Sociodemographic Disparities in the Diagnosis and Prognosis of Patients With Cervical Cancer: An Analysis of the Surveillance, Epidemiology, and End Results Program.

Background While the incidence and mortality rates of cervical cancer are declining due to improved prevention, screening, and treatment, inequitable access to care may contribute to worse patient outcomes. Therefore, we sought to evaluate sociodemographic disparities in the diagnosis and prognosis of patients with cervical cancer. Methodology The Surveillance, Epidemiology, and End Results (SEER) database was queried for adult women diagnosed with cervical cancer from 2010 to 2015. Sociodemographic groups of interest included patient race/ethnicity (non-Hispanic White/Hispanic White/Black/Other), residential setting (rural/urban), and county median household income (<$45,000/$45,000-59,999/$60,000-74,999/≥$75,000). Outcomes of interest included stage at diagnosis, receipt of hysterectomy, and overall survival (OS). Outcomes were evaluated using Pearson's chi-square test, multivariable logistic regression, and multivariable Cox proportional hazards. Results A total of 5,726 patients were identified with an average age of 50.1 years (SD = 14.6). Significant differences in cancer stage at diagnosis were identified based on race/ethnicity (p < 0.001) and household income (p = 0.012). On adjusted analysis, Black patients were found to be significantly less likely to receive a hysterectomy compared to non-Hispanic White patients (odds ratio (OR) = 0.46; 95% confidence interval (CI) = 0.37-0.56). Lower household income was associated with poorer survival for stage I (<$45,000 vs. >$75,000: hazard ratio (HR) = 1.53; 95% interquartile range (IQR) = 1.00-2.33), II ($45,000-59,999 vs. >$75,000: HR = 1.67; 95% IQR = 1.19-2.35), and IV (<$45,000 vs. >$75,000: HR = 1.64; 95% IQR = 1.22-2.29) disease. Black race was associated with poorer OS for stage IV disease (HR = 1.29; 95% IQR = 1.06-1.56). Conclusions This study highlights significant disparities in disease progression at diagnosis and OS for cervical cancer patients based on race/ethnicity and household income. These findings may assist policymakers in developing strategies for mitigating these disparities.

Robotic versus laparoscopic colectomy outcomes in colon adenocarcinoma in the elderly population: a propensity-score matched analysis of the National Cancer Database.

PURPOSE: While robotic surgery is more costly and involves longer intra-operative time, it has a technical advantage over laparoscopic surgery. With our aging population, patients are being diagnosed with colon cancer at older ages. The aim of this study is to compare laparoscopic versus robotic colectomy short- and long-term outcomes in elderly patients diagnosed with colon cancer at a national level. METHODS: This retrospective cohort study was conducted using the National Cancer Database. Subjects ≥ 80-years-old who were diagnosed with stage I to III colon adenocarcinoma and underwent a robotic or laparoscopic colectomy from 2010-2018 were included. The laparoscopic group was propensity-score matched in a 3:1 ratio to the robotic group with 9343 laparoscopic and 3116 robotic cases matched. The main outcomes evaluated were 30-day mortality, 30-day readmission rate, median survival, and length of stay. RESULTS: There was no significant difference in the 30-day readmission rate (OR = 1.1, CI = 0.94-1.29, p = 0.23) or 30-day mortality rate (OR = 1.05, CI = 0.86-1.28, p = 0.63) between both groups. Robotic surgery was associated with higher overall survival (42 vs 44.7 months, p < 0.001) using a Kaplan-Meier survival curve. Robotic surgery had a statistically significant shorter length of stay (6.4 vs. 5.9 days, p < 0.001). CONCLUSION: Robotic colectomies are associated with higher median survival rates and decrease in the length of hospital stay compared to laparoscopic colectomies in the elderly population.

Polypharmacy Prevalence and Perceptions of Deprescribing in Elderly Patients Among Community Primary Care Providers in Mid-Michigan Practices.

INTRODUCTION: Polypharmacy is common among the elderly and can predispose them to increased morbidity and higher healthcare expenditures. Deprescribing is an important aspect of preventative medicine to minimize polypharmacy-related adverse effects. Mid-Michigan has historically been considered a medically underserved area. We sought to describe polypharmacy prevalence and primary care provider (PCP) perceptions of deprescribing in the elderly at community practices in the region. METHODS: Medicare Part D claims data from 2018 to 2020 were queried to calculate the prevalence of polypharmacy, which is defined as Medicare beneficiaries who were concurrently prescribed at least five medications. PCPs from four community practices in adjacent counties in mid-Michigan, including two high- and two low-prescribing practices, were surveyed to assess their perceptions of deprescribing. RESULTS: The prevalence of polypharmacy in two adjacent mid-Michigan counties was 44.0% and 42.5%, which was similar to Michigan's overall prevalence of 40.7% (p = 0.720 and 0.844, respectively). Additionally, 27 survey responses were received from mid-Michigan PCPs (response rate, 30.7%). Most respondents expressed confidence in deprescribing in the elderly from a clinical standpoint (66.7%). Barriers to deprescribing included patient/family concerns (70.4%) and lack of time during office visits (37.0%). Facilitators to deprescribing included patient readiness (18.5%), collaboration with case managers/pharmacists (18.5%), and up-to-date medication lists (18.5%). An exploratory comparison of perceptions at high- and low-prescribing practices showed no significant differences. CONCLUSION: These findings demonstrate a high prevalence of polypharmacy in mid-Michigan and suggest that PCPs in the region are generally supportive of deprescribing. Potential targets to improve deprescribing in patients with polypharmacy include addressing visit length, patient/family concerns, increasing interdisciplinary collaboration, and medication reconciliation support.

The World Neurosurgery Global Champions Program: First-Year Experience of a Model Initiative for Reducing Disparities in Global Neurosurgical Literature.

OBJECTIVE: Most surgical journals are published in English, representing a challenge for researchers from non-Anglophone countries. We describe the implementation, workflow, outcomes, and lessons learned from the WORLD NEUROSURGERY Global Champions Program (GCP), a novel journal-specific English language editing program for articles rejected because of poor English grammar or usage. METHODS: The GCP was advertised via the journal website and social media. Applicants were selected to be a reviewer for the GCP if they demonstrated English proficiency on writing samples supplied in their application. The demographics of GCP members and characteristics and outcomes of articles edited by the GCP during its first year were reviewed. Surveys of GCP members and authors who used the service were conducted. RESULTS: Twenty-one individuals became part of the GCP, representing 8 countries and 16 languages apart from English. A total of 380 manuscripts were peer reviewed by the editor-in-chief, who determined these manuscripts to have potentially worthwhile content but needed to be rejected due to poor language. The authors of these manuscripts were informed of the existence of this language assistance program. Forty-nine articles (12.9%) were edited by the GCP in 41.6 ± 22.8 days. Of 40 articles resubmitted to WORLD NEUROSURGERY, 24 (60.0%) were accepted. GCP members and authors understood the purpose and workflow of the program and recognized improvements in article quality and the probability of acceptance through their participation. CONCLUSIONS: The WORLD NEUROSURGERY Global Champions Program mitigated a critical barrier to publication in an English language journal for authors from non-Anglophone countries. This program promotes research equity by providing a free, largely medical student and trainee operated, English language editing service. This model or a similar service can be replicated by other journals.

Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma.

Importance: Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred. Objective: To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma. Design, Setting, and Participants: Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021. Exposures: En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT. Main Outcomes and Measures: Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03. Results: A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001). Conclusions and Relevance: These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.

Nervous system involvement in SARS-coronavirus infection: a review on lessons learned from the previous outbreaks, ongoing pandemic and what to expect in the future.

Viral infections have been associated with the deleterious damage to nervous system resulting in impairment of the central nervous system as late sequalae infections. Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), several studies have reported patients developing adverse neurological signs and symptoms. Like the outbreak of SARS in 2003, the recent outbreak has undermined the norm of the nervous system. This review will summarize the possible mechanism of neurological manifestations, the clinical presentations of patients with such symptoms secondary to SARS coronaviruses, and the prospective role of neurology and neurosurgery practice in managing these symptoms in the current climate.

Time-to-enrollment in clinical trials investigating neurological recovery in chronic spinal cord injury: observations from a systematic review and ClinicalTrials.gov database.

Currently, large numbers of clinical trials are performed to investigate different forms of experimental therapy for patients suffering from chronic spinal cord injury (SCI). However, for the enrollment process, there are different views on how the time period between injury and interventions should be determined. Herein, we sought to evaluate the impact of time-to-enrollment in chronic SCI clinical trials. A data set comprising 957 clinical studies from clinicalTrials.gov was downloaded and analyzed focusing on the eligibility criteria for post-injury time-to-enrollment. We also aggregated individual patient data from nine clinical trials of regenerative interventions for chronic SCI selected by a systematic literature search from 1990 to 2018. Characteristics of the studies were assessed and compared by dividing into three groups based on time-to-enrollment (group 1 ≤ 12 months, group 2 = 12-23 months and group 3 ≥ 24 months). In ClinicalTrials.gov registry, 445 trials were identified for chronic SCI where 87% (385) were unrestricted in the maximum post-injury time for trial eligibility. From systematic literature search, nine studies and 156 patients (group 1 = 30, group 2 = 55 and group 3 = 71) were included. The range of time-to-enrollment was 0.5 to 321 months in those studies. We also observed various degrees of motor and sensory improvement in between three time-to-enrollment groups. Our results indicate that enrolling wide ranges of time-to-enrollment in a group may present imprecise outcomes. Clinical trial designs should consider appropriate post-injury time frames to evaluate therapeutic benefit.

Disparities in Reported Testing for 1p/19q Codeletion in Oligodendroglioma and Oligoastrocytoma Patients: An Analysis of the National Cancer Database.

PURPOSE: A chromosomal 1p/19q codeletion was included as a required diagnostic component of oligodendrogliomas in the 2016 World Health Organization (WHO) classification of central nervous system tumors. We sought to evaluate disparities in reported testing for 1p/19q codeletion among oligodendroglioma and oligoastrocytoma patients before and after the guidelines. METHODS: The National Cancer Database (NCDB) was queried for patients with histologically-confirmed WHO grade II/III oligodendroglioma or oligoastrocytoma from 2011-2017. Adjusted odds of having a reported 1p/19q codeletion test for patient- and hospital-level factors were calculated before (2011-2015) and after (2017) the guidelines. The adjusted likelihood of receiving adjuvant treatment (chemotherapy and/or radiotherapy) based on reported testing was also evaluated. RESULTS: Overall, 6,404 patients were identified. The reported 1p/19q codeletion testing rate increased from 45.8% in 2011 to 59.8% in 2017. From 2011-2015, lack of insurance (OR 0.77; 95% CI 0.62-0.97;p=0.025), lower zip code-level educational attainment (OR 0.62; 95% CI 0.49-0.78;p<0.001), and Northeast (OR 0.68; 95% CI 0.57-0.82;p<0.001) or Southern (OR 0.62; 95% CI 0.49-0.79;p<0.001) facility geographic region were negatively associated with reported testing. In 2017, Black race (OR 0.49; 95% CI 0.26-0.91;p=0.024) and Northeast (OR 0.50; 95% CI 0.30-0.84;p=0.009) or Southern (OR 0.42; 95% CI 0.22-0.78;p=0.007) region were negatively associated with reported testing. Patients with a reported test were more likely to receive adjuvant treatment (OR 1.73; 95% CI 1.46-2.04;p<0.001). CONCLUSION: Despite the 2016 WHO guidelines, disparities in reported 1p/19q codeletion testing by geographic region persisted while new disparities in race/ethnicity were identified, which may influence oligodendroglioma and oligoastrocytoma patient management.

Disparities in access to surgery for glioblastoma multiforme at high-volume Commission on Cancer-accredited hospitals in the United States.

OBJECTIVE: Although it has been shown that surgery for glioblastoma (GBM) at high-volume facilities (HVFs) may be associated with better postoperative outcomes, the use of such hospitals may not be equally distributed. The authors aimed to evaluate racial and socioeconomic differences in access to surgery for GBM at high-volume Commission on Cancer (CoC)-accredited hospitals. METHODS: The National Cancer Database was queried for patients with GBM that was newly diagnosed between 2004 and 2015. Patients who received no surgical intervention or those who received surgical intervention at a site other than the reporting facility were excluded. Annual surgical case volume was calculated for each hospital, with volume ≥ 90th percentile defined as an HVF. Multivariable logistic regression was performed to identify patient-level predictors for undergoing surgery at an HVF. Furthermore, multiple subgroup analyses were performed to determine the adjusted odds ratio of the likelihood of undergoing surgery at an HVF in 2016 as compared to 2004 for each patient subpopulation (by age, race, sex, educational group, etc.). RESULTS: A total of 51,859 patients were included, with 10.7% (n = 5562) undergoing surgery at an HVF. On multivariable analysis, Hispanic White patients (OR 0.58, 95% CI 0.49-0.69, p < 0.001) were found to have significantly lower odds of undergoing surgery at an HVF (reference = non-Hispanic White). In addition, patients from a rural residential location (OR 0.55, 95% CI 0.41-0.72, p < 0.001; reference = metropolitan); patients with nonprivate insurance status (Medicare [OR 0.78, 95% CI 0.71-0.86, p < 0.001], Medicaid [OR 0.68, 95% CI 0.60-0.78, p < 0001], other government insurance [OR 0.68, 95% CI 0.52-0.86, p = 0.002], or who were uninsured [OR 0.61, 95% CI 0.51-0.72, p < 0.001]); and lower-income patients ($50,354-$63,332 [OR 0.68, 95% CI 0.63-0.74, p < 0.001], $40,227-$50,353 [OR 0.84, 95% CI 0.76-0.92, p < 0.001]; reference = ≥ $63,333) were also found to be significantly associated with a lower likelihood of surgery at an HVF. Subgroup analyses revealed that elderly patients (age ≥ 65 years), both male and female patients and non-Hispanic White patients, and those with private insurance, Medicare, metropolitan residential location, median zip code-level household income in the first and second quartiles, and educational attainment in the first and third quartiles had increased odds of undergoing surgery at an HVF in 2016 compared to 2004 (all p ≤ 0.05). On the other hand, patients with other governmental insurance, patients with a rural residence, and those from a non-White racial category did not show a significant difference in odds of surgery at an HVF over time (all p > 0.05). CONCLUSIONS: The present analysis from the National Cancer Database revealed significant disparities in access to surgery at an HVF for GBM within the United States. Furthermore, there was evidence that these racial and socioeconomic disparities may have widened between 2004 and 2016. The findings should assist health policy makers in the development of strategies for improving access to HVFs for racially and socioeconomically disadvantaged populations.

Do all outpatient spine surgeries cost the same? Comparison of economic outcomes data from a state-level database for outpatient lumbar decompression performed in an ambulatory surgery center or hospital outpatient setting.

OBJECTIVE: Spinal procedures are increasingly conducted as outpatient procedures, with a growing proportion conducted in ambulatory surgery centers (ASCs). To date, studies reporting outcomes and cost analyses for outpatient spinal procedures in the US have not distinguished the various outpatient settings from each other. In this study, the authors used a state-level administrative database to compare rates of overnight stays and nonroutine discharges as well as index admission charges and cumulative 7-, 30-, and 90-day charges for patients undergoing outpatient lumbar decompression in freestanding ASCs and hospital outpatient (HO) settings. METHODS: For this project, the authors used the Florida State Ambulatory Surgery Database (SASD), offered by the Healthcare Cost and Utilization Project (HCUP), for the years 2013 and 2014. Patients undergoing outpatient lumbar decompression for degenerative diseases were identified using CPT (Current Procedural Terminology) and ICD-9 codes. Outcomes of interest included rates of overnight stays, rate of nonroutine discharges, index admission charges, and subsequent admission cumulative charges at 7, 30, and 90 days. Multivariable analysis was performed to assess the impact of outpatient type on index admission charges. Marginal effect analysis was employed to study the difference in predicted dollar margins between ASCs and HOs for each insurance type. RESULTS: A total of 25,486 patients were identified; of these, 7067 patients (27.7%) underwent lumbar decompression in a freestanding ASC and 18,419 (72.3%) in an HO. No patient in the ASC group required an overnight stay compared to 9.2% (n = 1691) in the HO group (p < 0.001). No clinically significant difference in the rate of nonroutine discharge was observed between the two groups. The mean index admission charge for the ASC group was found to be significantly higher than that for the HO group ($35,017.28 ± $14,335.60 vs $33,881.50 ± $15,023.70; p < 0.001). Patients in ASCs were also found to have higher mean 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.001) readmission charges. ASC procedures were associated with increased charges compared to HO procedures for patients on Medicare or Medicaid (mean index admission charge increase $4049.27, 95% CI $2577.87-$5520.67, p < 0.001) and for patients on private insurance ($4775.72, 95% CI $4171.06-$5380.38, p < 0.001). For patients on self-pay or no charge, a lumbar decompression procedure at an ASC was associated with a decrease in index admission charge of -$10,995.38 (95% CI -$12124.76 to -$9866.01, p < 0.001) compared to a lumbar decompression procedure at an HO. CONCLUSIONS: These "real-world" results from an all-payer statewide database indicate that for outpatient spine surgery, ASCs may be associated with higher index admission and subsequent 7-, 30-, and 90-day charges. Given that ASCs are touted to have lower overall costs for patients and better profit margins for physicians, these analyses warrant further investigation into whether this cost benefit is applicable to outpatient spine procedures.

Economic Burden of Hospitalizations Associated with Opioid Dependence Among Patients Undergoing Spinal Fusion.

BACKGROUND: The current study seeks to examine the association between chronic opioid use and postoperative outcomes for patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF). METHODS: The National Inpatient Sample was queried for patients with and without chronic opioid use undergoing ACDF or PLF for degenerative disc disease between 2012 and 2015 using ICD-9 diagnosis and procedure codes. Multivariable conditional logistic regression was performed to assess the association between chronic opioid use and length of stay (LOS), nonhome discharge, and hospital charge. RESULTS: A total of 391 patients undergoing ACDF and 644 patients undergoing PLF with opioid dependence were identified. On multivariable regression analysis, opioid dependence was significantly associated with an increased LOS (mean, 3.09 days vs. 2.16 days; odds ratio (OR) for prolonged LOS (>3 days), 2.11; 95% confidence interval [CI], 1.43-3.14; P < 0.001). Although on unadjusted analyses, patients with opioid dependence undergoing ACDF were found to have higher hospital charges (mean, U.S. $18,698.42 vs. $11,378.61; P < 0.001) and higher rates of nonroutine discharge (19.18% vs. 10.21%; P < 0.001), the multivariable regression analyses found no significant association between opioid dependence and odds of hospital charges >75th percentile (OR, 1.44; 95% CI, 0.84-2.47; P = 0.188) or nonroutine discharge (OR, 1.48; 95% CI, 0.93-2.34; P = 0.098). For those undergoing PLF, opioid dependence was significantly associated with increased hospital charges (mean, U.S. $37,712.98 vs. $30,475.43, P < 0.001; OR for hospital charge >75th percentile, 1.78, 95% CL, 1.23-2.58, P = 0.002), LOS (mean, 3.42 days vs. 2.30 days; OR for prolonged LOS, 1.53; 95% CI, 1.16-2.00; P = 0.003), and nonroutine discharge (46.89% vs. 36.47%; OR, 1.74; 95% CI, 1.34-2.26; P < 0.001) on both unadjusted and adjusted multivariable regression analyses. CONCLUSIONS: Our analysis using a national administrative database showed that opioid dependence may be associated with worse economic outcomes for patients undergoing ACDF and PLF.

Prevalence and Trends in Management of Idiopathic Normal Pressure Hydrocephalus in the United States: Insights from the National Inpatient Sample.

BACKGROUND: Over the past 2 decades, management of idiopathic normal pressure hydrocephalus (iNPH) has evolved significantly. In the current study, we sought to evaluate the national prevalence and management trends of iNPH in the United States using a national database. METHODS: The National Inpatient Sample was queried for patients with an International Classification of Diseases diagnosis code for iNPH from 2007 to 2017. Trends in prevalence and procedure type were evaluated per 100,000 discharges and as a percentage of discharges, using weighted discharges. Utilization of procedure type across U.S. regions and hospital types was also compared. RESULTS: From 2007 to 2017, 302,460 weighted discharges with any diagnosis code for iNPH, aged ≥60 years, were identified. Prevalence ranged from 0.04% to 0.20% (41/100,000 to 202/100,000) among admitted patients ≥60 years old, giving an average prevalence during the study duration of 0.18% (179/100,000). Of 66,759 weighted discharges with a primary diagnosis code of iNPH undergoing surgical management, ventriculoperitoneal shunt (72.0% of discharges, n = 48,977) was most commonly used; of these, 9.3% (n = 4567) were performed laparoscopically. This result was followed by lumbar peritoneal shunt (15.1% of discharges, n = 10,441). Up to 15.1% (n = 9990) of discharges reported only a lumbar puncture, assumed to be only diagnostic, for screening, or part of serial cerebrospinal fluid removal procedures. Significant discrepancies in procedure utilization were also identified among hospitals in the Western, Southern, Northeast and Midwest regions, as well as between urban and rural hospitals (P < 0.05). CONCLUSIONS: We have summarized the national prevalence of iNPH, trends in its management over the previous decade and trends by region and hospital type.

Utility of the 5-Item Modified Frailty Index for Predicting Adverse Outcomes Following Elective Anterior Cervical Discectomy and Fusion.

BACKGROUND: Frailty is an increasingly studied tool for preoperative risk stratification, but its prognostic value for anterior cervical discectomy and fusion (ACDF) patients is unclear. We sought to evaluate the association of the 5-item modified Frailty Index (5i-mFI) with 30-day adverse outcomes following ACDF and its predictive performance compared with other common metrics. METHODS: The National Surgical Quality Improvement Program was queried from 2016-2018 for patients undergoing elective ACDF for degenerative diseases. Outcomes of interest included 30-day complications, extended length of stay (LOS), non-home discharge, and unplanned readmissions. Unadjusted/adjusted odds ratios were calculated. The discriminatory performance of the 5i-mFI compared with age, American Society of Anesthesiologists (ASA) classification, and body mass index was computed using the area under the receiver operating characteristic curve (AUC). RESULTS: A total of 23,754 patients were identified. On adjusted analysis, an index of 1 was significantly associated with extended LOS, non-home discharge, and unplanned readmissions (P < 0.001, P = 0.023, P = 0.003, respectively), but not complications (all P > 0.05). An index ≥2 was significantly associated with each outcome (all P < 0.001). The 5i-mFI was found to have a significantly higher AUC than body mass index for each outcome, a similar AUC compared with ASA classification and age for complications and unplanned readmissions, and a significantly lower AUC than ASA classification and age for extended LOS and non-home discharge. CONCLUSIONS: The 5i-mFI was found to be significantly associated with 30-day adverse outcomes following ACDF but had similar or lesser predictive performance compared with more universally available and easily implemented metrics, such as ASA classification and age.

Is postoperative atelectasis following lumbar fusion more prevalent among patients with chronic opioid use?

OBJECTIVE: Chronic opioid use (COU) remains on the rise globally, acting as a marker for patient morbidity and a risk factor for adverse health outcomes. Opioid use is a risk factor for respiratory depression, which may lead to dysfunctional breathing, a known cause of atelectasis. The objective of this study was to determine whether COU is associated with increased rates of postoperative atelectasis among patients undergoing lumbar fusion. MATERIALS & METHODS: Three State Inpatient Databases were used to identify patients who underwent an elective lumbar fusion through an anterior, posterior or circumferential approach in Florida, Kentucky and New York between 2013-2015. Patients with COU and those with postoperative atelectasis were identified using ICD diagnosis codes. Three operative groups were created and subsequently matched using propensity scores in order to provide comparable cohorts for analysis. Three-to-one propensity score matching was conducted using the variables of age, sex, race, number of chronic diagnoses and geographic state of admission. Multivariable logistic regressions were used to examine the relationship between COU and postoperative atelectasis. RESULTS: A total of 3618 lumbar fusions were identified. Atelectasis was noted in 1.33 % of NCOU patients and 2.32 % of COU patients. On multivariable analysis, while controlling for the Elixhauser Mortality Index and patient insurance status, COU was significantly associated with atelectasis in posterior lumbar fusion (OR = 2.27; CI: 1.09-4.72; p = 0.028) and circumferential lumbar fusion (OR = 4.68; CI: 1.52-14.45; p = 0.007). The Elixhauser Mortality Index was also significantly associated with atelectasis in posterior lumbar fusion (OR = 1.08; CI: 1.04-1.11; p < 0.001) and circumferential lumbar fusion (OR = 1.09; CI: 1.03-1.16; p = 0.002). CONCLUSION: Higher rates of postoperative atelectasis were found among patients with COU following posterior and circumferential lumbar fusions. The Elixhauser Mortality Index was also independently associated with atelectasis. Knowledge of these risks may allow for earlier identification and intervention in patients who are at risk.

Use of teriparatide prior to lumbar fusion surgery lowers two-year complications for patients with poor bone health.

INTRODUCTION: Poor bone health can create challenges in management which are amplified for patients undergoing spinal fusion. Although previously shown to improve outcomes postoperatively, the impact of preoperative teriparatide use on long-term complications remains unclear. In this study, we investigated the complication rates within two years of surgery for osteoporotic and osteopenic patients using teriparatide prior to lumbar fusion procedures. METHODS: Patients with poor bone health undergoing any lumbar fusion surgery at a single institution between 2008 and 2018 were identified and subsequently divided into two groups as teriparatide and non-teriparatide group. Baseline demographics, patient and surgery related factors, and two-year complications were collected through a retrospective chart review. Multivariable logistic regression was performed to evaluate the association between teriparatide usage and development of any related postoperative complication. RESULTS: A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8-68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64-75.8). Overall, there were no statistically significant differences in terms of individual complications between the groups. However, on adjusted regression analysis, teriparatide use was associated with significantly lower odds of related complications for lumbar fusion patients (p = 0.049). CONCLUSION: Teriparatide use prior to lumbar fusion procedures resulted in reduced rate of osteoporosis-related complications within two years postoperatively. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.

Predictors of adverse outcomes and cost after surgical management for idiopathic normal pressure hydrocephalus: Analyses from a national database.

INTRODUCTION: We utilized a national administrative database to investigate drivers of immediate adverse economic and hospital outcomes, including non-routine discharge, prolonged length of stay (LOS), and admission costs among patients undergoing surgery for idiopathic normal pressure hydrocephalus (iNPH). METHODS: The National Inpatient Sample (NIS) was queried from 2007 to 2017 for patients aged ≥60 with a diagnosis code for iNPH undergoing surgery. Multivariable logistic-regression models and Wald χ2 were used to identify drivers of non-routine discharge, prolonged length of stay (LOS) (>75th percentile) and higher admission costs (>90th percentile). RESULTS: A total of 13,363 patients with iNPH undergoing surgical management were identified. The most common comorbidity reported in the cohort was a cardiovascular pathology (56.9 %, n = 7,787), followed by urinary pathology (37.2 %, n = 5,084), osteoarthritis (7.8 %, n = 1,071), Alzheimer's disease (4.6 %, n = 626) and cerebrovascular pathology (4.2 %, n = 569). The most frequently employed procedure was ventriculo-peritoneal (VP) shunt placement (65.6 %, n = 8,942) of which 89.8 % (n = 8,027) were performed open and 10.2 % (n = 915) laparoscopically. This was followed by lumbo-peritoneal (LP) shunting (15.5 %, n = 2,115), lumbar puncture alone (screened, serial CSF removal) (14.8 %, n = 2,013), endoscopic third ventriculostomy (ETV) (2%, n = 274), ventriculo-atrial (VA) shunt (0.95 %, n = 130) and ventriculo-pleural (Vpleural) shunt (0.46 %, n = 64). The median (IQR) LOS was 3 days (2-5), the rate of non-routine discharge was 37.3 % and median (IQR) cost was $11,230 ($7,735-15,590). On multivariable-analysis, emergent-admission (OR 2.91), older age (76-90: OR 1.55; 90+: OR 2.66), VP shunt (open: OR 3.09; laparoscopic: OR 2.32), ETV (OR 3.16), VA/VPleural shunt (OR 2.73) and hospital admission in Northeast-region compared to Midwest (OR 1.27) were found to be associated with increased risk of non-routine discharge. Some of the highly significant associated factors for prolonged LOS included emergent-admission (OR 11.34), ETV (OR 10.92), VA/VPleural shunt (OR 7.79) and open VP shunt (OR 8.24). For increased admission costs, some of the highly associated factors included VA/VPleural shunt (OR 18.48), laparoscopic VP shunt (OR 9.92), open VP shunt (OR 12.72) and ETV (OR 9.34). Predictor importance analysis revealed emergent admission, number of diagnosis codes (comorbidities) open VP shunt, hospital region, age] and revision or removal of shunt to be the most important drivers of these outcomes. CONCLUSION: Analyses from a national database indicate that among patients with iNPH, an emergent-admission may be the most significant risk-factor of adverse economic outcomes and higher costs.

Chronic opioid use is associated with increased postoperative urinary retention, length of stay and non-routine discharge following lumbar fusion surgery.

BACKGROUND: The incidence of chronic opioid use (COU) is increasing with health related complications impacting both patients and healthcare services. OBJECTIVE: The aim of this study was to identify the impact of COU on postoperative urinary retention (PUR) in patients following lumbar fusion surgery as well as its impact on length of stay (LOS) and non-routine discharges (NRD). MATERIALS & METHODS: The State Inpatient Databases were utilised to identify patients undergoing elective lumbar fusion procedures. Patients with and without COU were separated into groups and matched using 3:1 propensity score matching. PUR, LOS in the upper quartile and discharge to a location other than home were the outcomes of interest. Multivariable logistic regression was used to examine the impact of COU on the above outcomes and Wald chi-square tests were used to determine the factors with the most significant associations. RESULTS: COU was significant for PUR (p = 0.037), prolonged LOS (p < 0.001), and NRD (p < 0.001). Factors most significantly associated with PUR were Elixhauser Mortality Index and COU both with p < 0.05. Factors associated with prolonged LOS and NRD were Elixhauser Mortality Index, COU, and insurance status. CONCLUSION: COU has a notable impact on PUR, LOS, and NRD. The Elixhauser Mortality Index and insurance status of patients also showed predictive utility for these outcomes. This knowledge enables us to identify sources of pressure for health services and approach them strategically through increased awareness.

Institutional databases may underestimate the risk factors for 30-day unplanned readmissions compared to national databases.

OBJECTIVE: The National Surgical Quality Improvement Program (NSQIP) and National Readmissions Database (NRD) are two widely used databases for research studies. However, they may not provide generalizable information in regard to individual institutions. Therefore, the objective of the present study was to evaluate 30-day readmissions following anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) procedures by using these two national databases and an institutional cohort. METHODS: The NSQIP and NRD were queried for patients undergoing elective ACDF and PLF, with the addition of an institutional cohort. The outcome of interest was 30-day readmissions following ACDF and PLF, which were unplanned and related to the index procedure. Subsequently, univariable and multivariable analyses were conducted to determine the predictors of 30-day readmissions by using both databases and the institutional cohort. RESULTS: Among all identified risk factors, only hypertension was found to be a common risk factor between NRD and the institutional cohort following ACDF. NSQIP and the institutional cohort both showed length of hospital stay to be a significant predictor for 30-day related readmission following PLF. There were no overlapping variables among all 3 cohorts for either ACDF or PLF. Additionally, the national databases identified a greater number of risk factors for 30-day related readmissions than did the institutional cohort for both procedures. CONCLUSIONS: Overall, significant differences were seen among all 3 cohorts with regard to top predictors of 30-day unplanned readmissions following ACDF and PLF. The higher quantity of significant predictors found in the national databases may suggest that looking at single-institution series for such analyses may result in underestimation of important variables affecting patient outcomes, and that big data may be helpful in addressing this concern.

Comparison of Costs and Postoperative Outcomes between Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Compression Fractures: Analysis from a State-Level Outpatient Database.

BACKGROUND: Vertebral cement augmentation techniques are routinely used to treat osteoporotic vertebral compression fractures (VCFs). In the current study, we used a state-level outpatient database to compare costs and postoperative outcomes between vertebroplasty and kyphoplasty. METHODS: We queried the 2016 Florida State-Ambulatory Surgery Database of the Healthcare Cost and Utilization Project for patients undergoing thoracolumbar vertebroplasty or kyphoplasty for osteoporotic VCFs. Demographic and clinical characteristics, as well as postoperative outcomes were compared between the 2 groups. RESULTS: A total of 105 patients (11.6%) who underwent vertebroplasty and 801 patients (88.4%) who underwent kyphoplasty were identified. Patients undergoing kyphoplasty were more likely to stay overnight or longer, with the P value trending toward significance (kyphoplasty with >1 day stay: 7.4% vs. vertebroplasty with >1 day stay: 1.9%; P = 0.086). Patients undergoing vertebroplasty had a significantly higher rate of discharge to home routine compared with patients undergoing kyphoplasty (97.1% [n = 102] vs. 94.1% [n = 754]; P < 0.001). Undergoing kyphoplasty was also associated with higher index admission costs ($40,706 vs. $18,965; P < 0.001) and higher readmission costs ($27,038 vs. $11,341; P = 0.046). The rates of 30-day and 90-day readmission were similar between the 2 groups (all P > 0.05). The rates of 30-day, 90-day, and overall readmission because of a new-onset fracture were also similar (all P > 0.05). However, vertebroplasty had a higher rate of readmissions associated with a procedure within a year (21.9% [n = 23] vs. 14.5% [n = 116]; P = 0.047). CONCLUSIONS: Our analyses from a state-level database of patients undergoing vertebroplasty and kyphoplasty for osteoporotic VCFs show similar postoperative outcomes for the 2 procedures but a higher cost for kyphoplasty.