Inferior Clinical Outcomes for Patients with Medicaid Insurance After Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients.

BACKGROUND: It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery. METHODS: The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction. RESULTS: A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (ß = 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (ß =1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (ß = -0.07; 95% CI -0.01 to -0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05). CONCLUSIONS: Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.

Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics.

OBJECTIVE: We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%. METHODS: A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation. RESULTS: A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient. CONCLUSIONS: The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.

Trends in Utilization and Cost of Inpatient Spinal Cord Stimulation: Analysis of Data from 2008 to 2014.

OBJECTIVE: In this study, we sought to characterize contemporary trends in cost and utilization of spinal cord stimulation (SCS). METHODS: The Healthcare Cost and Utilization Project-National Inpatient Sample was queried for inpatient admissions from 2008 to 2014 where SCS was performed. We then determined the rates and costs of SCS performed in this time frame to treat diagnoses that we classified as device-related complications, degenerative spine disease, pain syndromes, and neuropathies/neuritis/nerve lesions. Least-squares regression was performed to determine the yearly trends for each indication adjusted by the total number of yearly hospitalizations for that diagnosis. RESULTS: We identified a total of 6876 admissions in whom an SCS was performed. The overall rate of inpatient SCS procedures performed has decreased by 45% from 2008 to 2014 (14.0 to 7.7 procedures per 100,000 admissions). Adjusted analysis for yearly trends also demonstrated a declining trend for all indications; however, this was not found to be statistically significant, except for device-related complications (P = 0.004). The median inflation-adjusted cost of an admission where SCS was performed increased slightly by 7.4% from $26,200 (IQR: $16,700-$33,800) in 2008 to $28,100 (IQR: $19,600-$36,900) in 2014. Billed hospital charges demonstrated a significant increase with median inflation-adjusted admission charge of $66,068 in 2008 to $110,672 in 2014. CONCLUSIONS: Despite a declining contemporary trend in inpatient SCS, an increase was noted in admission costs and hospital charges. A significant declining trend was noted in revision SCS implantations due to device-related complications.

Cost of Readmissions Following Anterior Cervical Discectomy and Fusion: Insights from the Nationwide Readmissions Database.

BACKGROUND: Postoperative readmissions are a significant driver of variation in bundled care costs associated with cervical spine surgery. OBJECTIVE: To determine the factors predicting the cost of readmission episodes following elective anterior cervical discectomy and fusion (ACDF). METHODS: We queried the Healthcare Cost and Utilization Project Nationwide Readmissions Database for patients undergoing elective ACDF during 2012 to 2015. Multivariable linear regression was performed to establish the factors associated with the cost of each 30-/90-d readmission episode. RESULTS: A total of 139 877 and 113 418 patients met inclusion criteria for the evaluation of 30- and 90-d readmissions, respectively. Among these, the national rates of 30- and 90-d readmission after an elective ACDF were 3% and 6%, respectively. The median cost of a 30- and 90-d readmission episode was $6727 (IQR: $3844-$13 529) and $8507 (IQR: $4567-$17 460), respectively. Relative predictor importance analysis revealed that the number of procedures at index admission (IA), length of stay at IA, and time elapsed between index surgical admission and readmission were the top predictors of both 30- and 90-d readmission costs (all P < .001). Although cervical myelopathy accounted for only 3.6% of all 30-d readmissions, it accounted for the largest share (8%) of 30-d readmission costs. CONCLUSION: In this analysis from a national all-payer database, we determined the factors associated with the cost of readmissions following elective ACDF. These results are important in assisting policymakers and payers with a better risk adjustment in bundled care payment systems and for surgeons in implementing readmission cost-reduction efforts.

Perceptions of overlapping surgery in neurosurgery based on practice volume: A multi-institutional survey.

OBJECTIVE: Overlapping surgery, accepted by many as two distinct operations occurring at the same time but without coincident critical portions, has been said to improve patient access to surgical care. With recent controversy, some are opposed to this practice due to concerns regarding its safety. In this manuscript, we sought to investigate the perceptions of overlapping surgery among neurosurgical leadership and the association of these perceptions with neurosurgical case volume. PATIENTS AND METHODS: We conducted a self-administered survey of neurosurgery department chair and residency program directors of institutions participating in the Vizient Clinical Database/Resource (CDB/RM), an administrative database of 117 United States (US) medical centers and their 300 affiliated hospitals. We queried participants regarding yearly departmental case-volume, frequency of overlapping surgery in daily practice and the degree of overlapping they find acceptable. RESULTS: Of the 236 surveys disseminated, a total of 70 responses were received with a response rate of 29.7.%, which is comparable to previously reported response rates among neurosurgeons and other physicians. Our respondents consisted of 43 of 165 chairs (26.1.%) and 27 of 66 program directors (40.0.%) representing 64 unique hospitals/institutions out of 216 (29.6.%). Based on the responses to question involving case volume, we divided our responders into high volume hospitals (HVH) (n = 44; > 2000 cases per year) and low volume hospitals (LVH) (N = 26). More HVH were found to have frequent occurrence of overlapping surgery (50% weekly and 20.9.% daily vs LVH's 26.9.% weekly and 3.8.% daily, p = 0.003) and considered two overlapping surgeries without overlap of critical portion as acceptable (38.6.% vs 26.9.%, p = 0.10). CONCLUSIONS: Our survey results showed that neurosurgical departments with high-volume practices were more likely to practice overlapping surgery on a regular basis and to view it as an acceptable practice. The association between overlapping surgery and the volume-outcome relationship should be further evaluated.

Is Length of Stay Influenced by the Weekday On Which Lumbar Surgery is Performed?

BACKGROUND: Reducing length of stay (LOS) in a safe manner has the potential to save significant costs for the care of patients undergoing elective lumbar spine surgery. Due to the relative absence on weekends of staff required for discharging patients to rehabilitation or nursing facilities, we hypothesize that patients undergoing lumbar surgery later in the week have a longer LOS than their counterparts. OBJECTIVE: To analyze the effect of day of the week for lumbar surgery on LOS. METHODS: Patients undergoing surgery for lumbar degenerative disease were prospectively enrolled in the multicenter quality and outcomes database registry. A multivariable proportional odds regression model was built with LOS as the outcome of interest and patient and surgical variables as covariates. RESULTS: A total of 11 897 patients were analyzed. Among those discharged home, the regression analysis demonstrated significantly higher odds of longer LOS for patients undergoing surgery on Friday as compared to Monday (P < .001). Among those discharged to a facility, there were significantly higher odds of longer LOS for patients undergoing surgery on Wednesday (P < .001), Thursday (P < .001), and Friday (P = .002) as compared to Monday. CONCLUSION: The findings of this study suggest that lumbar patients undergoing fusions and those discharged to a facility have longer LOS when surgery is later in the week. Scheduling these patients for surgery earlier in the week and ensuring adequate resources for patient disposition on weekends may lead to LOS reduction and cost savings for hospitals, payers, and patients alike.

Does patient selection account for the perceived cost savings in outpatient spine surgery? A meta-analysis of current evidence and analysis from an administrative database.

OBJECTIVEFrom 1994 to 2006 outpatient spinal surgery increased 5-fold. The perceived cost savings with outcomes comparable to or better than those achieved with inpatient admission for the same procedures are desirable in an era where health expenditures are scrutinized. The increase in outpatient spine surgery is also driven by the proliferation of ambulatory surgery centers. In this study, the authors hypothesized that the total savings in outpatient spine surgery is largely driven by patient selection and biases toward healthier patients.METHODSA meta-analysis assessed patient selection factors and outcomes associated with outpatient spine procedures. Pooled odds ratios and mean differences were calculated using a Bayesian random-effects model. The authors extended this analysis in a novel way by using the results of the meta-analysis to examine cost data from an administrative database of academically affiliated hospitals. A Bayesian approach with priors informed by the meta-analysis was used to compare costs for inpatient and outpatient performance of anterior cervical discectomy and fusion (ACDF) and lumbar laminectomy.RESULTSSixteen studies with a total of 370,195 patients met the inclusion criteria. Outpatient procedures were associated with younger patient age (mean difference [MD] -2.34, 95% credible interval [CrI] -4.39 to -0.34) and no diabetes diagnosis (odds ratio [OR] 0.78, 95% CrI 0.54-0.97). Outpatient procedures were associated with a lower likelihood of reoperation (OR 0.42, 95% CrI 0.16-0.80), 30-day readmission (OR 0.39, 95% CrI 0.16-0.74), and complications (OR 0.29, 95% CrI 0.15-0.50) and with lower overall costs (MD -$121,392.72, 95% CrI -$216,824.81 to -$23,632.92). Additional analysis of the national administrative data revealed more modest cost savings than those found in the meta-analysis for outpatient spine surgeries relative to inpatient spine surgeries. Estimated cost savings for both younger patients ($555 for those age 30-35 years [95% CrI -$733 to -$374]) and older patients ($7290 for those age 65-70 years [95% CrI -$7380 to -$7190]) were less than the overall cost savings found in the meta-analysis.CONCLUSIONSCompared to inpatient spine surgery, outpatient spine surgery was associated with better short-term outcomes and an initial reduction in direct costs. A selection bias for outpatient procedures toward younger, healthier patients may confound these results. The additional analysis of the national database suggests that cost savings in the outpatient setting may be less than previously reported and a result of outpatient procedures being offered more frequently to younger and healthier individuals.

Insurance correlates with improved access to care and outcome among glioblastoma patients.

Background: The current standard of care for glioblastoma (GBM) constitutes maximal safe surgical resection, followed by fractionated radiation and temozolomide. This treatment regimen is logistically burdensome, and in a health care system in which access to care is variable, there may be patients with worsened outcomes due to inadequate access to optimal treatment. Methods: The National Cancer Database was queried for patients with diagnoses of GBM in 2006-2014. Patients were grouped according to insurance status: private insurance, Medicare, Medicaid, or uninsured. Treatments provided (surgery, radiation, and chemotherapy) were compared between groups in univariate and multivariable logistic regression analysis. Results: A total of 61614 patients were analyzed. Compared with private insurance, the odds of surgery for Medicaid and uninsured patients were 0.72 (95% CI: 0.66-0.79) and 0.77 (95% CI: 0.69-0.87), respectively (P < 0.001). The multivariable odds of receiving radiotherapy were 0.91 (95% CI: 0.86-0.96), 0.62 (95% CI: 0.57-0.68), and 0.47 (95% CI: 0.43-0.52) for Medicare, Medicaid, and uninsured patients, respectively (all P < 0.001). In addition, the odds of receiving chemotherapy were 0.94 (95% CI: 0.89-0.99), 0.53 (95% CI: 0.49-0.57), and 0.41 (95% CI: 0.38-0.46) for Medicare, Medicaid, and uninsured patients, respectively (all P < 0.001). Conclusion: Insurance status and type of insurance coverage appear to impact treatments rendered for GBM, independently of other variables. Furthermore, we find that such differential access to care significantly impacts survival. Ensuring adequate access to care for all patients with diagnoses of glioblastoma is critical to optimize survival, especially as therapies continue to advance.

Allegations of Failure to Obtain Informed Consent in Spinal Surgery Medical Malpractice Claims.

Importance: Predictive factors associated with increased risk of medical malpractice litigation have been identified, including severity of injury, physician sex, and error in diagnosis. However, there is a paucity of literature investigating informed consent in spinal surgery malpractice. Objective: To investigate the failure to obtain informed consent as an allegation in medical malpractice claims for patients undergoing a spinal procedure. Design, Setting, and Participants: In this retrospective cohort study, a national medicolegal database was searched for malpractice claim cases related to spinal surgery for all years available (ie, January 1, 1980, through December 31, 2015). Main Outcomes and Measures: Failure to obtain informed consent and associated medical malpractice case verdict. Results: A total of 233 patients (117 [50.4%] male and 116 [49.8%] female; 80 with no informed consent allegation and 153 who cited lack of informed consent) who underwent spinal surgery and filed a malpractice claim were studied (mean [SD] age, 47.1 [13.1] years in the total group, 45.8 [12.9] years in the control group, and 47.9 [13.3] years in the informed consent group). Median interval between year of surgery and year of verdict was 5.4 years (interquartile range, 4-7 years). The most common informed consent allegations were failure to explain risks and adverse effects of surgery (52 [30.4%]) and failure to explain alternative treatment options (17 [9.9%]). In bivariate analysis, patients in the control group were more likely to require additional surgery (45 [56.3%] vs 53 [34.6%], P = .002) and have more permanent injuries compared with the informed consent group (46 [57.5%] vs 63 [42.0%], P = .03). On multivariable regression analysis, permanent injuries were more often associated with indemnity payment after a plaintiff verdict (odds ratio [OR], 3.12; 95% CI, 1.46-6.65; P = .003) or a settlement (OR, 6.26; 95% CI, 1.06-36.70; P = .04). Informed consent allegations were significantly associated with less severe (temporary or emotional) injury (OR, 0.52; 95% CI, 0.28-0.97; P = .04). In addition, allegations of informed consent were found to be predictive of a defense verdict vs a plaintiff ruling (OR, 0.41; 95% CI, 0.17-0.98; P = .046) or settlement (OR, 0.01; 95% CI, 0.001-0.15; P < .001). Conclusions and Relevance: Lack of informed consent is an important cause of medical malpractice litigation. Although associated with a lower rate of indemnity payments, malpractice lawsuits, including informed consent allegations, still present a time, money, and reputation toll for physicians. The findings of this study can therefore help to improve preoperative discussions to protect spinal surgeons from malpractice claims and ensure that patients are better informed.

Minimally Invasive Surgery Versus Open Surgery Spinal Fusion for Spondylolisthesis: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Compare minimally invasive surgery (MIS) and open surgery (OS) spinal fusion outcomes for the treatment of spondylolisthesis. SUMMARY OF BACKGROUND DATA: OS spinal fusion is an interventional option for patients with spinal disease who have failed conservative therapy. During the past decade, MIS approaches have increasingly been used, with potential benefits of reduced surgical trauma, postoperative pain, and length of hospital stay. However, current literature consists of single-center, low-quality studies with no review of approaches specific to spondylolisthesis only. METHODS: This first systematic review of the literature regarding MIS and OS spinal fusion for spondylolisthesis treatment was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search of Medline/PubMed, Cochrane, EMBASE, and Scopus databases yielded 2489 articles. These articles were screened against established criteria for inclusion into this study. RESULTS: A total of five retrospective and five prospective articles with a total of 602 patients were found. Reported spondylolisthesis grades were I and II only. Overall, MIS was associated with less intraoperative blood loss (mean difference [MD], -331.04 mL; 95% confidence interval [CI], -490.48 to -171.59; P < 0.0001) and shorter length of hospital stay (MD, -1.74 days; 95% CI, -3.04 to -0.45; P = 0.008). There was no significant difference overall between MIS and OS in terms of functional or pain outcomes. Subgroup analysis of prospective studies revealed MIS had greater operative time (MD, 19.00 minutes; 95% CI, 0.90 to 37.10; P = 0.04) and lower final functional scores (weighted MD, -1.84; 95% CI, -3.61 to -0.07; P = 0.04) compared with OS. CONCLUSION: Current data suggests spinal fusion by MIS is a safe and effective approach to treat grade I and grade II spondylolisthesis. Moreover, although prospective trials associate MIS with better functional outcomes, longer-term and randomized trials are warranted to validate any association found in this study. LEVEL OF EVIDENCE: 2.

Provider volume and short-term outcomes following surgery for spinal metastases.

This study aimed to analyze the impact of surgeon and hospital volume on short-term outcomes following surgery for spinal metastases. Data from the Nationwide Inpatient Sample (NIS; 2003-2009) were extracted. Patients who underwent decompression and/or fusion for metastatic spinal tumors were identified via International Classification of Diseases, Ninth Revision codes. Surgeon and hospital volume were evaluated as a continuous variable. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (OR) of in-hospital mortality, post-operative complication development, non-routine discharges, prolonged length of stay, and high hospital charges with increasing surgeon and hospital volume. In total 3,069 admissions were examined. The overall in-hospital mortality rate was 4.4% and in-hospital complication rate 29.7%; non-routine discharges occurred in 63.3% of patients. Increasing provider volume was not associated with lower odds of in-hospital mortality. However, increasing surgeon volume was associated with significantly lower odds of developing an in-hospital complication (OR 0.70; 95% confidence interval [CI], 0.58-0.85) and having a non-routine discharge (OR 0.76; 95% CI, 0.66-0.87). Increasing hospital volume was not associated with lower odds of developing a post-operative complication (OR 1.17; 95% CI, 1.00-1.37), but was associated with lower odds of having a non-routine discharge (OR 0.83; 95% CI, 0.73-0.95). Patients operated on by higher volume surgeons were less likely to have a prolonged length of stay (over 14 days); higher hospital volume was associated with increased odds of high hospital charges (over $295,511 USD). In this study utilizing the NIS administrative database, patients with metastatic spinal tumors treated by higher volume surgeons had significantly lower complication rates, were more likely to be discharged home following surgery, and were less likely to have a prolonged length of stay. Increasing hospital volume was associated with lower non-routine discharge rates, but with higher hospital charges. Better outcomes with higher volume surgeons may be a reflection of patient selection, and further research is needed to corroborate our findings.