Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases.

BACKGROUND CONTEXT: We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data. PURPOSE: To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment. PATIENT SAMPLE: We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019. OUTCOME MEASURES: One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily. METHODS: All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score. RESULTS: When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score. CONCLUSIONS: The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.

The Cost-Effectiveness of Surgical Intervention for Spinal Metastases: A Model-Based Evaluation.

BACKGROUND: Operative and nonoperative treatments for spinal metastases are expensive interventions with a high rate of complications. We sought to determine the cost-effectiveness of a surgical procedure compared with nonoperative management as treatment for spinal metastases. METHODS: We constructed a Markov state-transition model with health states defined by ambulatory status and estimated the quality-adjusted life-years (QALYs) and costs for operative and nonoperative management of spine metastases. We considered 2 populations: 1 in which patients presented with independent ambulatory status and 1 in which patients presented with nonambulatory status due to acute (e.g., <48 hours) metastatic epidural compression. We defined the efficacy of each treatment as a likelihood of maintaining, or returning to, independent ambulation. Transition probabilities for the model, including the risks of mortality and becoming dependent or nonambulatory, were obtained from secondary data analysis and published literature. Costs were determined from Medicare reimbursement schedules. We conducted analyses over patients' remaining life expectancy from a health system perspective and discounted outcomes at 3% per year. We conducted sensitivity analyses to account for uncertainty in data inputs. RESULTS: Among patients presenting as independently ambulatory, QALYs were 0.823 for operative treatment and 0.800 for nonoperative treatment. The incremental cost-effectiveness ratio (ICER) for a surgical procedure was $899,700 per QALY. Among patients presenting with nonambulatory status, those undergoing surgical intervention accumulated 0.813 lifetime QALY, and those treated nonoperatively accumulated 0.089 lifetime QALY. The incremental cost-effectiveness ratio for a surgical procedure was $48,600 per QALY. The cost-effectiveness of a surgical procedure was most sensitive to the variability of its efficacy. CONCLUSIONS: Our data suggest that the value to society of a surgical procedure for spinal metastases varies according to the features of the patient population. In patients presenting as nonambulatory due to acute neurologic compromise, surgical intervention provides good value (ICER, $48,600 per QALY). There is a low value for a surgical procedure performed for patients who are ambulatory at presentation (ICER, $899,700 per QALY). LEVEL OF EVIDENCE: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

Prospective validation of a clinical prediction score for survival in patients with spinal metastases: the New England Spinal Metastasis Score.

BACKGROUND CONTEXT: The New England Spinal Metastasis Score (NESMS) was proposed as an intuitive and accessible prognostic tool for predicting survival in patients with spinal metastases. We designed an appropriately powered, prospective, longitudinal investigation to validate the NESMS. PURPOSE: To prospectively validate the NESMS. STUDY DESIGN: Prospective longitudinal observational cohort study. PATIENT SAMPLE: Patients, aged 18 and older, presenting for treatment with spinal metastatic disease. OUTCOME MEASURES: One-year mortality (primary); 6-month mortality and mortality at any time point following enrollment (secondary). METHODS: The date of enrollment was set as time zero for all patients. The NESMS was assigned based on data collected at the time of enrollment. Patients were prospectively followed to one of two predetermined end-points: death, or survival at 365 days following enrollment. Survival was visually assessed with Kaplan-Meier curves and then analyzed using multivariable logistic regression, followed by Bayesian regression to assess for robustness of point estimates and 95% confidence intervals (CI). RESULTS: This study included 180 patients enrolled between 2017 and 2018. Mortality within 1-year occurred in 56% of the cohort. Using NESMS 3 as the referent, those with a score of 2 had significantly greater odds of mortality (odds ratio 7.04; 95% CI 2.47, 20.08), as did those with a score of 1 (odds ratio 31.30; 95% CI 8.82, 111.04). A NESMS score of 0 was associated with perfect prediction, as 100% of individuals with this score were deceased at 1-year. Similar determinations were encountered for mortality at 6-months and overall. CONCLUSIONS: This study validates the NESMS and demonstrates its utility in prognosticating survival for patients with spinal metastatic disease, irrespective of selected treatment strategy. This is the first study to prospectively validate a prognostic utility for patients with spinal metastases. The NESMS can be directly applied to patient care, hospital-based practice and health-care policy.

Clinician Experiences in Treatment Decision-Making for Patients with Spinal Metastases: A Qualitative Study.

BACKGROUND: Effective management of metastatic disease requires multidisciplinary input and entails high risk of disease-related and treatment-related morbidity and mortality. The factors that influence clinician decision-making around spinal metastases are not well understood. We conducted a qualitative study that included a multidisciplinary cohort of physicians to evaluate the decision-making process for treatment of spinal metastases from the clinician's perspective. METHODS: We recruited operative and nonoperative clinicians, including orthopaedic spine surgeons, neurosurgeons, radiation oncologists, and physiatrists, from across North America to participate in either a focus group or a semistructured interview. All interviews were audiorecorded and transcribed verbatim. We then performed a thematic analysis using all of the available transcript data. Investigators sequentially coded transcripts and identified recurring themes that encompass overarching patterns in the data and directly bear on the guiding study question. This was followed by the development of a thematic map that visually portrays the themes, the subthemes, and their interrelatedness, as well as their influence on treatment decision-making. RESULTS: The thematic analysis revealed that numerous factors influence provider-based decision-making for patients with spinal metastases, including clinical elements of the disease process, treatment guidelines, patient preferences, and the dynamics of the multidisciplinary care team. The most prominent feature that resonated across all of the interviews was the importance of multidisciplinary care and the necessity of cohesion among a team of diverse health-care providers. Respondents emphasized aspects of care-team dynamics, including effective communication and intimate knowledge of team-member preferences, as necessary for the development of appropriate treatment strategies. Participants maintained that the primary role in decision-making should remain with the patient. CONCLUSIONS: Numerous factors influence provider-based decision-making for patients with spinal metastases, including multidisciplinary team dynamics, business pressure, and clinician experience. Participants maintained a focus on shared decision-making with patients, which contrasts with patient preferences to defer decisions to the physician, as described in prior work. CLINICAL RELEVANCE: The results of this thematic analysis document the numerous factors that influence provider-based decision-making for patients with spinal metastases. Our results indicate that provider decisions regarding treatment are influenced by a combination of clinical characteristics, perceptions of patient quality of life, and the patient's preferences for care.

Post-operative hyperglycemia and its association with surgical site infection after instrumented spinal fusion.

OBJECTIVE: To evaluate the correlation between postoperative hyperglycemia and surgical site infection among patients who underwent primary instrumented spinal fusion surgery. PATIENTS AND METHODS: We collected data on all eligible patients treated at our institution over the course of 2005-2017. We defined serum hyperglycemia using a primary threshold of serum glucose ≥140 mg/dL and used ≥115 mg/dL as a secondary test. We used logistic regression techniques to evaluate unadjusted results for serum hyperglycemia on revision surgeries for infection, followed by sequential adjustment for sociodemographic and procedural characteristics. RESULTS: We included 3664 patients. Surgical site infections occurred in 4%. Post-operative hyperglycemia was significantly associated with a higher rate of revision surgery for infection (p = 0.02). Following adjusted analysis, hyperglycemia remained a statistically significant predictor for revision surgery due to infection (OR 2.19; 95 % CI 1.13, 4.25). Similar results were evident when using the lower threshold of ≥115 mg/dL (OR 2.36; 95 % CI 1.06, 5.23). CONCLUSIONS: This study highlights the importance of measuring serum glucose after spinal fusion and the need for heightened surveillance and/or treatment in those who exhibit postoperative hyperglycemia. In this context, it could be advantageous to use a lower threshold for hyperglycemia (115 mg/dL) in order to trigger interventions for glycemic control.

The Prognostic Value of Laboratory Markers and Ambulatory Function at Presentation for Post-Treatment Morbidity and Mortality Following Epidural Abscess.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop a comprehensive understanding of the prognostic value of laboratory markers on morbidity and mortality following epidural abscess. SUMMARY OF BACKGROUND DATA: Spinal epidural abscess is a serious medical condition with high rates of morbidity. The value of laboratory data in forecasting morbidity and mortality after epidural abscess remains underexplored. METHODS: We obtained clinical data on patients treated for epidural abscess at two academic centers from 2005 to 2017. Our primary outcome was the development of one or more complications within 90-days of presentation, with mortality a secondary measure. Primary predictors included serum albumin, serum creatinine, platelet-lymphocyte ratio, and ambulatory status at presentation. We used multivariable logistic regression techniques to adjust for confounders. The most parsimonious set of variables influencing both complications and mortality were considered to be clinically significant. These were then examined individually and in combination to assess for synergy along with model-discrimination and calibration. We performed internal validation with a bootstrap procedure using sampling with replacement. RESULTS: We included 449 patients in this analysis. Complications were encountered in 164 cases (37%). Mortality within 1-year occurred in 39 patients (9%). Regression testing determined that serum albumin, serum creatinine, and ambulatory status at presentation were clinically important predictors of outcome, with albumin more than 3.5 g/dL, creatinine less than or equal to 1.2 mg/dL, and independent ambulatory function at presentation considered favorable characteristics. Patients with no favorable findings had increased likelihood of 90-day complications (odds ratio [OR] 5.43; 95% confidence intervals [CI] 1.98, 14.93) and 1-year mortality (OR 8.94; 95% CI 2.03, 39.37). Those with one favorable characteristic had greater odds of complications (OR 4.00; 95% CI 2.05, 7.81) and mortality (OR 5.71; 95% CI 1.60, 20.43). CONCLUSION: We developed a nomogram incorporating clinical and laboratory values to prognosticate outcomes after treatment for epidural abscess. The results can be used in shared-decision making and counseling. LEVEL OF EVIDENCE: 3.

Prognostic value of laboratory values in older patients with cervical spine fractures.

OBJECTIVES: To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture. PATIENTS AND METHODS: We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques. RESULTS: We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months. CONCLUSIONS: This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Incidental Durotomy Is Associated With Increased Risk of Delirium in Patients Aged 65 and Older.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the impact of incidental durotomy during spine surgery on the development of delirium in patients aged 65 and older. SUMMARY OF BACKGROUND DATA: Delirium after spine surgery has been shown to increase the risk of adverse events, including morbidity and readmissions. Durotomy has previously been postulated to influence the risk of delirium, but this has not been explored in patients 65 and older, the demographic at greatest risk of developing delirium. METHODS: We obtained clinical data on 766 patients, including 182 with incidental durotomy, from the Partners healthcare registry (2012-2019). Patients had their medical records abstracted and age, biologic sex, body mass index, smoking status, preoperative diagnosis, use of a fusion-based procedure, and number of comorbidities were recorded. Our primary outcome was the development of delirium. Our primary predictor was incidental durotomy. We used logistic regression techniques to adjust for sociodemographic and clinical confounders. We performed propensity score matching as a sensitivity test. We hypothesized that elderly patients would be at increased risk of delirium following durotomy. RESULTS: Delirium was identified in 142 patients (19%). Among patients with an incidental durotomy, 26% were diagnosed with delirium. The incidence of delirium was 16% in the control group. Following adjusted analysis, the likelihood of delirium was significantly greater in patients with a durotomy (odds ratio [OR] 1.91; 95% confidence interval [CI] 1.27, 2.88). After propensity score matching, durotomy remained significantly associated with delirium in multivariable adjusted analyses (OR 1.90; 95% CI 1.07, 3.39). CONCLUSION: This investigation is among the first to specifically evaluate an association between durotomy and delirium in elderly patients undergoing spine surgery. The increased association between durotomy and delirium in this cohort should prompt increased surveillance and interventions designed to minimize the potential for cognitive deterioration or impairment during postoperative management of a durotomy. LEVEL OF EVIDENCE: 3.

Patient experiences of decision-making in the treatment of spinal metastases: a qualitative study.

BACKGROUND: In the treatment of spinal metastases the risks of surgery must be balanced against potential benefits, particularly in light of limited life-expectancy. Patient experiences and preferences regarding decision-making in this context are not well explored. PURPOSE: We performed a qualitative study involving patients receiving treatment for spinal metastatic disease. We sought to understand factors that influenced decision-making around care for spinal metastases. STUDY SETTING: Three tertiary academic medical centers. PATIENT SAMPLE: We recruited patients presenting for treatment of spinal metastatic disease at one of three tertiary centers in Boston, MA. OUTCOME MEASURES: We conducted semistructured interviews using a guide that probed participants' experiences with making treatment decisions. METHODS: We performed a thematic analysis that produced a list of themes, subthemes, and statement explaining how the themes related to the study's guiding questions. Patients were recruited until thematic saturation was reached. RESULTS: We interviewed 23 participants before reaching thematic saturation. The enormity of treatment decisions, and of the diagnosis of spinal metastases itself, shaped participant preferences for who should take responsibility for the decision and whether to accept treatments bearing greater risk of complications. Pre-existing participant beliefs about decision-making and about surgery interacted with the clinical context in a way that tended to promote accepting physician recommendations and delaying or avoiding surgery. CONCLUSIONS: The diagnosis of spinal metastatic disease played an outsized role in shaping participant preferences for agency in treatment decision-making. Further research should address strategies to support patient understanding of treatment options in clinical contexts-such as spinal metastases-characterized by ominous underlying disease and high-risk, often urgent interventions.

Laboratory markers as useful prognostic measures for survival in patients with spinal metastases.

BACKGROUND CONTEXT: Laboratory values have been found to be useful predictive measures of survival following surgery. The utility of laboratory values for prognosticating outcomes among patients with spinal metastases has not been studied. PURPOSE: To determine the prognostic capacity of laboratory values at presentation including white blood cell count, serum albumin and platelet-lymphocyte ratio (PLR) in patients with spinal metastases. STUDY DESIGN: Retrospective review of records from two tertiary care centers (2005-2017). PATIENT SAMPLE: Patients, aged 40 to 80, who received operative or nonoperative management for spinal metastases. OUTCOME MEASURES: Survival, complications, or hospital readmissions within 90 days of treatment and a composite measure for treatment failure accounting for changes in ambulatory function and mortality at 6 months following presentation. METHODS: Multivariable Cox proportional hazard regression analysis was used to analyze the relationship between laboratory values and length of survival, adjusting for confounders. Multivariable logistic regression was used in analyses related to 6-month and 1-year mortality, complications, readmissions, and treatment failure. A scoring rubric was developed based on the performance of laboratory values in the multivariable tests. Internal validation was performed using a bootstrap simulation that consisted of sampling with replacement and 1,000 replications. RESULTS: We included 1,216 patients. Thirty-seven percent of patients received a surgical intervention and 63% were treated nonoperatively. Median survival for the cohort as a whole was 255 days (interquartile range 93-642 days). The PLR (hazard ratio [HR] 1.53; 95% confidence interval [CI] 1.29, 1.80; p<.001) and albumin (HR 0.54; 95% CI 0.45, 0.64; p<.001) were significantly associated with survival, whereas WBC count (HR 1.08; 95% CI 0.86, 1.36; p=.50) was not associated with this outcome. Similar findings were encountered for 6-month and 1-year mortality as well as the composite measure for treatment failure. The PLR and albumin performed well in our scoring rubric and findings were preserved in the bootstrapping validation. CONCLUSIONS: Individuals with low serum albumin and elevated PLR should be advised regarding the impact of these laboratory markers on outcomes including survival, irrespective of treatments received. An effort should also be made to optimize nutrition and PLR, if practicable, before treatment to minimize the potential for development of adverse events.

Design of the prospective observational study of spinal metastasis treatment (POST).

BACKGROUND CONTEXT: There are several prognostic scores available that intend to inform decision-making for patients with spinal metastases. Many of these have not been found to reliably predict survival across the continuum of care. Recently, our group developed the New England Spinal Metastasis Score (NESMS). While the NESMS demonstrated many of the necessary attributes of a useful prediction tool, it has yet to be validated prospectively. PURPOSE: To describe the prospective observational study of spinal metastasis treatment (POST). This investigation examined the performance of the NESMS, compared its predictive capacity with other scoring systems and determined its ability to identify patients who benefit the most from surgery. STUDY DESIGN: Prospective observational study at two medical centers. PATIENT SAMPLE: Patients age 18 and older with spinal metastases involving the spine. OUTCOME MEASURES: Survival, post-treatment morbidity and health-related quality of life outcomes. METHODS: The POST study assessed patients at baseline and at 1-month, 3-month, 6-month, and 12-month time-points. During the baseline assessment patient demographics, past medical history and assessment of co-morbidities, surgical history, primary tumor histology, and ambulatory status were recorded along with the designated treatment strategy (eg, operative or nonoperative). The NESMS and other predictive scores for each patient were calculated based on baseline data. Study-specific surveys administered at all time-points consisted of the EuroQuol 5-Dimension and Short-Form (SF)-12, Visual Analog Scale (VAS) for pain, and PROMIS assessment of global health. RESULTS: Two hundred patients were enrolled in POST from 2017 to 2019. Patients were followed to one of the two predetermined study end-points (ie, mortality, or completion of the 12-month follow-up). Survival was considered the principle dependent variable. Post-treatment morbidity and health-related quality of life outcomes were considered secondarily. Analyses, by aim, relied on Cox proportional hazards regression, repeated measures logistic regression, propensity score matching and multivariable logistic regression. CONCLUSION: The POST's findings are anticipated to provide evidence regarding the prognostic capabilities of the NESMS as well as that of other popular grading schemes for survival, post-treatment complications and physical as well as mental function.

Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.

Non-operative management of spinal metastases: A prognostic model for failure.

OBJECTIVES: To describe patient-specific characteristics associated with non-operative failure leading to surgery. PATIENTS AND METHODS: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. RESULTS: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). CONCLUSION: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.

Predicting survival in older patients treated for cervical spine fractures: development of a clinical survival score.

BACKGROUND CONTEXT: Emerging literature has identified the importance of pretreatment health and functional status as influential in the prognostication of survival. A comprehensive, accessible, predictive model for survival following cervical spine fracture has yet to be developed. PURPOSE: To develop an accessible and intuitive predictive model for survival in individuals aged 50 and older treated for cervical spine fractures. STUDY DESIGN: Retrospective review of records from two tertiary care centers (2009-2016). PATIENT SAMPLE: Patients age 50 and older who received operative or nonoperative management for cervical fractures. OUTCOME MEASURES: One-year mortality was the primary outcome with 3-month and 2-year mortality considered secondarily. METHODS: Multivariable logistic regression was used to identify factors independently associated with mortality. The magnitude and precision of the relationship with 1-year mortality for statistically significant variables determined weighting in the scoring system subsequently developed. Score performance was tested through multivariable regression and bootstrap simulation. In a sensitivity test, the performance of the score developed for 1-year mortality was assessed using figures for the 3-month and 2-year time-points. RESULTS: We included 1,758 patients. Mortality rates were 12% at 3 months, 17% at 1 year, and 21% at 2 years. Following multivariable testing age, injury severity score and Glasgow coma scale demonstrated the strongest predictive values for a base score, followed by serum albumin and ambulatory status. The resultant composite score ranged from 0 (base score≤4, albumin≤3.5 g/dL, and dependent/nonambulator at presentation) to a maximum of 4 (base score≥5, albumin>3.5 g/dL, and independent ambulator at presentation). Following multivariable analysis, when compared to patients with a score of 4, significantly increased odds of 1-year mortality were appreciated for those with scores of 3 (odds ratio [OR] 7.35; 95% confidence interval [CI] 3.77, 14.32), 2 (OR 8.43; 95% CI 4.66, 15.25), 1 (OR 17.47; 95% CI 9.81, 31.11), and 0 (OR 26.58; 95% CI 13.87, 50.92). Score performance was unchanged in bootstrap testing and sensitivity analyses. CONCLUSIONS: We have developed a useful prognostic utility capable of informing survival in individuals age 50 and older, following cervical spine fractures. The score can be applied to adjust patient expectations, anticipate outcomes, and as an adjunct to decision-making in the postinjury period.

Changes in healthcare delivery following spinal fracture in Medicare Accountable Care Organizations.

BACKGROUND CONTEXT: Accountable Care Organizations (ACOs) were designed to reduce healthcare costs while simultaneously improving quality. Given that the success of ACOs is predicated on controlling costs, concerns have been expressed that patients could be adversely affected through restricted access to surgery, including in the context of spine fracture care. PURPOSE: Evaluate the impact of Medicare ACO formation on the utilization of surgery and outcomes following spinal fractures. STUDY DESIGN: Retrospective review of Medicare claims (2009-2014). PATIENT SAMPLE: Patients treated for spinal fractures in an ACO or non-ACO. OUTCOME MEASURES: The utilization of surgery as treatment for spinal fractures, in-hospital mortality, 90-day complications, or hospital readmission within 90-days injury. METHODS: We used a pre-post study design to compare outcomes for patients treated in ACOs versus non-ACOs. Receipt of surgery for treatment of a spinal fracture was the primary outcome, with mortality, complications and readmissions treated secondarily. We used multivariable logistic regression adjusting for confounders to determine the association between environment of care (ACO vs. non-ACO) and the outcomes of interest. In all testing, beneficiaries treated in non-ACOs during 2009 to 2011 were used as the referent. RESULTS: During 2009 to 2011, 9% (n=10,866) of patients treated in non-ACOs received surgery, whereas a similar percentage (9%; n=210) underwent surgery in ACOs. This figure decreased to 8% (n=9,857) for individuals treated in non-ACOs over 2012 to 2014, although the surgical rate remained unchanged for those receiving care in an ACO (9%; n=227). There was no difference in the use of surgery among patients treated in ACOs (OR 0.96; 95% CI 0.79, 1.18) over 2012 to 2014. Similar increases in the odds of mortality were observed for both ACOs and non-ACOs during this period. A marginal, yet significant increase in complications was observed among ACOs, although there was no change in the odds of readmission. CONCLUSIONS: Our study found that the formation of ACOs did not result in alterations in the use of surgery for spinal fractures or substantive changes in outcomes. As ACOs continue to evolve, more emphasis should be placed on the incorporation of measures directly related to surgical and trauma care in the determinants of risk-based reimbursements.

Ambulatory status after surgical and nonsurgical treatment for spinal metastasis.

BACKGROUND: Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. This study evaluated the effects of operative and nonoperative management on maintenance of ambulatory function and survival for patients treated for spinal metastases. METHODS: Propensity matching was used to yield an analytic sample in which operatively and nonoperatively treated patients were similar with respect to key baseline covariates. The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. It evaluated the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes. RESULTS: Nine hundred twenty-nine individuals eligible for inclusion were identified, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation (3% vs 16%; relative risk [RR], 0.16; 95% confidence interval [CI], 0.06-0.46) as well as a reduced risk of 6-month mortality (20% vs 29%; RR, 0.69; 95% CI, 0.49-0.98). CONCLUSIONS: These results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients' preferences regarding surgical risk, mortality, and ambulatory status.

Prognosticating outcomes and survival for patients with lumbar spinal metastases: Results of a bayesian regression analysis.

OBJECTIVES: To assess the impact of surgical intervention on survival, ambulatory capacity, complications and readmissions following treatment for lumbar metastases. PATIENTS AND METHODS: We identified all adult patients treated for lumbar metastases between 2005-2017. To limit the potential for inherent bias to influence determinations, we used principal component analysis to identify confounders to be included in multivariable testing. Multivariable logistic regression was performed, followed by Bayesian analysis to generate conservative estimates of effect size and 95% confidence intervals (CI). In a sensitivity test, analyses were repeated in a population where patients who died before they could initiate treatment were excluded. RESULTS: In the period under study, we identified 571 patients who met inclusion criteria. Twenty-one percent of the cohort received a surgical intervention. Bayes regression indicated surgical intervention was independently associated with decreased mortality at 6-months (odds ratio [OR] 0.49; 95% CI 0.34, 0.68) and 1-year (OR 0.63; 95% CI 0.51, 0.76), along with lower odds of being non-ambulatory at 6-months following presentation (OR 0.29; 95% CI 0.18, 0.45). Surgery was also associated with increased odds of complications (OR 1.60; 95% CI 1.24, 2.06) and readmissions (OR 1.37; 95% CI 1.09, 1.72). Numerous clinical characteristics were found to be associated with the outcomes of interest including serum albumin, lung metastases and vertebral body collapse. CONCLUSIONS: Given the favorable outcomes associated with the incorporation of surgery as a component of treatment, we believe that such interventions may be considered part of the treatment approach in patients with lumbar metastases.

The Impact of Vancomycin and Cefazolin as Standard Preoperative Antibiotic Prophylaxis on Surgical Site Infections Following Instrumented Spinal Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess whether administration of prophylactic vancomycin, in addition to cefazolin decreased revision surgeries for postoperative infection (SSI) as well as the need for revisions overall. SUMMARY OF BACKGROUND DATA: In 2010 our institution implemented an antibiotic prophylaxis regimen consisting of intravenous vancomycin and cefazolin that applied to all patients receiving surgical implants. The impact of this change in prophylactic antibiotic regimen on SSIs following instrumented spinal fusions remains unknown. METHODS: We conducted a prepost analysis evaluating the effect of the change in antibiotic prophylaxis on SSIs following instrumented spinal fusions. We collected data on all eligible patients over the course of 2005 to 2009 and 2011 to 2015. We used logistic regression techniques to evaluate unadjusted results for the prophylactic antibiotic protocol on all revision surgeries, as well as those for SSI, followed by sequential adjustments for sociodemographic factors and surgical characteristics. RESULTS: Revision surgeries performed for a diagnosis of infection were reduced from a rate of 4% (n = 57) in the period 2005 to 2009 to 2% (n = 44) over 2011 to 2015 (P < 0.001). At the same time, the incidence of revision surgeries for any cause was also reduced (14% in 2005-2009 vs. 9% in 2011-2015; P < 0.001). In adjusted analysis, the odds of a revision procedure for SSI were reduced by 50% following introduction of the protocol (OR 0.50; 95% CI 0.33, 0.76). No significant difference in the organisms responsible for SSI was identified between 2005 and 2009 and 2011 and 2015 (P = 0.22). CONCLUSION: This natural experiment has shown some utility for a preoperative prophylactic antibiotic regimen of vancomycin and cefazolin, including meaningful reductions in revision procedures performed for SSI. This is the first effort we are aware of to consider a uniform institutional protocol that employs the use of intravenous vancomycin and cefazolin as prophylactic agents. LEVEL OF EVIDENCE: 2.

Disparities in Rates of Surgical Intervention Among Racial and Ethnic Minorities in Medicare Accountable Care Organizations.

OBJECTIVE: To assess the effect of Accountable Care Organizations (ACOs) on the use of surgical services among racial and ethnic minorities. BACKGROUND: Health reform efforts were expected to reduce healthcare disparities. The impact of ACOs on existing disparities in access to surgical care remains unknown. METHODS: We used national Medicare data (2009-2014) to compare rates of surgery among white, African American, Hispanic, and Asian Medicare beneficiaries for coronary artery bypass grafting, colectomy, total hip arthroplasty, hip fracture repair, and lumbar spine surgery. We performed a pre-post difference in differences analysis between African American, Hispanic, and Asian patients receiving surgical care in ACO and non-ACO organizations before and after the implementation of ACOs. The time period 2009 to 2011 was considered the pre-ACO period, and 2012 to 2014 the post-ACO period. RESULTS: Rates of surgical intervention in the ACO cohort were significantly lower (P < 0.001) as compared to non-ACOs for whites, African Americans, Hispanics, and Asians in both the pre- and post-ACO periods. There was no significant difference in the adjusted change in the rate of surgical interventions among minority patients as compared to whites in ACOs and non-ACOs between 2009 to 2011 and 2012 to 2014. The odds of receiving surgical intervention were lowest for minority patients in ACOs during the post-ACO period (P < 0.001). CONCLUSIONS: We found persistent differences in the use of surgery among racial and ethnic minorities between the time periods 2009 to 2011 and 2012 to 2014. These disparities were not impacted by the formation of ACOs. Programs that specifically incentivize ACOs to improve surgical access for minorities may be necessary.

Alterations in 90-day morbidity, mortality, and readmission rates following spine surgery in Medicare Accountable Care Organizations (2009-2014).

BACKGROUND CONTEXT: The impact of Accountable Care Organizations (ACOs) on healthcare quality and outcomes, including morbidity, mortality, and readmissions, has not been substantially investigated, especially following spine surgery. PURPOSE: To evaluate the impact of ACO formation on postoperative outcomes in the 90-day period following spine surgery. STUDY DESIGN: Retrospective review of national Medicare claims data (2009-2014). PATIENT SAMPLE: Patients who underwent one of four lumbar spine surgical procedures in an ACO or non-ACO. OUTCOME MEASURES: The development of in-hospital mortality, complications or hospital readmission within 90 days of the surgical procedure. METHODS: The primary outcome measures included postsurgical complications and readmissions at 90 days following surgery. In-hospital mortality and 30-day outcomes were considered secondarily. The primary predictor variable consisted of ACO enrollment designation. Multivariable logistic regression analysis was utilized to adjust for confounders and determine the independent effect of ACO enrollment on postsurgical outcomes. The multivariable model included a propensity score adjustment that accounted for factors associated with the preferential enrollment of patients in ACOs, namely, sociodemographic characteristics, medical co-morbidities, hospital teaching status, bed size, and location. RESULTS: In all, there were 344,813 patients identified for inclusion in this analysis with 97% (n = 332,890) treated in non-ACOs and 3% (n = 11,923) in an ACO. Although modest changes were apparent across both ACOs and non-ACOs over the time-period studied, improvements were slightly more dramatic in non-ACOs leading to statistically significant differences in both 90-day complications and readmissions. Specifically, in the period 2012-2014, ACOs demonstrated an 18% increase in the odds of 90-day complications and a 14% elevation in the odds of 90-day readmissions when compared to non-ACOs. There was no difference in hospital mortality between ACOs and non-ACOs. CONCLUSIONS: Our study of Medicare data from 2009 to 2014 failed to demonstrate superior reductions in postoperative morbidity, mortality, and readmissions for beneficiaries treated in ACOs as compared to non-ACOs. These results indicate that meaningful changes in postoperative outcomes should not be anticipated based on organizational participation in ACOs at present.