of decisions it can inform. Another approach systematically adapts full HTA methods by leveraging HTA evidence from other settings. We call this "adaptive" HTA (aHTA), although in settings where time is the main constraint, it is also called "rapid HTA." METHODS: The objectives of this scoping review were to identify and map existing aHTA methods, and to assess their triggers, strengths, and weaknesses. This was done by searching HTA agencies' and networks' websites, and the published literature. Findings have been narratively synthesized. RESULTS: This review identified 20 countries and 1 HTA network with aHTA methods in the Americas, Europe, Africa, and South-East Asia. These methods have been characterized into 5 types: rapid reviews, rapid cost-effectiveness analyses, rapid manufacturer submissions, transfers, and de facto HTA. Three characteristics "trigger" the use of aHTA instead of full HTA: urgency, certainty, and low budget impact. Sometimes, an iterative approach to selecting methods guides whether to do aHTA or full HTA. aHTA was found to be faster and more efficient, useful for decision makers, and to reduce duplication. Nevertheless, there is limited standardization, transparency, and measurement of uncertainty. CONCLUSIONS: aHTA is used in many settings. It has potential to improve the efficiency of any priority-setting system, but needs to be better formalized to improve uptake, particularly for nascent HTA systems.

Three Approaches to Improve a Practical Guide on Evidence-Informed Deliberative Processes for Health Benefit Package Design Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide".

As countries around the world seek to deliver universal health coverage, they must prioritize which services to pay for with public funds, to whom, and at what cost. Countries are increasingly using health technology assessment (HTA) to identify which interventions provide the best value for money and merit inclusion in their health benefit packages (HBPs)-the explicit lists of health services provided using public funds. Oortwijn et al understand the importance of providing practical guidance on the foundation of HBP design, and their article, "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide," provides recommendations for HTA bodies to improve the legitimacy of their decision-making by incorporating four elements in their HBP procedures: stakeholder involvement, evidence-informed evaluation, transparency, and appeal. This article proposes three approaches to enhance the value of the guide: moving from structure to compliance and performance, prioritizing key issues of legitimacy within HBP processes, and acknowledging potential the costs and risks associated with the use of this framework.

The Evolution of Health Benefits Packages in Colombia: Thirty Years of Successes and Failures.

Health benefits packages in Colombia-what is covered, by whom, and at what cost-have evolved over the past thirty years. Coverage changed from two explicit health benefits packages (with benefits linked to ability to contribute) to an implicit approach that covers, in theory, everything for everyone, excluding a narrow negative list of services and health technologies. This article explores the evolution of priority setting in Colombia during two periods of major reform. Each period had its own advantages and disadvantages associated with different institutional arrangements, processes, and methodologies. Colombia's evolution provides several lessons for other low- and middle-income countries interested in institutionalizing evidence-based priority-setting.

International Partnerships to Develop Evidence-informed Priority Setting Institutions: Ten Years of Experience from the International Decision Support Initiative (iDSI).

All health systems must set priorities. Evidence-informed priority-setting (EIPS) is a specific form of systematic priority-setting which involves explicit consideration of evidence to determine the healthcare interventions to be provided. The international Decision Support Initiative (iDSI) was established in 2013 as a collaborative platform to catalyze faster progress on EIPS, particularly in low- and middle-income countries. This article summarizes the successes, challenges, and lessons learned from ten years of iDSI partnering with countries to develop EIPS institutions and processes. This is a thematic documentary analysis, structured by iDSI's theory of change, extracting successes, challenges, and lessons from three external evaluations and 19 internal reports to funders. We identified three phases of iDSI's work-inception (2013-15), scale-up (2016-2019), and focus on Africa (2019-2023). iDSI has established a global platform for coordinating EIPS, advanced the field, and supported regional networks in Asia and Africa. It has facilitated progress in securing high-level commitment to EIPS, strengthened EIPS institutions, and developed capacity for health technology assessments. This has resulted in improved decisions on service provision, procurement, and clinical care. Major lessons learned include the importance of sustained political will to develop EIPS; a clear EIPS mandate; inclusive governance structures appropriate to health financing context; politically sensitive and country-led support to EIPS, taking advantage of policy windows for EIPS reforms; regional networks for peer support and long-term sustainability; utilization of context appropriate methods such as adaptive HTA; and crucially, donor-funded global health initiatives supporting and integrating with national EIPS systems, not undermining them.

Organizational Formation for Priority Setting: Historical Perspectives and Thematic Analysis of India's Health Technology Assessment Agency.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis.

BACKGROUND: The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis. HYPOTHESIS: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis. PATIENTS AND METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). RESULTS: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization. DISCUSSIONS: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status. LEVEL OF EVIDENCE: III.

Real-Time Vehicle Roll Angle Estimation Based on Neural Networks in IoT Low-Cost Devices.

The high rate of vehicle-crash victims has a fatal economic and social impact in today’s societies. In particular, road crashes where heavy vehicles are involved cause more severe damage because they are prone to rollover. For this reason, many researches are focused on developing RSC Roll Stability Control (RSC) systems. Concerning the design of RSC systems with an adequate performance, it is mandatory to know the dynamics of the vehicle. The main problem arises from the lack of ability to directly capture several required dynamic vehicle variables, such as roll angle, from low-cost sensors. Previous studies demonstrate that low-cost sensors can provide data in real-time with the required precision and reliability. Even more, other research works indicate that neural networks are efficient mechanisms to estimate roll angle. Nevertheless, it is necessary to assess that the fusion of data coming from low-cost devices and estimations provided by neural networks can fulfill hard real-time processing constraints, achieving high level of accuracy during circulation of a vehicle in real situations. In order to address this issue, this study has two main goals: (1) Design and develop an IoT based architecture, integrating ANN in low cost kits with different hardware architectures in order to estimate under real-time constraints the vehicle roll angle. This architecture is able to work under high dynamic conditions, by following specific best practices and considerations during its design; (2) assess that the IoT architecture deployed in low-cost experimental kits achieve the hard real-time performance constraints estimating the roll angle with the required calculation accuracy. To fulfil these objectives, an experimental environment was set up, composed of a van with two set of low-cost kits, one including a Raspberry Pi 3 Model Band the other having an Intel Edison System on Chip linked to a SparkFun 9 Degrees of Freedom module. This experimental environment be tested in different maneuvers for comparison purposes. Neural networks embedded in low-cost sensor kits provide roll angle estimations highly approximated to real values. Even more, Intel Edison and Raspberry Pi 3 Model B have enough computing capabilities to successfully run roll angle estimation based on neural networks to determine rollover risk situations, fulfilling real-time operation restrictions stated for this problem.

Design of Low-Cost Vehicle Roll Angle Estimator Based on Kalman Filters and an Iot Architecture.

In recent years, there have been many advances in vehicle technologies based on the efficient use of real-time data provided by embedded sensors. Some of these technologies can help you avoid or reduce the severity of a crash such as the Roll Stability Control (RSC) systems for commercial vehicles. In RSC, several critical variables to consider such as sideslip or roll angle can only be directly measured using expensive equipment. These kind of devices would increase the price of commercial vehicles. Nevertheless, sideslip or roll angle or values can be estimated using MEMS sensors in combination with data fusion algorithms. The objectives stated for this research work consist of integrating roll angle estimators based on Linear and Unscented Kalman filters to evaluate the precision of the results obtained and determining the fulfillment of the hard real-time processing constraints to embed this kind of estimators in IoT architectures based on low-cost equipment able to be deployed in commercial vehicles. An experimental testbed composed of a van with two sets of low-cost kits was set up, the first one including a Raspberry Pi 3 Model B, and the other having an Intel Edison System on Chip. This experimental environment was tested under different conditions for comparison. The results obtained from low-cost experimental kits, based on IoT architectures and including estimators based on Kalman filters, provide accurate roll angle estimation. Also, these results show that the processing time to get the data and execute the estimations based on Kalman Filters fulfill hard real time constraints.

VEHIOT: Design and Evaluation of an IoT Architecture Based on Low-Cost Devices to Be Embedded in Production Vehicles.

Nowadays, the current vehicles are incorporating control systems in order to improve their stability and handling. These control systems need to know the vehicle dynamics through the variables (lateral acceleration, roll rate, roll angle, sideslip angle, etc.) that are obtained or estimated from sensors. For this goal, it is necessary to mount on vehicles not only low-cost sensors, but also low-cost embedded systems, which allow acquiring data from sensors and executing the developed algorithms to estimate and to control with novel higher speed computing. All these devices have to be integrated in an adequate architecture with enough performance in terms of accuracy, reliability and processing time. In this article, an architecture to carry out the estimation and control of vehicle dynamics has been developed. This architecture was designed considering the basic principles of IoT and integrates low-cost sensors and embedded hardware for orchestrating the experiments. A comparison of two different low-cost systems in terms of accuracy, acquisition time and reliability has been done. Both devices have been compared with the VBOX device from Racelogic, which has been used as the ground truth. The comparison has been made from tests carried out in a real vehicle. The lateral acceleration and roll rate have been analyzed in order to quantify the error of these devices.

[Model for a risk-focused approach to health inspection, surveillance, and control in Colombia]. / Modelo para la inspección, vigilancia y control sanitario con enfoque de riesgos en Colombia.

Colombian Ministry of Health Resolution 1229 of 2013 established that health inspection, surveillance, and control (IVC, Spanish acronym) should be based on a risk-focused approach. In 2014 Colombia´s National Food and Drugs Surveillance Institute (INVIMA) designed and implemented a risk-based health surveillance model called IVC-SOA. This model measures the risks of drugs, medical devices, food, and cosmetics by taking into account three factors: severity of the product (S), occurrence of product failure (O), and the potentially affected population (A) - hence its name, SOA. The model incorporates 40 variables and statistical methods that make it possible to create a risk profile for each entity surveyed, and thus to generate a ranking to determine which should be inspected. The objective of this report is to describe the methodology and results obtained following the design and implementation of the IVC-SOA model created by the regulatory agency in Colombia, and its impact on health surveillance effectiveness.

Modelo para la inspección, vigilancia y control sanitario con enfoque de riesgos en Colombia / Model for a risk-focused approach to health inspection, surveillance, and control in Colombia / Modelo para inspeção, vigilância e controle sanitários com enfoque de riscos na Colômbia

En Colombia, a partir de la Resolución 1229 de 2013 del Ministerio de Salud, se estableció que la inspección, vigilancia y control (IVC) sanitario debían realizarse con enfoque de riesgos. Así, en 2014, el Instituto Nacional de Vigilancia de Medicamentos y Alimentos (INVIMA) diseñó e implementó un modelo de vigilancia sanitaria basado en riesgos llamado IVC-SOA. Este modelo mide el riesgo de los medicamentos, dispositivos médicos, alimentos y cosméticos considerando tres factores: la severidad del producto (S), la ocurrencia de falla del producto (O) y la población potencialmente afectada (A), de allí su nombre SOA. El modelo incorpora 40 variables y métodos estadísticos que permite crear un perfil de riesgos para cada una de las entidades que permite crear un perfil de riesgos para cada una de las entidades vigiladas y así generar un ranking para determinar cuáles de estas deben ser inspeccionadas. El objetivo de este informe es presentar la metodología y los resultados obtenidos luego del diseño e implementación del modelo IVC-SOA creado por la agencia reguladora en Colombia y su efecto en la efectividad de la vigilancia sanitaria.

Colombian Ministry of Health Resolution 1229 of 2013 established that health inspection, surveillance, and control (IVC, Spanish acronym) should be based on a risk-focused approach. In 2014 Colombia´s National Food and Drugs Surveillance Institute (INVIMA) designed and implemented a risk-based health surveillance model called IVC-SOA. This model measures the risks of drugs, medical devices, food, and cosmetics by taking into account three factors: severity of the product (S), occurrence of product failure (O), and the potentially affected population (A) - hence its name, SOA. The model incorporates 40 variables and statistical methods that make it possible to create a risk profile for each entity surveyed, and thus to generate a ranking to determine which should be inspected. The objective of this report is to describe the methodology and results obtained following the design and implementation of the IVC-SOA model created by the regulatory agency in Colombia, and its impact on health surveillance effectiveness.

A Resolução 1229 de 2013 do Ministério da Saúde da Colômbia estabeleceu que a inspeção, vigilância e controle (IVC) sanitários devem ser realizados com um enfoque de riscos. Assim, em 2014, o Instituto Nacional de Vigilância de Medicamentos e Alimentos (INVIMA) projetou e implementou um modelo de vigilância sanitária baseado em riscos, denominado IVC-SOA. Este modelo avalia o risco dos medicamentos, dispositivos médicos, alimentos e cosméticos com base em três fatores: severidade (S), ocorrência de falha do produto (P) e população potencialmente afetada (A), daí a sigla SOA. O modelo inclui 40 variáveis e métodos estatísticos que permitem traçar um perfil de riscos para cada uma das entidades em vigilância e gerar um ranking para determinar quais devem ser inspecionadas. O objetivo deste relatório é apresentar a metodologia e os resultados obtidos após o projeto e implementação do modelo IVC-SOA desenvolvido pelo órgão regulador da Colômbia e o impacto resultante na efetividade da vigilância sanitária.

Impact of Glycemic Control on Morbidity and Mortality in Adult Idiopathic Scoliosis Patients Undergoing Spinal Fusion.

STUDY DESIGN: This is a retrospective analysis of administrative database. OBJECTIVE: To elucidate the effect of glycemic control on surgical outcomes of middle-aged and elderly idiopathic scoliosis patients undergoing spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Diabetes mellitus (DM) is a condition thought to adversely affect outcomes of spine surgery. However, no study has stratified glycemic control levels and their impact on outcome for idiopathic scoliosis patients receiving a spinal fusion surgery. Previous studies may have reported higher than true rates of complications for controlled diabetic patients, who are the majority of diabetic patients. MATERIALS AND METHODS: The Nationwide Inpatient Sample was queried from years 2002 to 2011. We extracted idiopathic scoliosis patients older than 45 years of age that received spinal fusion and analyzed complications and outcomes variables among 3 cohorts: nondiabetic patients, controlled diabetics, and uncontrolled diabetics. Multivariate analyses were used to assess whether glycemic control was a risk factor for adverse postoperative outcomes. RESULTS: Controlled diabetics had significantly increased rates of acute renal failure (ARF), while uncontrolled diabetics had significantly increased rates of acute postoperative hemorrhage. In multivariate analyses controlling for patient factors and comorbidities, controlled DM was found to be an independent predictor of ARF [odds ratio (OR), 1.863; 95% confidence interval (CI), 1.346-2.579; P=0.0002), and uncontrolled DM was found to be a significant risk factor for acute postoperative hemorrhage (OR, 2.182; 95% CI, 1.192-3.997; P=0.0115), ARF (OR, 4.839; 95% CI, 1.748-13.392; P=0.0024), deep vein thrombosis (OR, 5.825; 95% CI, 1.329-25.522, P=0.0194) and in-patient mortality (OR, 8.889; 95% CI, 1.001-78.945; P=0.0499). CONCLUSIONS: Controlled DM was found to be a risk factor for ARF in adult idiopathic scoliosis patients undergoing spinal fusion surgery, while uncontrolled DM was shown to be a risk factor for postoperative hemorrhage, ARF, deep vein thrombosis, and mortality. The present study provides valuable data for better informed consent for patients with diabetes considering surgery for idiopathic scoliosis. LEVEL OF EVIDENCE: Level III.

Effect of Surgeon Volume on Complications, Length of Stay, and Costs Following Anterior Cervical Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To identify the association between surgeon volume and inpatient complications, length of stay, and costs associated with ACF. SUMMARY OF BACKGROUND DATA: Increased surgeon volume may be associated with improved outcomes after surgical procedures. However, there is a lack of information on the effect of surgeon volume on short-term outcomes after anterior cervical fusion (ACF). METHODS: A retrospective cohort study of ACF patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Surgeon volume was divided into three categories, volume <25th percentile, 25th to 74th percentile, and ≥75th percentile of surgeon volume. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital costs between surgeon volume categories. RESULTS: A total of 419,212 ACF patients were identified. The 25th percentile for volume was 5 cases per year, and the 75th percentile for volume was 67 cases per year. Volume <25th percentile was associated with increased rates of any adverse event (odd ratio, OR 3.8, P < 0.001), and multiple individual complications including death (OR 2.5, P=0.014), myocardial infarction (OR4.4, P < 0.001), sepsis (OR 4.1, P < 0.001), and surgical site infection (OR 4.0, P < 0.001). Notably, volume ≥75th percentile was associated with decreased rates of any adverse event (OR 0.7, P < 0.001) and death (OR 0.6, P = 0.028). On multivariate analysis, length of stay was significantly increased by 2.3 days (P < 0.001) for surgeons <25th percentile of volume and was decreased by 0.3 days for surgeons with volume ≥75th percentile. Hospital costs were $4569 more for surgeons with <25th percentile of volume and $1213 less for surgeons with ≥75th percentile volume. CONCLUSION: In this nationally representative sample, surgeons with volume <25th percentile had significantly increased complications, length of stay, and costs. Conversely, surgeons with ≥75th percentile volume experienced decreased complications, length of stay, and costs. LEVEL OF EVIDENCE: 4.

[Proposed model for managing drugs used for unregistered indications in Colombia]. / Propuesta de un modelo de gestión de medicamentos en indicaciones no registradas en Colombia.

The use of drugs for unregistered indications, known as "off-label" use, is a practice that creates problems of rational use and access when other options are not available. Health systems should address this situation, particularly in connection with decisions concerning coverage, while trying to minimize health risks and clearly define the roles and responsibilities of the parties involved. Colombia's Ministry of Health and Social Protection (MinSalud), together with the National University of Colombia and national experts, developed a proposal for a model for managing drugs being used for unregistered indications (off-label) and their potential reimbursement with public resources, taking into account international practices and country characteristics. The management model is non-punitive and is geared toward promoting the rational use of these drugs so that barriers to access are reduced whenever their use is supported by solid scientific evidence. The model addresses patient safeguards in the bioethical domain and the roles and responsibilities of the prescriber and government entities.

Propuesta de un modelo de gestión de medicamentos en indicaciones no registradas en Colombia / Proposed model for managing drugs used for unregistered indications in Colombia

El uso de medicamentos en indicaciones no registradas (INR), conocido como uso “off-label”, es una práctica que genera problemas de uso racional y de acceso cuando no existen alternativas disponibles. Los sistemas de salud deben gestionar esta realidad, sobre todo cuando se trata de decisiones de cobertura, buscando minimizar los riesgos para la salud y estableciendo de forma clara los papeles y las responsabilidades de los agentes involucrados. El Ministerio de Salud y Protección Social de Colombia (MinSalud), junto con con la Universidad Nacional de Colombia y expertos nacionales, diseñaron una propuesta de modelo de gestión del uso de medicamentos en indicaciones no registradas (off-label) y su potencial reembolso con recursos públicos, teniendo en cuenta prácticas internacionales y la realidad nacional. El modelo de gestión es no punitivo y está orientado a la promoción del uso racional de estos medicamentos, de forma que se reduzcan las barreras al acceso cuando su uso está respaldado por pruebas cientificas de calidad. El modelo incorpora elementos de garantías bioéticas del paciente, los papeles y las responsabilidades del prescriptor y de las entidades de gobierno.

The use of drugs for unregistered indications, known as “off-label” use, is a practice that creates problems of rational use and access when other options are not available. Health systems should address this situation, particularly in connection with decisions concerning coverage, while trying to minimize health risks and clearly define the roles and responsibilities of the parties involved. Colombia's Ministry of Health and Social Protection (MinSalud), together with the National University of Colombia and national experts, developed a proposal for a model for managing drugs being used for unregistered indications (off-label) and their potential reimbursement with public resources, taking into account international practices and country characteristics. The management model is non-punitive and is geared toward promoting the rational use of these drugs so that barriers to access are reduced whenever their use is supported by solid scientific evidence. The model addresses patient safeguards in the bioethical domain and the roles and responsibilities of the prescriber and government entities.

The Internet as a communication tool for orthopedic spine fellowships in the United States.

BACKGROUND CONTEXT: Orthopedic residents seeking additional training in spine surgery commonly use the Internet to manage their fellowship applications. Although studies have assessed the accessibility and content of Web sites in other medical specialties, none have looked at orthopedic spine fellowship Web sites (SFWs). PURPOSE: The purpose of this study was to evaluate the accessibility of information from commonly used databases and assess the content of SFWs. STUDY DESIGN: This was a Web site accessibility and content evaluation study. METHODS: A comprehensive list of available orthopedic spine fellowship programs was compiled by accessing program lists from the SF Match, North American Spine Society, Fellowship and Residency Electronic Interactive Database (FREIDA), and Orthopaedicsone.com (Ortho1). These databases were assessed for accessibility of information including viable links to SFWs and responsive program contacts. A Google search was used to identify SFWs not readily available on these national databases. SFWs were evaluated based on online education and recruitment content. RESULTS: Evaluators found 45 SFWs of 63 active programs (71%). Available SFWs were often not readily accessible from national program lists, and no program afforded a direct link to their SFW from SF Match. Approximately half of all programs responded via e-mail. Although many programs described surgical experience (91%) and research requirements (87%) during the fellowship, less than half mentioned didactic instruction (46%), journal clubs (41%), and national meetings or courses attended (28%). Evaluators found an average 45% of fellow recruitment content. Comparison of SFWs by program characteristics revealed three significant differences. Programs with greater than one fellowship position had greater online education content than programs with a single fellow (p=.022). Spine fellowships affiliated with an orthopedic residency program maintained greater education (p=.006) and recruitment (p=.046) content on their SFWs. CONCLUSIONS: Most orthopedic spine surgery programs underuse the Internet for fellow education and recruitment. The inaccessibility of information and paucity of content on SFWs allow for future opportunity to optimize these resources.

The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery.

STUDY DESIGN: Retrospective administrative database analysis. OBJECTIVE: To determine the impact of glycemic control on perioperative complications and outcomes in patients undergoing degenerative cervical spine surgery. SUMMARY OF BACKGROUND DATA: Diabetes mellitus (DM) is a highly prevalent systemic disease that has been shown to increase morbidity and mortality after spine surgery. Few studies have demonstrated negative effects on patients with DM who undergo cervical spine procedures; however, whether glycemic control influences surgical outcome is still unknown. METHODS: The Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent cervical spine surgery for degenerative conditions were identified using the International Classification of Diseases Ninth Revision, Clinical Modification, codes. Three surgical cohorts were chosen: controlled diabetic, uncontrolled diabetic, and patients without diabetes. Patient demographics, surgical procedures, perioperative complications and postoperative outcomes were assessed. RESULTS: The prevalence of controlled and uncontrolled diabetic patients undergoing degenerative cervical spine surgery had been increasing significantly from 2002 to 2011. Compared with patients without diabetes, uncontrolled diabetic patients had significantly increased odds of respiratory, cardiac, and genitourinary complications. Uncontrolled diabetic patients also had significantly increased risk of pulmonary embolism and postoperative infection. Uncontrolled diabetic patients had increased risk of inpatient mortality (odds ratio = 6.39, 95% confidence interval = 4.09-10.00, P < 0.0001) and increased mean length of stay (almost 5 d) compared with nondiabetic patients. Similarly, controlled diabetic patients increased the odds of perioperative complications; however not nearly to the same degree. Controlled diabetic patients extended the mean length of stay by almost a day (P < 0.0001) and significantly increased costs compared with nondiabetic patients. CONCLUSION: Poor glycemic control increases the odds of inpatient mortality and perioperative complications in patients undergoing degenerative cervical spine surgery. Controlling DM before degenerative cervical spine surgery may lead to better outcomes and decreased costs. LEVEL OF EVIDENCE: Therapeutic Level 3.

Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To assess the effect glycemic control has on perioperative morbidity and mortality in patients undergoing elective degenerative lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Diabetes mellitus (DM) is a prevalent disease of glucose dysregulation that has been demonstrated to increase morbidity and mortality after spine surgery. However, there is limited understanding of whether glycemic control influences surgical outcomes in patients with DM undergoing lumbar spine procedures for degenerative conditions. METHODS: The Nationwide Inpatient Sample was analyzed from 2002 to 2011. Hospitalizations were isolated on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery and diagnoses codes for degenerative conditions of the lumbar spine. Patients were then classified into 3 cohorts: controlled diabetic, uncontrolled diabetic, and nondiabetic. Patient demographic data, acute complications, and hospitalization outcomes were determined for each cohort. RESULTS: A total of 403,629 (15.7%) controlled diabetic patients and 19,421 (0.75%) uncontrolled diabetic patients underwent degenerative lumbar spine surgery from 2002 to 2011. Relative to nondiabetic patients, uncontrolled diabetic patients had significantly increased odds of cardiac complications, deep venous thrombosis, and postoperative shock; in addition, uncontrolled diabetic patients also had an increased mean length of stay (approximately, 2.5 d), greater costs (1.3-fold), and a greater risk of inpatient mortality (odds ratio=2.6, 95% confidence interval=1.5-4.8, P<0.0009). Controlled diabetic patients also had increased risk of acute complications and inpatient mortality when compared with nondiabetic patients, but not nearly to the same magnitude as uncontrolled diabetic patients. CONCLUSION: Suboptimal glycemic control in diabetic patients undergoing degenerative lumbar spine surgery leads to increased risk of acute complications and poor outcomes. Patients with uncontrolled DM, or poor glucose control, may benefit from improving glycemic control prior to surgery. LEVEL OF EVIDENCE: 3.