How Do the True Intraoperative Costs of Endoscopic Diskectomy Compare With Microdiskectomy for Lumbar Disk Herniations? A Time-Driven Activity-Based Cost Analysis.

BACKGROUND AND OBJECTIVES: Endoscopic lumbar diskectomy (ED) is a minimally invasive option for addressing lumbar disk herniations. With the introduction of value-based care systems, assessing the true cost of certain procedures is critical when creating reimbursement models and comparing procedures. Here, we compared the costs of performing a microdiskectomy (MD) and ED using time-driven activity-based costing. METHODS: Total cost for the intraoperative episode was calculated using time-driven activity-based costing methodology. Individual costs were obtained by direct observation and electronic medical records and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. A retrospective analysis was performed on 202 patients who underwent lumbar diskectomy through either MD (n = 167) or ED (n = 35) from 2018 to 2022. Personnel cost was calculated by multiplying the cost per unit time for each personnel type by the length of time spent in the operating room. Supply cost was calculated by aggregating the cost of all individual supplies, from medications to consumables to surgical trays, used during the case. Univariate and multivariable regression analyses were performed comparing the costs between these procedures. RESULTS: The average intraoperative cost per case for ED and MD was $3915 ± $1025 and $3162 ± $954, respectively. Multivariable regression analysis revealed that ED had higher total cost (ß-coefficient: $912 ± $281, P = <.01) and supply cost (ß-coefficient: $474 ± $155, P = <.01) than MD. When accounting for surgeon as a covariate, however, total cost (P = .478) and supply cost (P = .468) differences between ED and MD were negligible. CONCLUSION: ED has shown to be a better value option in addressing lumbar disk herniations, mostly because of advantages in perioperative care. Here, we show that when correcting for surgeon-level effects, the cost between the two procedures is statistically insignificant, reaffirming the value provided by ED.

Do Busier Surgeons Have Lower Intraoperative Costs? An Analysis of Anterior Cervical Discectomy and Fusion Using Time-Driven Activity-Based Costing.

STUDY DESIGN: The present study is a single-center, retrospective cohort study of patients undergoing neurosurgical anterior cervical discectomy and fusion (ACDF). OBJECTIVE: Our objective was to use time-driven activity-based costing (TDABC) methodology to determine whether surgeons' case volume influenced the true intraoperative costs of ACDFs performed at our institution. SUMMARY OF BACKGROUND DATA: Successful participation in emerging reimbursement models, such as bundled payments, requires an understanding of true intraoperative costs, as well as the modifiable drivers of those costs. Certain surgeons may have cost profiles that are favorable for these "at-risk" reimbursement models, while other surgeons may not. METHODS: Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. All surgeons performing ACDFs at our primary and affiliated hospital sites from 2017 to 2022 were divided into four volume-based cohorts: 1-9 cases (n=10 surgeons, 38 cases), 10-29 cases (n=7 surgeons, 126 cases), 30-100 cases (n=3 surgeons, 234 cases), and > 100 cases (n=2 surgeons, 561 cases). RESULTS: The average total intraoperative cost per case was $7,116 +/- $2,945. The major cost contributors were supply cost ($4,444, 62.5%) and personnel cost ($2,417, 34.0%). A generalized linear mixed model utilizing Poisson distribution was performed with the surgeon as a random effect. Surgeons performing 1-9 total cases, 10-29 cases, and 30-100 cases had increased total cost of surgery (P < 0.001; P < 0.001; and P<0.001, respectively) compared to high-volume surgeons (> 100 cases). Among all volume cohorts, high-volume surgeons also had the lowest mean supply cost, personnel cost, and operative times, while the opposite was true for the lowest-volume surgeons (1-9 cases). CONCLUSION: It is becoming increasingly important for hospitals to identify modifiable sources of variation in cost. We demonstrate a novel use of TDABC for this purpose. LEVEL OF EVIDENCE: Level-III.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

What is the Marginal Cost of Using Robot Assistance or Navigation for Transforaminal Lumbar Interbody Fusion? A Time-Driven Activity-Based Cost Analysis.

BACKGROUND AND OBJECTIVE: Our primary objective was to compare the marginal intraoperative cost of 3 different methods for pedicle screw placement as part of transforaminal lumbar interbody fusions (TLIFs). Specifically, we used time-driven activity-based costing to compare costs between robot-assisted TLIF (RA-TLIF), TLIF with intraoperative navigation (ION-TLIF), and freehand (non-navigated, nonrobotic) TLIF. METHODS: Total cost was divided into direct and indirect costs. We identified all instances of RA-TLIF (n = 20), ION-TLIF (n = 59), and freehand TLIF (n = 233) from 2020 to 2022 at our institution. Software was developed to automate the extraction of all intraoperatively used personnel and material resources from the electronic medical record. Total costs were determined through a combination of direct observation, electronic medical record extraction, and interdepartmental collaboration (business operations, sterile processing, pharmacy, and plant operation departments). Multivariable linear regression analysis was performed to compare costs between TLIF modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. RESULTS: The average total intraoperative cost per case for the RA-TLIF, ION-TLIF, and freehand TLIF cohorts was $24 838 ± $10 748, $15 991 ± $6254, and $14 498 ± $6580, respectively. Regression analysis revealed that RA-TLIF had significantly higher intraoperative cost compared with both ION-TLIF (ß-coefficient: $7383 ± $1575, P < .001) and freehand TLIF (ß-coefficient: $8182 ± $1523, P < .001). These cost differences were primarily driven by supply cost. However, there were no significant differences in intraoperative cost between ION-TLIF and freehand TLIF ( P = .32). CONCLUSION: We demonstrate a novel use of time-driven activity-based costing methodology to compare different modalities for executing the same type of lumbar fusion procedure. RA-TLIF entails significantly higher supply cost when compared with other modalities, which explains its association with higher total intraoperative cost. The use of ION, however, does not add extra expense compared with freehand TLIF when accounting for confounders. This might have implications as surgeons and hospitals move toward bundled payments.

What is the Marginal Intraoperative Cost of Using an Exoscope or Operative Microscope for Anterior Cervical Discectomy and Fusion? A Time-Driven Activity-Based Cost Analysis.

OBJECTIVE: Our primary objective was to compare the intraoperative costs of 3 different surgical visualization techniques for anterior cervical discectomy and fusion (ACDF). Specifically, we used time-driven activity-based costing (TDABC) methodology to compare costs between ACDFs performed with operative microscopes (OM-ACDF), exoscopes (EX-ACDF), and loupes (loupes-ACDF). METHODS: Total cost was divided into direct and indirect costs. Individual costs were obtained by direct observation, electronic medical records, and through querying multiple departments (business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented. We identified all instances of loupes-ACDF (n = 882), EX-ACDF (n = 26), and OM-ACDF (n = 52) performed at our institution. We performed multivariable linear regression analyses to compare costs between these modalities, accounting for patient-specific factors as well as number of levels fused, surgeon, and hospital site. RESULTS: The average total intraoperative costs per loupes-ACDF, EX-ACDF, and OM-ACDF cases were $7081 +/- $2,942, $7951 +/- $3,488, and $6557 +/- $954, respectively. Regression analysis revealed no difference in intraoperative cost between loupes-ACDF and EX-ACDF (P = 0.717), loupes-ACDF and OM-ACDF (0.954), or OM-ACDF and EX-ACDF (0.217). On a more granular level, however, EX-ACDF was associated with increased cost of consumables, including drapes, compared to both OM-ACDF (ß-coefficient: $369 +/- $121, P = 0.002) and loupes-ACDF (ß-coefficient: $284 +/- $86, P = 0.001). CONCLUSIONS: Although hospitals may be aware of the purchasing fees associated with microscopes and exoscopes, there is no clear documentation of how these technologies affect intraoperative cost. We demonstrate a novel use of TDABC for this purpose.

Implementation of a Private Payer Bundled Payment Model While Maintaining High-Value Lumbar Spinal Fusion.

STUDY DESIGN: Retrospective single-institution cohort. OBJECTIVE: To evaluate the implementation of a commercial bundled payment model in patients undergoing lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: BPCI-A caused significant losses for many physician practices, prompting private payers to establish their own bundled payment models. The feasibility of these private bundles has yet to be evaluated in spine fusion. METHODS: Patients undergoing lumbar fusion from October to December 2018 in BPCI-A before our institution's departure were included for BPCI-A analysis. Private bundle data was collected from 2018 to 2020. Analysis of the transition was conducted among Medicare-aged beneficiaries. Private bundles were grouped by calendar year (Y1, Y2, Y3). Stepwise multivariate linear regression was performed to measure independent predictors of net deficit. RESULTS: The net surplus was the lowest in Y1 ($2,395, P =0.03) but did not differ between our final year in BPCI-A and subsequent years in private bundles (all, P >0.05). AIR and SNF patient discharges decreased significantly in all private bundle years compared with BPCI. Readmissions fell from 10.7% (N=37) in BPCI-A to 4.4% (N=6) in Y2 and 4.5% (N=3) Y3 of private bundles ( P <0.001). Being in Y2 or Y3 was independently associated with a net surplus in comparison to the Y1 (ß: $11,728, P =0.001; ß: $11,643, P =0.002). Postoperatively, length of stay in days (ß: $-2,982, P <0.001), any readmission (ß: -$18,825, P =0.001), and discharge to AIR (ß: $-61,256, P <0.001) or SNF (ß: $-10,497, P =0.058) were all associated with a net deficit. CONCLUSIONS: Nongovernmental bundled payment models can be successfully implemented in lumbar spinal fusion patients. Constant price adjustment is necessary so bundled payments remain financially beneficial to both parties and systems overcome early losses. Private insurers who have more competition than the government may be more willing to provide mutually beneficial situations where cost is reduced for payers and health systems. LEVEL OF EVIDENCE: 3.

Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States.

STUDY DESIGN: Retrospective study with epidemiologic analysis of public Medicare data. OBJECTIVE: The purpose of this study is to use geospatial analysis to identify disparities in access to cervical spine fusions in metropolitan Medicare populations. SUMMARY OF BACKGROUND DATA: Cervical spine fusion is among the most common elective procedures performed by spine surgeons and is the most common surgical intervention for degenerative cervical spine disease. Although some studies have examined demographic and socioeconomic trends in cervical spine fusion, few have attempted to identify where disparities exist and quantify them at a community level. METHODS: Center for Medicare and Medicaid Services physician billing and Medicare demographic data sets from 2013 to 2020 were filtered to contain only cervical spine fusion procedures and then combined with US Census socioeconomic data. The Moran Index geospatial clustering algorithm was used to identify statistically significant hotspot and coldspots of cervical spine fusions per 100,000 Medicare members at a county level. Univariate and multivariate analysis was subsequently conducted to identify demographic and socioeconomic factors that are associated with access to care. RESULTS: A total of 285,405 cervical spine fusions were analyzed. Hotspots of cervical spine fusion were located in the South, while coldspots were throughout the Northern Midwest, the Northeast, South Florida, and West Coast. The percent of Medicare patients that were Black was the largest negative predictor of cervical spine fusions per 100,000 Medicare members ( ß =-0.13, 95% CI: -0.16, -0.10). CONCLUSIONS: Barriers to access can have significant impacts on health outcomes, and these impacts can be disproportionately felt by marginalized groups. Accounting for socioeconomic disadvantage and geography, this analysis found the Black race to be a significant negative predictor of access to cervical spine fusions. Future studies are needed to further explore potential socioeconomic barriers that exist in access to specialized surgical care. LEVEL OF EVIDENCE: Level III-retrospective.

Utilization of In-Hospital Orthopaedic Spine Consultations: Evaluating the Impact of Health Care Policy.

Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study's findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers.

Gender disparities among speakers at major spine conferences.

PURPOSE: To examine ten-year trends in gender representation in speaking roles at major spine conferences. BACKGROUND CONTEXT: Medical conferences play an important role in career opportunities. There is little analysis on gender representation of major spine conferences despite several studies demonstrating gender disparities within spine surgery. STUDY DESIGN: Observational study. SAMPLE: A total of 20,181 abstract speakers across 10 years of academic conferences for six spine societies. OUTCOME MEASURES: Percent of female abstract presenters. MATERIALS AND METHODS: We collated the annual meeting programs of six major spine conferences (North American Spine Society (NASS), Scoliosis Research Society (SRS), International Meeting on Advanced Spine Techniques (IMAST), Global Spine Congress (GSC), American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Spine Summit, and the Cervical Spine Research Society (CSRS)) dating from 2013 to 2022. Departmental websites, society webpages, or personal social media were identified for images or the use of gendered pronouns in order to determine speaker gender for each speaker type. All categorical variables were compared using Pearson chi-square analysis. RESULTS: Women constituted 1,816 (9.0%) of all 20,181 identified conference speakers. Female representation was highest at NASS (N=680, 12.2%) but lowest at CSRS (6.6%) and GSC (7.1%). Spine Summit (7.4%), IMAST (9.92%), and GSC (9.87%) demonstrated the largest annual percent increases in female representation. Institutions in Middle East and Africa (1.4%), and Central and South America (1.8%) supported the lowest percent of female speakers. Women were significantly less likely to be speakers or moderators/course faculty than to be podium abstract presenters (p<.001). The percent of women as invited speakers (10.4% vs. 5.5%, p=.001) and moderators (11.4% vs. 3.7%, p<.001) increased significantly over the study period, with annual increases of 8.8% and 20.8%, respectively, from 2013 to 2022 (p<.001). CONCLUSIONS: While academic spine societies have made significant progress in promoting gender representation, especially among invited speakers and session moderators, women continue to be underrepresented compared to the percent of women in orthopedic surgery and neurosurgery.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Assessment of a Private Payer Bundled Payment Model for Lumbar Decompression Surgery.

INTRODUCTION: Although bundled payment models are well-established in Medicare-aged individuals, private insurers are now developing bundled payment plans. The role of these plans in spine surgery has not been evaluated. Our objective was to analyze the performance of a private insurance bundled payment program for lumbar decompression and microdiskectomy. METHODS: A retrospective review was conducted of all lumbar decompressions in a private payer bundled payment model at a single institution from October 2018 to December 2020. 120-day episode of care cost data were collected and reported as net profit or loss regarding set target prices. A stepwise multivariable linear regression model was developed to measure the effect of patient and surgical factors on net surplus or deficit. RESULTS: Overall, 151 of 468 (32.2%) resulted in a deficit. Older patients (58.6 vs. 50.9 years, P < 0.001) with diabetes (25.2% vs. 13.9%, P = 0.004), hypertension (38.4% vs. 28.4%, P = 0.038), heart disease (13.9% vs. 7.57%, P = 0.030), and hyperlipidemia (51.7% vs. 35.6%, P = 0.001) were more likely to experience a loss. Surgically, decompression of more levels (1.91 vs. 1.19, P < 0.001), posterior lumbar decompression (86.8% vs. 56.5%, P < 0.001), and performing surgery at a tertiary hospital (84.8% vs. 70.3%, P < 0.001) were more likely to result in loss. All readmissions resulted in a loss (4.64% vs. 0.0%, P < 0.001). On multivariable regression, microdiskectomy (ß: $2,398, P = 0.012) and surgery in a specialty hospital (ß: $1,729, P = 0.096) or ambulatory surgery center (ß: $3,534, P = 0.055) were associated with cost savings. Increasing number of levels, longer length of stay, active smoking, and history of cancer, dementia, or congestive heart failure were all associated with degree of deficit. CONCLUSIONS: Preoperatively optimizing comorbidities and using risk stratification to identify those patients who may safely undergo surgery at a facility other than an inpatient hospital may help increase cost savings in a bundled payment model of working-age and Medicare-age individuals.

Procedures employing interbody devices and multi-level fusion require target price adjustment to build a sustainable lumbar fusion bundled payment model.

BACKGROUND CONTEXT: Bundled payment models require risk adjustment to ensure appropriate targets are set. While this may be standardized for many services, spine fusions demonstrate significant variability in approach, invasiveness, and use of implants, that may require further risk adjustment. PURPOSE: To evaluate variability in costs of spinal fusion episodes in a private insurer bundle payment program and identify whether current procedural terminology (CPT) code modifications are necessary for sustainable implementation. STUDY DESIGN/SETTING: Retrospective single-institution cohort study. PATIENT SAMPLE: A total of 542 lumbar fusion episodes in a private insurer bundled payment program from October 2018 to December 2020. OUTCOME MEASURES: A total of 120-day episode of care net surplus/deficit, 90-day readmissions, discharge disposition, and length of hospital stay. METHODS: A review was conducted of all lumbar fusions in a single institution's payer database. Surgical characteristics (approach [posterior lumbar decompression and fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), and circumferential fusion], levels fused, and primary vs revision) were collected from manual chart review. Episode of care cost data were collected as net surplus or deficit with respect to target prices. A multivariate linear regression model was constructed to measure the independent effects of primary versus revision, levels fused, and approach on the net cost savings. RESULTS: Most procedures were PLDFs (N=312, 57.6%), single-level (N=416, 76.8%) and primary fusions (N=477, 88.0%). Overall, 197 (36.3%) resulted in a deficit, and were more likely to be three levels (7.11% vs 2.03%, p=.005), revisions (18.8% vs 8.12%, p<.001), and TLIF (47.7% vs 35.1%, p<.001) or circumferential fusions (p<.001). One-level PLDFs resulted in the greatest cost savings per episode ($6,883). Across both PLDFs and TLIFs, 3-level procedures resulted in significant deficit of -$23,040 and -$18,887, respectively. For circumferential fusions, 1-level fusions resulted in deficit of -$17,169 per case which rose to -$64,485 and -$49,222 for 2- and 3-level fusions. All 2- and 3-level circumferential spinal fusions resulted in a deficit. On multivariable regression, TLIF and circumferential fusions were independently associated with a deficit of -$7,378 (p=.004) and -$42,185 (p<.001), respectively. Three-level fusions were independently associated with an additional -$26,003 deficit compared to single-level fusions (p<.001). CONCLUSIONS: Interbody fusions, especially circumferential fusions, and multi-level procedures are not adequately risk adjusted by current bundled payment models. Health systems may not be able to financially support these alternative payment models with improved procedure-specific risk adjustment.

The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion.

BACKGROUND CONTEXT: Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population. PURPOSE: To identify patient barriers to PROM completion one year following lumbar spine fusion. STUDY DESIGN/SETTING: Retrospective single-institution cohort study. PATIENT SAMPLE: A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively. METHODS: A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders. RESULTS: A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion. CONCLUSIONS: Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.

Development of a comprehensive assessment tool to measure the quality of care for individuals with traumatic spinal cord injuries.

OBJECTIVE: To develop a comprehensive assessment tool to evaluate the Quality of Care (QoC) in managing individuals with traumatic spinal cord injuries (TSCI). METHOD: At first, the concepts of QoC for TSCI were identified by conducting a qualitative interview along with re-evaluation of the results of a published scoping review (conceptualization). After operationalization of indicators, they were valued by using the expert panel method. Afterward, the content validity index (CVI) and content validity ratio (CVR) were calculated and served as cut-offs for indicator selection. Then specific questions were developed for each indicator and classified into three categories: pre-hospital, in-hospital, and post-hospital. Data availability of the National Spinal Cord Injury Registry of Iran (NSCIR-IR) was subsequently used to design questions that represent indicators in an assessment tool format. The comprehensiveness of the tool was evaluated using a 4-item Likert scale by the expert panel. RESULT: Twelve experts participated in conceptualization and 11 experts participated in operationalization phase. Overall, 94 concepts for QoC were identified from published scoping review (87 items) and qualitative interviews (7 items). The process of operationalization and indicator selection led to the development of 27 indicators with acceptable content validity. Finally, the assessment tool contained three pre-hospital, twelve in-hospital, nine post-hospital, and three mixed indicators. Ninety-one percent of experts evaluated the entire tool as comprehensive. CONCLUSION: Our study presents a health-related QoC tool that contains a comprehensive set of indicators to assess the QoC for individuals with TSCI. However, this tool should be used in various situations to establish construct validity further.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression. SUMMARY OF BACKGROUND DATA: Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression. METHODS: Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05. RESULTS: A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (ß = $324.70, P < 0.001), comorbid depression (ß = $4368.30, P = 0.037), revision procedures (ß = $6538.43, P =0.012), increased hospital length of stay (per day) (ß = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (ß = $14,417.42, P = 0.001), incidence of a complication (ß = $8178.07, P < 0.001), and readmission (ß = $18,734.24, P < 0.001) within 90 days. CONCLUSIONS: Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Evaluation of Hospital Compliance With Federal Price Transparency Regulations and Variability of Negotiated Rates for Spinal Fusion.

INTRODUCTION: To improve price transparency, the Centers for Medicare & Medicaid Services (CMS) requires hospitals to post accessible pricing data for common elective procedures along with all third-party-negotiated rates. We aimed to evaluate hospital compliance with CMS regulations for both price estimators and machine-readable files for spinal fusions and to evaluate factors contributing to variability in hospital-negotiated pricing. METHODS: We reviewed the top 100 orthopaedic hospitals ranked by US News & World Report to assess compliance with CMS price transparency regulations for all spine diagnosis-related groups. We recorded gross inpatient charge, cash price, and deidentified maximum and minimum rates for the 11 spine diagnosis-related groups (DRGs). Variability was compared with geographic practice costs (GPCI), expected Medicare reimbursements, and poverty rate and median income ratio. RESULTS: Only 72% of hospitals were fully compliant in reporting spinal fusions on their price estimator, and 39% were fully compliant in reporting all mandatory rates for spinal fusions. The overall estimated cash price was $96,979 ± $56,262 and $62,595 ± $40,307 for noncervical and cervical fusion, respectively. Cash prices at top 50 hospitals were higher for both noncervical and cervical fusions ( P = 0.0461 and P = 0.0341, respectively). The average minimum negotiated rates ranged from 0.88 to 1.15 times the expected Medicare reimbursement, while maximum and cash prices were 3.41 to 3.90 and 2.53 to 4.08 times greater than Medicare reimbursement. GPCI demonstrated little to no correlation with DRG pricing. However, minimum negotiated rates and cash prices demonstrated weak positive correlations with the median income ratio and weak negative correlations with the poverty rate. DISCUSSION: Most US hospitals are not fully compliant with CMS price transparency regulations for spinal fusions despite increased overall utilization of price estimators and machine-readable files. Although higher ranked hospitals charged more for spinal fusions, DRG prices remain widely variable with little to no correlation with practice cost or socioeconomic parameters.

Predictors of Academic Productivity Among Spine Surgeons.

INTRODUCTION: The relationship between research productivity in training and future productivity as an attending spine surgeon is not well-established in the literature nor has the effect of geographic location of training institutions on future academic success been investigated. The aim of our study was to (1) summarize characteristics of academically productive spine surgeons, (2) assess predictors of long-term academic productivity, and (3) establish the effect of geographic location on long-term academic productivity. METHODS: A query was conducted of the 2021 to 2022 North American Spine Society Spine Fellowship Directory of all orthopaedic and neurosurgical spine fellowship selection committee members for each institution participating in the spine fellowship match. The attending publication rate and h- index were determined. A multivariate linear regression model was developed. P value was set to <0.05. RESULTS: We identified 310 orthopaedic and neurosurgical spine surgeons, representing 76 fellowship programs. Multivariate linear regression analysis identified that the publications during residency ( P < 0.001) and during fellowship ( P < 0.001) were significant predictors of an increased publication rate as an attending surgeon. By contrast, the preresidency publication rate ( P = 0.729) was not significantly predictive of the attending publication rate. Multivariate analysis of h- index found that residency publication rate had a positive correlation ( P = 0.031) compared with preresidency ( P = 0.579) or fellowship ( P = 0.257) rates. Attendings who had attended residency in the Northeast and currently practicing in the Northeast had a higher publication rate ( P < 0.001 and P = 0.004, respectively). DISCUSSION: A higher number of publications in residency and fellowship were markedly predictive of an increased publication rate as an attending spine surgeon. By contrast, preresidency publications may not be indicative of future academic productivity as an attending. Location may also contribute to attending publication rate and favor those who undergo residency training and ultimately practice in the Northeast.

Risk stratification of patients undergoing outpatient lumbar decompression surgery.

BACKGROUND CONTEXT: Reimbursement has slowly transitioned from a fee-for-service model to a bundled payment model after introduction of the United States Centers for Medicare and Medicaid Services bundled payment program. To minimize healthcare costs, some surgeons are trying to minimize healthcare expenditures by transitioning appropriately selected lumbar decompression patients to outpatient procedure centers. PURPOSE: To prepare a risk stratification calculator based on machine learning algorithms to improve surgeon's preoperative predictive capability of determining whether a patient undergoing lumbar decompression will meet inpatient vs. outpatient criteria. Inpatient criteria was defined as any overnight hospital stay. STUDY DESIGN/SETTING: Retrospective single-institution cohort. PATIENT SAMPLE: A total of 1656 patients undergoing primary lumbar decompression. OUTCOME MEASURES: Postoperative outcomes analyzed for inclusion into the risk calculator included length of stay. METHODS: Patients were split 80-20 into a training model and a predictive model. This resulted in 1,325 patients in the training model and 331 into the predictive model. A logistic regression analysis ensured proper variable inclusion into the model. C-statistics were used to understand model effectiveness. An odds ratio and nomogram were created once the optimal model was identified. RESULTS: A total of 1,656 patients were included in our cohort with 1,078 dischared on day of surgery and 578 patients spending ≥ 1 midnight in the hospital. Our model determined older patients (OR=1.06, p<.001) with a higher BMI (OR=1.04, p<0.001), higher back pain (OR=1.06, p=.019), increasing American Society of Anesthesiologists (ASA) score (OR=1.39, p=.012), and patients with more levels decompressed (OR=3.66, p<0.001) all had increased risks of staying overnight. Patients who were female (OR=0.59, p=.009) and those with private insurance (OR=0.64, p=.023) were less likely to be admitted overnight. Further, weighted scores based on training data were then created and patients with a cumulative score over 118 points had a 82.9% likelihood of overnight. Analysis of the 331 patients in the test data demonstrated using a cut-off of 118 points accurately predicted 64.8% of patients meeting inpatient criteria compared to 23.0% meeting outpatient criteria (p<0.001). Area under the curve analysis showed a score greater than 118 predicted admission 81.4% of the time. The algorithm was incorporated into an open access digital application available here: https://rothmanstatisticscalculators.shinyapps.io/Inpatient_Calculator/?_ga=2.171493472.1789252330.1671633274-469992803.1671633274 CONCLUSIONS: Utilizing machine-learning algorithms we created a highly reliable predictive calculator to determine if patients undergoing outpatient lumbar decompression would require admission. Patients who were younger, had lower BMI, lower preoperative back pain, lower ASA score, less levels decompressed, private insurance, lived with someone at home, and with minimal comorbidities were ideal candidates for outpatient surgery.

A Multi-Disciplinary Review of Time-Driven Activity-Based Costing: Practical Considerations for Spine Surgery.

STUDY DESIGN: A multi-disciplinary review. OBJECTIVES: To provide a roadmap for implementing time-driven activity-based costing (TDABC) for spine surgery. This is achieved by organizing and scrutinizing publications in the spine, neurosurgical, and orthopedic literature which utilize TDABC and related methodologies. METHODS: PubMed and Google Scholar were searched for relevant articles. The articles were selected by two independent researchers. After article selection, data was extracted and summarized into research domains. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) systematic review process was followed. RESULTS: Of the 524 articles screened, thirty-five articles met the inclusion criteria. Each included article was examined and reviewed to define the primary research question and objective. Comparing different procedures was the most common primary objective. Direct observation along with one other strategy (surveys, interviews, surgical database, or EMR) was most commonly employed during process map development. Across all surgical subspecialties (spine, neurologic, and orthopedic surgery), costs were divided into direct cost, indirect cost, cost to patient, and total costs. The most commonly calculated direct costs included personnel and supply costs. Facility costs, hospital overhead costs, and utilities were the most commonly calculated indirect costs. Transportation costs and parental lost wages were considered when calculating cost to patient. The total cost was a sum of direct costs, indirect costs, and costs to the patient. CONCLUSION: TDABC provides a common platform to accurately estimate costs of care delivery. Institutions embarking on TDABC for spine surgery should consider the breadth of methodologies highlighted in this review to determine which type of calculations are appropriate for their practice.