Limited English proficiency, cardiovascular risk factors, cardiovascular disease, and in-hospital COVID-19 outcomes.

OBJECTIVES: Cardiovascular risk factors and history of cardiovascular disease are associated with greater morbidity and mortality in patients hospitalized with COVID-19. Limited English proficiency (LEP) has also been associated with worse outcomes in this setting, including requiring intensive care unit (ICU) level of care and in-hospital death. Whether non-English-language preference (NELP) modifies the association between cardiovascular risk factors or disease and outcomes in patients hospitalized with COVID-19 is unknown. STUDY DESIGN: Retrospective cohort study of adult patients admitted to a large New England health system between March 1 and December 31, 2020, who tested positive for COVID-19. NELP was defined as having a preferred language that was not English noted in the electronic health record. METHODS: Cardiovascular risk factors, history of cardiovascular disease, and NELP were related to the primary composite clinical outcome-death or ICU admission-using multivariable binary logistic regression adjusted for demographic and clinical characteristics. Interaction terms for NELP and model covariates were evaluated. RESULTS: Of 3582 patients hospitalized with COVID-19, 1024 (28.6%) had NELP; 812 (79.3%) of the patients with NELP received interpreter services. Death or ICU admission occurred in 794 (22.2%) of the hospitalized patients. NELP was not significantly associated with the primary composite outcome in unadjusted or adjusted analyses. In the adjusted analyses, only male gender, coronary artery disease, pulmonary circulatory disease, and liver disease significantly predicted the primary outcome. NELP did not modify the effect of these associations. CONCLUSIONS: NELP was not significantly associated with odds of death or ICU admission, nor did it modify the association between cardiovascular risk factors or history of cardiovascular disease and this composite outcome. Because most patients with NELP received interpreter services, these findings may support the role of such services in ensuring equitable outcomes.

Risk factors of emergency department visits following elective cervical and lumbar surgical procedures: a multi-institution analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors. METHODS: This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses. RESULTS: Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits. CONCLUSIONS: The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

The impact of anxiety and depression on lumbar spine surgical outcomes: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: The presence of depression and anxiety has been associated with negative outcomes in spine surgery patients. While it seems evident that a history of depression or anxiety can negatively influence outcome, the exact additive effect of both has not been extensively studied in a multicenter trial. The purpose of this study was to investigate the relationship between a patient's history of anxiety and depression and their patient-reported outcomes (PROs) after lumbar surgery. METHODS: Patients in the Michigan Spine Surgery Improvement Collaborative registry undergoing lumbar spine surgery between July 2016 and December 2021 were grouped into four cohorts: those with a history of anxiety only, those with a history of depression only, those with both, and those with neither. Primary outcomes were achieving the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System Physical Function 4-item Short Form (PROMIS PF), EQ-5D, and numeric rating scale (NRS) back pain and leg pain, and North American Spine Society patient satisfaction. Secondary outcomes included surgical site infection, hospital readmission, and return to the operating room. Multivariate Poisson generalized estimating equation models were used to report incidence rate ratios (IRRs) from patient baseline variables. RESULTS: Of the 45,565 patients identified, 3941 reported a history of anxiety, 5017 reported a history of depression, 9570 reported both, and 27,037 reported neither. Compared with those who reported having neither, patients with both anxiety and depression had lower patient satisfaction at 90 days (p = 0.002) and 1 year (p = 0.021); PROMIS PF MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p = 0.006); EQ-5D MCID at 90 days (p < 0.001), 1 year (p < 0.001), and 2 years (p < 0.001); NRS back pain MCID at 90 days (p < 0.001) and 1 year (p < 0.001); and NRS leg pain MCID at 90 days (p < 0.001), 1 year (p = 0.024), and 2 years (p = 0.027). Patients with anxiety only (p < 0.001), depression only (p < 0.001), or both (p < 0.001) were more likely to be readmitted within 90 days. Additionally, patients with anxiety only (p = 0.015) and both anxiety and depression (p = 0.015) had higher rates of surgical site infection. Patients with anxiety only (p = 0.006) and depression only (p = 0.021) also had higher rates of return to the operating room. CONCLUSIONS: The authors observed an association between a history of anxiety and depression and negative outcome after lumbar spine surgery. In addition, they found an additive effect of a history of both anxiety and depression with an increased risk of negative outcome when compared with either anxiety or depression alone.

Does Tighter Glycemic Control Beyond Hemoglobin A1c of 8% Improve Outcome for Lumbar Spine Surgery? A MSSIC Study.

BACKGROUND AND OBJECTIVES: Diabetes mellitus is associated with increased risk of postoperative adverse outcomes. Previous studies have emphasized the role of glycemic control in postoperative complications. This study aims to ascertain whether controlling hemoglobin A1c (HbA1c) lower than 8% preoperatively results in meaningful risk reduction or improved outcomes. METHODS: We used patient-level data from the Michigan Spine Surgery Improvement Collaborative registry, focusing on patients who underwent elective lumbar spine surgery between 2018 and 2021. The primary outcomes were length of stay and the occurrence of postoperative adverse events. Secondary outcomes included patient satisfaction, achievement of a minimum clinically important difference (MCID) of Patient-Reported Outcomes Measurement Information System-Physical Function, the EuroQol-5D and NRS of leg and back pain, and return to work. RESULTS: A total of 11 348 patients were included in this analysis. Patients with HbA1c above the thresholds before surgery had significantly higher risks of urinary retention for all 3 possible threshold values (incidence rate ratio [IRR] = 1.30, P = .015; IRR = 1.35, P = .001; IRR = 1.25, P = .011 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively). They also had longer hospital stay (IRR = 1.04, P = .002; IRR = 1.03, P = .001; IRR = 1.03, P < .001 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and had higher risks of developing any complication with HbA1c cutoff of 7.5% (IRR = 1.09, P = .010) and 7% (IRR = 1.12, P = .001). Diabetics with preoperative HbA1c above all 3 thresholds were less likely to achieve Patient-Reported Outcomes Measurement Information System MCID at the 90-day follow-up (IRR = .81, P < .001; IRR = .86, P < .001; IRR = .90, P = .007 for the HbA1c cutoffs of 8%, 7.5%, and 7%, respectively) and less likely to achieve EuroQol-5D MCID at the 2-year follow-up (IRR = .87, P = .027; IRR = .84, P = .005 for the HbA1c cutoffs of 7.5% and 7%, respectively). CONCLUSION: Our study suggests that reducing HbA1c below 8% may have diminishing returns regarding reducing complications after spine surgery.

Risk factors for not reaching minimal clinically important difference at 90 days and 1 year after elective lumbar spine surgery: a cohort study.

OBJECTIVE: Patient-perceived functional improvement is a core metric in lumbar surgery for degenerative disease. It is important to identify both modifiable and nonmodifiable risk factors that can be evaluated and possibly optimized prior to elective surgery. This case-control study was designed to study risk factors for not achieving the minimal clinically important difference (MCID) in Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS PF) score. METHODS: The authors queried the Michigan Spine Surgery Improvement Collaborative database to identify patients who underwent elective lumbar surgical procedures with PROMIS PF scores. Cases were divided into two cohorts based on whether patients achieved MCID at 90 days and 1 year after surgery. Patient characteristics and operative details were analyzed as potential risk factors. RESULTS: The authors captured 10,922 patients for 90-day follow-up and 4453 patients (40.8%) did not reach MCID. At the 1-year follow-up period, 7780 patients were identified and 2941 patients (37.8%) did not achieve MCID. The significant demographic characteristic-adjusted relative risks (RRs) for both groups (RR 90 day, RR 1 year) included the following: symptom duration > 1 year (1.34, 1.41); previous spine surgery (1.25, 1.30); African American descent (1.25, 1.20); chronic opiate use (1.23, 1.25); and less than high school education (1.20, 1.34). Independent ambulatory status (0.83, 0.88) and private insurance (0.91, 0.85) were associated with higher likelihood of reaching MCID at 90 days and 1 year, respectively. CONCLUSIONS: Several key unique demographic risk factors were identified in this cohort study that precluded optimal postoperative functional outcomes after elective lumbar spine surgery. With this information, appropriate preoperative counseling can be administered to assist in shaping patient expectations.

Cervical disc arthroplasty versus anterior cervical discectomy and fusion: an analysis of the Michigan Spine Surgery Improvement Collaborative Database.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are established surgical options for the treatment of cervical radiculopathy, myelopathy, and cervical degenerative disc disease. However, current literature does not demonstrate a clear superiority between ACDF and CDA. PURPOSE: To investigate procedural and patient-reported outcomes of ACDF and CDA among patients included in the Michigan Spine Surgery Improvement Collaborative (MSSIC) database. DESIGN: Retrospective study of prospectively collected outcomes registry data. PATIENT SAMPLE: Individuals within the MSSIC database presenting with radiculopathy, myelopathy, or cervical spondylosis refractory to typical conservative care undergoing primary ACDF or CDA from January 4, 2016, to November 5, 2021. OUTCOME MEASURES: Perioperative measures (including surgery length, length of stay, return to OR, any complications), patient-reported functional outcomes at 2-year follow-up (including return to work, patient satisfaction, PROMIS, EQ-5D, mJOA). METHODS: Patients undergoing ACDF were matched 4:1 with those undergoing CDA; propensity analysis performed on operative levels (1- and 2- level procedures), presenting condition, demographics, and comorbidities. Initial comparisons performed with univariate testing and multivariate analysis performed with Poisson generalized estimating equation models clustering on hospital. RESULTS: A total of 2,208 patients with ACDF and 552 patients with CDA were included. Baseline demographics were similar, with younger patients undergoing CDA (45.6 vs 48.6 years; p<.001). Myelopathy was more frequent in ACDF patients (30% vs 25%; p=.015). CDA was more frequently planned as an outpatient procedure. Length of stay was increased in ACDF (1.3 vs 1.0 days; p<.001). Functional outcomes were similar, with comparable proportions of patients meeting minimal clinically important difference thresholds in neck pain, arm pain, PROMIS, EQ-5D, and mJOA score. After multivariate regression, no significant differences were seen in surgical or functional outcomes. CONCLUSIONS: This study demonstrates similar outcomes for those undergoing ACDF and CDA at 2 years. Previous meta-analyses of CDA clinical trial data adhere to strict inclusion and exclusion criteria required by clinical studies; this registry data provides "real world" clinical outcomes reflecting current practices for ACDF and CDA patient selection.

Association of prolonged symptom duration with poor outcomes in lumbar spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: There is a scarcity of large multicenter data on how preoperative lumbar symptom duration relates to postoperative patient-reported outcomes (PROs). The objective of this study was to determine the effect of preoperative and baseline symptom duration on PROs at 90 days, 1 year, and 2 years after lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations between January 1, 2017, to December 31, 2021, with a follow-up of 2 years. Patients were stratified into three subgroups based on symptom duration: < 3 months, 3 months to < 1 year, and ≥ 1 year. The primary outcomes were reaching the minimal clinically important difference (MCID) for the PROs (i.e., leg pain, Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), EQ-5D, North American Spine Society satisfaction, and return to work). The EQ-5D score was also analyzed as a continuous variable to calculate quality-adjusted life years. Multivariable Poisson generalized estimating equation models were used to report adjusted risk ratios, with the < 3-month cohort used as the reference. RESULTS: There were 37,223 patients (4670 with < 3-month duration, 9356 with 3-month to < 1-year duration, and 23,197 with ≥ 1-year duration) available for analysis. Compared with patients with a symptom duration of < 1 year, patients with a symptom duration of ≥ 1 year were significantly less likely to achieve an MCID in PROMIS PF, EQ-5D, back pain relief, and leg pain relief at 90 days, 1 year, and 2 years postoperatively. Similar trends were observed for patient satisfaction and return to work. With the EQ-5D score as a continuous variable, a symptom duration of ≥ 1 year was associated with 0.04, 0.05, and 0.03 (p < 0.001) decreases in EQ-5D score at 90 days, 1 year, and 2 years after surgery, respectively. CONCLUSIONS: A symptom duration of ≥ 1 year was associated with poorer outcomes on several outcome metrics. This suggests that timely referral and surgery for degenerative lumbar pathology may optimize patient outcome.

Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS: Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS: Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS: The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS: A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)-level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS: This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

Expected Costs of Primary Dental Treatments and Endoscopic Sinus Surgery for Odontogenic Sinusitis.

OBJECTIVES: Treatment of odontogenic sinusitis (ODS) due to apical periodontitis (AP) is highly successful when both dental treatment and endoscopic sinus surgery (ESS) are performed. Variation exists in the literature with regard to types and timing of dental treatments and ESS when managing ODS. This study modeled expected costs of different primary dental and sinus surgical treatment pathways for ODS due to AP. STUDY DESIGN: Decision-tree economic model. METHODS: Decision-tree models were created based on cost and treatment success probabilities. Using Medicare and consumer online databases, cost data were obtained for the following dental and sinus surgical treatments across the United States: root canal therapy (RCTx), revision RCTx, apicoectomy, extraction, dental implant, bone graft, and ESS (maxillary, ± anterior ethmoid, ± frontal). A literature review was performed to determine probabilities of dental and sinus disease resolution after different dental treatments. Expected costs were determined for primary dental extraction, RCTx, and ESS pathways, and sensitivity analyses were performed. RESULTS: Expected costs for the three different primary treatment pathways when dental care was in-network and all diseased sinuses opened during ESS were as follows: dental extraction ($4,753.83), RCTx ($4,677.34), and ESS ($7,319.85). CONCLUSIONS: ODS due to AP can be successfully treated with primary dental treatments, but ESS is still frequently required. Expected costs of primary dental extraction and RCTx were roughly equal. Primary ESS had a higher expected cost, but may still be preferred in patients with prominent sinonasal symptoms. Patients' insurance coverage may also impact decision-making. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1346-1355, 2022.

Reproducibility of Hospital Rankings Based on Centers for Medicare & Medicaid Services Hospital Compare Measures as a Function of Measure Reliability.

Importance: Unreliable performance measures can mask poor-quality care and distort financial incentives in value-based purchasing. Objective: To examine the association between test-retest reliability and the reproducibility of hospital rankings. Design, Setting, and Participants: In a cross-sectional design, Centers for Medicare & Medicaid Services Hospital Compare data were analyzed for the 2017 (based on 2014-2017 data) and 2018 (based on 2015-2018 data) reporting periods. The study was conducted from December 13, 2020, to September 30, 2021. This analysis was based on 28 measures, including mortality (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), readmissions (acute myocardial infarction, congestive heart failure, pneumonia, and coronary artery bypass grafting), and surgical complications (postoperative acute kidney failure, postoperative respiratory failure, postoperative sepsis, and failure to rescue). Exposures: Measure reliability based on test-retest reliability testing. Main Outcomes and Measures: The reproducibility of hospital rankings was quantified by calculating the reclassification rate across the 2017 and 2018 reporting periods after categorizing the hospitals into terciles, quartiles, deciles, and statistical outliers. Linear regression analysis was used to examine the association between the reclassification rate and the intraclass correlation coefficient for each of the classification systems. Results: The analytic cohort consisted of 28 measures from 4452 hospitals with a median of 2927 (IQR, 2378-3160) hospitals contributing data for each measure. The hospitals participating in the Inpatient Prospective Payment System (n = 3195) had a median bed size of 141 (IQR, 69-261), average daily census of 70 (IQR, 24-155) patients, and a median disproportionate share hospital percentage of 38.2% (IQR, 18.7%-36.6%). The median intraclass correlation coefficient was 0.78 (IQR, 0.72-0.81), ranging between 0.50 and 0.85. The median reclassification rate was 70% (IQR, 62%-71%) when hospitals were ranked by deciles, 43% (IQR, 39%-45%) when ranked by quartiles, 34% (IQR, 31%-36%) when ranked by terciles, and 3.8% (IQR, 2.0%-6.2%) when ranked by outlier status. Increases in measure reliability were not associated with decreases in the reclassification rate. Each 0.1-point increase in the intraclass correlation coefficient was associated with a 6.80 (95% CI, 2.28-11.30; P = .005) percentage-point increase in the reclassification rate when hospitals were ranked into performance deciles, 4.15 (95% CI, 1.16-7.14; P = .008) when ranked into performance quartiles, 1.47 (95% CI, 1.84, 4.77; P = .37) when ranked into performance terciles, and 3.70 (95% CI, 1.30-6.09; P = .004) when ranked by outlier status. Conclusions and Relevance: In this study, more reliable measures were not associated with lower rates of reclassifying hospitals using test-retest reliability testing. These findings suggest that measure reliability should not be assessed with test-retest reliability testing.

The role of postoperative antibiotic duration on surgical site infection after lumbar surgery.

OBJECTIVE: Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI). METHODS: The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis. RESULTS: Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008). CONCLUSIONS: Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.

Race, Ethnicity, Neighborhood Characteristics, and In-Hospital Coronavirus Disease-2019 Mortality.

BACKGROUND: Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. OBJECTIVE: The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. RESEARCH DESIGN: Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. SUBJECTS: Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. MEASURES: The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. RESULTS: Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. CONCLUSIONS: Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.

Preoperative HbA1c > 8% Is Associated With Poor Outcomes in Lumbar Spine Surgery: A Michigan Spine Surgery Improvement Collaborative Study.

BACKGROUND: Preoperative hemoglobin A1c (HbA1c) is a useful screening tool since a significant portion of diabetic patients in the United States are undiagnosed and the prevalence of diabetes continues to increase. However, there is a paucity of literature analyzing comprehensive association between HbA1c and postoperative outcome in lumbar spine surgery. OBJECTIVE: To assess the prognostic value of preoperative HbA1c > 8% in patients undergoing elective lumbar spine surgery. METHODS: The Michigan Spine Surgery Improvement Collaborative (MSSIC) database was queried to track all elective lumbar spine surgeries between January 2018 and December 2019. Cases were divided into 2 cohorts based on preoperative HbA1c level (≤8% and >8%). Measured outcomes include any complication, surgical site infection (SSI), readmission (RA) within 30 d (30RA) and 90 d (90RA) of index operation, patient satisfaction, and the percentage of patients who achieved minimum clinically important difference (MCID) using Patient-Reported Outcomes Measurement Information System. RESULTS: We captured 4778 patients in this study. Our multivariate analysis demonstrated that patients with HbA1c > 8% were more likely to experience postoperative complication (odds ratio [OR] 1.81, 95% CI 1.20-2.73; P = .005) and be readmitted within 90 d of index surgery (OR 1.66, 95% CI 1.08-2.54; P = .021). They also had longer hospital stay (OR 1.12, 95% CI 1.03-1.23; P = .009) and were less likely to achieve functional improvement after surgery (OR 0.64, 95% CI 0.44-0.92; P = .016). CONCLUSION: HbA1c > 8% is a reliable predictor of poor outcome in elective lumbar spine surgery. Clinicians should consider specialty consultation to optimize patients' glycemic control prior to surgery.

Properties of the overall hospital Star Ratings and consumer choice.

OBJECTIVES: To examine characteristics of the CMS Overall Hospital Quality Star Ratings related to their use by consumers for choosing hospitals. STUDY DESIGN: Observational study using secondary data analyses. METHODS: Hospital Star Rating data reported in February 2019 and additional quality data from California and New York were used, with a mix of analytical approaches including descriptive statistics, correlational analysis, and Poisson regression models. RESULTS: The distribution of hospitals' Star Rating summary scores was tightly compressed, with no hospitals at or near the scores that would be obtained if a hospital were either best or worst across all quality domains. Hospitals did not consistently perform well or poorly across the range of measures and quality groups included in the Star Ratings. On average, for a given quality measure included in the Star Rating program, 12% of 1-star hospitals received top-quartile scores and 16% of 5-star hospitals received bottom-quartile scores. No significant associations were found between hospitals' overall Star Ratings and their performance on a set of condition-specific quality measures for hospitals in California and New York State. CONCLUSIONS: Hospitals' overall scores clustered in the middle of the potential distribution of scores; no hospitals were either best at everything or worst at everything. The Star Ratings did not predict hospital quality scores for separate quality measures related to specific medical conditions or health care needs. These 2 observations suggest that the Star Ratings are of limited value to consumers choosing hospitals for specific care needs.

Disparities in outcomes after spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

OBJECTIVE: Most studies on racial disparities in spine surgery lack data granularity to control for both comorbidities and self-assessment metrics. Analyses from large, multicenter surgical registries can provide an enhanced platform for understanding different factors that influence outcome. In this study, the authors aimed to determine the effects of race on outcomes after lumbar surgery, using patient-reported outcomes (PROs) in 3 areas: the North American Spine Society patient satisfaction index, the minimal clinically important difference (MCID) on the Oswestry Disability Index (ODI) for low-back pain, and return to work. METHODS: The Michigan Spine Surgery Improvement Collaborative was queried for all elective lumbar operations. Patient race/ethnicity was categorized as Caucasian, African American, and "other." Measures of association between race and PROs were calculated with generalized estimating equations (GEEs) to report adjusted risk ratios. RESULTS: The African American cohort consisted of a greater proportion of women with the highest comorbidity burden. Among the 7980 and 4222 patients followed up at 1 and 2 years postoperatively, respectively, African American patients experienced the lowest rates of satisfaction, MCID on ODI, and return to work. Following a GEE, African American race decreased the probability of satisfaction at both 1 and 2 years postoperatively. Race did not affect return to work or achieving MCID on the ODI. The variable of greatest association with all 3 PROs at both follow-up times was postoperative depression. CONCLUSIONS: While a complex myriad of socioeconomic factors interplay between race and surgical success, the authors identified modifiable risk factors, specifically depression, that may improve PROs among African American patients after elective lumbar spine surgery.

Adjusting Quality Measures For Social Risk Factors Can Promote Equity In Health Care.

Risk adjustment of quality measures using clinical risk factors is widely accepted; risk adjustment using social risk factors remains controversial. We argue here that social risk adjustment is appropriate and necessary in defined circumstances and that social risk adjustment should be the default option when there are valid empirical arguments for and against adjustment for a given measure. Social risk adjustment is an important way to avoid exacerbating inequity in the health care system.

Harmonized outcome measures for use in degenerative lumbar spondylolisthesis patient registries and clinical practice.

OBJECTIVE: The development of new treatment approaches for degenerative lumbar spondylolisthesis (DLS) has introduced many questions about comparative effectiveness and long-term outcomes. Patient registries collect robust, longitudinal data that could be combined or aggregated to form a national and potentially international research data infrastructure to address these and other research questions. However, linking data across registries is challenging because registries typically define and capture different outcome measures. Variation in outcome measures occurs in clinical practice and other types of research studies as well, limiting the utility of existing data sources for addressing new research questions. The purpose of this project was to develop a minimum set of patient- and clinician-relevant standardized outcome measures that are feasible for collection in DLS registries and clinical practice. METHODS: Nineteen DLS registries, observational studies, and quality improvement efforts were invited to participate and submit outcome measures. A stakeholder panel was organized that included representatives from medical specialty societies, health systems, government agencies, payers, industries, health information technology organizations, and patient advocacy groups. The panel categorized the measures using the Agency for Healthcare Research and Quality's Outcome Measures Framework (OMF), identified a minimum set of outcome measures, and developed standardized definitions through a consensus-based process. RESULTS: The panel identified and harmonized 57 outcome measures into a minimum set of 10 core outcome measure areas and 6 supplemental outcome measure areas. The measures are organized into the OMF categories of survival, clinical response, events of interest, patient-reported outcomes, and resource utilization. CONCLUSIONS: This effort identified a minimum set of standardized measures that are relevant to patients and clinicians and appropriate for use in DLS registries, other research efforts, and clinical practice. Collection of these measures across registries and clinical practice is an important step for building research data infrastructure, creating learning healthcare systems, and improving patient management and outcomes in DLS.

Association of Stratification by Proportion of Patients Dually Enrolled in Medicare and Medicaid With Financial Penalties in the Hospital-Acquired Condition Reduction Program.

Importance: The Hospital-Acquired Condition Reduction Program (HACRP) is a value-based payment program focused on safety events. Prior studies have found that the program disproportionately penalizes safety-net hospitals, which may perform more poorly because of unmeasured severity of illness rather than lower quality. A similar program, the Hospital Readmissions Reduction Program, stratifies hospitals into 5 peer groups for evaluation based on the proportion of their patients dually enrolled in Medicare and Medicaid, but the effect of stratification on the HACRP is unknown. Objective: To characterize the hospitals penalized by the HACRP and the distribution of financial penalties before and after stratification. Design, Setting, and Participants: This economic evaluation used publicly available data on HACRP performance and penalties merged with hospital characteristics and cost reports. A total of 3102 hospitals participating in the HACRP in fiscal year 2020 (covering data from July 1, 2016, to December 31, 2018) were studied. Exposures: Hospitals were divided into 5 groups based on the proportion of patients dually enrolled, and penalties were assigned to the lowest-performing quartile of hospitals in each group rather than the lowest-performing quartile overall. Main Outcomes and Measures: Penalties in the prestratification vs poststratification schemes. Results: The study identified 3102 hospitals evaluated by the HACRP. Safety-net hospitals received $111 333 384 in penalties before stratification compared with an estimated $79 087 744 after stratification-a savings of $32 245 640. Hospitals less likely to receive penalties after stratification included safety-net hospitals (33.6% penalized before stratification vs 24.8% after stratification, Δ = -8.8 percentage points [pp], P < .001), public hospitals (34.1% vs 30.5%, Δ = -3.6 pp, P = .003), hospitals in the West (26.8% vs 23.2%, Δ = -3.6 pp, P < .001), hospitals in Medicaid expansion states (27.3% vs 25.6%, Δ = -1.7 pp, P = .003), and hospitals caring for the most patients with disabilities (32.2% vs 28.3%, Δ = -3.9 pp, P < .001) and from racial/ethnic minority backgrounds (35.1% vs 31.5%, Δ = -3.6 pp, P < .001). In multivariate analyses, safety-net status and treating patients with highly medically complex conditions were associated with higher odds of moving from penalized to nonpenalized status. Conclusions and Relevance: This economic evaluation suggests that stratification of hospitals would be associated with a narrowing of disparities in penalties and a marked reduction in penalties for safety-net hospitals. Policy makers should consider adopting stratification for the HACRP.