Reliable Prediction of Discharge Disposition Following Cervical Spine Surgery With Ensemble Machine Learning and Validation on a National Cohort.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The purpose of this study is to develop a machine learning algorithm to predict nonhome discharge after cervical spine surgery that is validated and usable on a national scale to ensure generalizability and elucidate candidate drivers for prediction. SUMMARY OF BACKGROUND DATA: Excessive length of hospital stay can be attributed to delays in postoperative referrals to intermediate care rehabilitation centers or skilled nursing facilities. Accurate preoperative prediction of patients who may require access to these resources can facilitate a more efficient referral and discharge process, thereby reducing hospital and patient costs in addition to minimizing the risk of hospital-acquired complications. METHODS: Electronic medical records were retrospectively reviewed from a single-center data warehouse (SCDW) to identify patients undergoing cervical spine surgeries between 2008 and 2019 for machine learning algorithm development and internal validation. The National Inpatient Sample (NIS) database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for external validation of algorithm performance. Gradient-boosted trees were constructed to predict nonhome discharge across patient cohorts. The area under the receiver operating characteristic curve (AUROC) was used to measure model performance. SHAP values were used to identify nonlinear risk factors for nonhome discharge and to interpret algorithm predictions. RESULTS: A total of 3523 cases of cervical spine fusion surgeries were included from the SCDW data set, and 311,582 cases were isolated from NIS. The model demonstrated robust prediction of nonhome discharge across all cohorts, achieving an area under the receiver operating characteristic curve of 0.87 (SD=0.01) on both the SCDW and nationwide NIS test sets. Anterior approach only, age, elective admission status, Medicare insurance status, and total Elixhauser Comorbidity Index score were the most important predictors of discharge destination. CONCLUSIONS: Machine learning algorithms reliably predict nonhome discharge across single-center and national cohorts and identify preoperative features of importance following cervical spine fusion surgery.

Robust prediction of nonhome discharge following elective anterior cervical discectomy and fusion using explainable machine learning.

PURPOSE: Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. METHODS: 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model's decision making. RESULTS: The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. CONCLUSION: We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model's "thinking" aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.

A Nationwide Study Characterizing the Risk and Outcome Profiles of Multilevel Fusion Procedures in Neuromuscular Scoliosis Patients with Neurofibromatosis Type 1.

BACKGROUND: Spine abnormalities are a common manifestation of Neurofibromatosis Type 1 (NF1); however, the outcomes of surgical treatment for NF1-associated spinal deformity are not well explored. The purpose of this study was to investigate the outcome and risk profiles of multilevel fusion surgery for NF1 patients. METHODS: The National Inpatient Sample was queried for NF1 and non-NF1 patient populations with neuromuscular scoliosis who underwent multilevel fusion surgery involving eight or more vertebral levels between 2004 and 2017. Multivariate regression modeling was used to explore the relationship between perioperative variables and pertinent outcomes. RESULTS: Of the 55,485 patients with scoliosis, 533 patients (0.96%) had NF1. Patients with NF1 were more likely to have comorbid solid tumors (P < 0.0001), clinical depression (P < 0.0001), peripheral vascular disease (P < 0.0001), and hypertension (P < 0.001). Following surgery, NF1 patients had a higher incidence of hydrocephalus (0.6% vs. 1.9% P = 0.002), seizures (4.9% vs. 5.7% P = 0.006), and accidental vessel laceration (0.3% vs.1.9% P = 0.011). Although there were no differences in overall complication rates or in-hospital mortality, multivariate regression revealed NF1 patients had an increased probability of pulmonary (OR 0.5, 95%CI 0.3-0.8, P = 0.004) complications. There were no significant differences in utilization, including nonhome discharge or extended hospitalization; however, patients with NF1 had higher total hospital charges (mean -$18739, SE 3384, P < 0.0001). CONCLUSIONS: These findings indicate that NF1 is associated with certain complications following multilevel fusion surgery but does not appear to be associated with differences in quality or cost outcomes. These results provide some guidance to surgeons and other healthcare professionals in their perioperative decision making by raising awareness about risk factors for NF1 patients undergoing multilevel fusion surgery. We intend for this study to set the national baseline for complications after multilevel fusion in the NF1 population.

Comparative Analysis of Early Outcomes and Complications of PSO Among Neurosurgeons and Orthopedic Surgeons.

STUDY DESIGN: Retrospective comparative cohort study using the National Surgical Quality Improvement Program. OBJECTIVE: The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. METHODS: Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. RESULTS: Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P =0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P =0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. CONCLUSIONS: The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.

The Impact of Obstructive Sleep Apnea on Clinical, Perioperative, and Cost Outcomes in Patients Who Underwent Posterior Cervical Decompression and Fusion: A Single-Center Retrospective Analysis From 2008 to 2016.

BACKGROUND: Obstructive sleep apnea (OSA) is a pervasive problem that can result in diminished neurocognitive performance, increased risk of all-cause mortality, and significant cardiovascular disease. While previous studies have examined risk factors that influence outcomes following cervical fusion procedures, to our knowledge, no study has examined the cost or outcome profiles for posterior cervical decompression and fusion (PCDF) procedures in patients with OSA. METHODS: All cases at a single institution between 2008 and 2016 involving a PCDF were included. The primary outcome was prolonged extubation, defined as an extubation that took place outside of the operating room. Secondary outcomes included admission to the intensive care unit (ICU), complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 days, emergency room visit within 30 and 90 days, and higher total costs. RESULTS: We reviewed 1191 PCDF cases, of which 93 patients (7.81%) had a history of OSA. At the univariate level, patients with OSA had higher rates of ICU admissions (33.3% vs 16.8%, P < 0.0001), total complications (29.0% vs 19.0%, P = 0.0202), and respiratory complications (12.9% vs 6.6%, P = 0.0217). Multivariate regression analyses revealed no difference in the odds of a prolonged extubation (P = 0.4773) and showed that history of OSA was not predictive of higher costs. However, a significant difference was observed in the odds of having an ICU admission (P = 0.0046). CONCLUSION: While patients with sleep apnea may be more likely to be admitted to the ICU postoperatively, OSA status a lone is not a risk factor for poor primary and secondary clinical outcomes following posterior cervical fusion procedures. CLINICAL RELEVANCE: Various deformities of the cervical spine can exert extraluminal forces that partially collapse or obstruct the airway, thereby predisposing patients to OSA; however, no study has examined the cost or outcome profiles for PCDF procedures in patients with OSA. Therefore, this investigation highlights the ways in which OSA influences the risks, outcomes, and costs following PCDF using medical data from an institutional registry.

Pragmatic Prediction of Excessive Length of Stay After Cervical Spine Surgery With Machine Learning and Validation on a National Scale.

BACKGROUND: Extended postoperative hospital stays are associated with numerous clinical risks and increased economic cost. Accurate preoperative prediction of extended length of stay (LOS) can facilitate targeted interventions to mitigate clinical harm and resource utilization. OBJECTIVE: To develop a machine learning algorithm aimed at predicting extended LOS after cervical spine surgery on a national level and elucidate drivers of prediction. METHODS: Electronic medical records from a large, urban academic medical center were retrospectively examined to identify patients who underwent cervical spine fusion surgeries between 2008 and 2019 for machine learning algorithm development and in-sample validation. The National Inpatient Sample database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for out-of-sample validation of algorithm performance. Gradient-boosted trees predicted LOS and efficacy was assessed using the area under the receiver operating characteristic curve (AUROC). Shapley values were calculated to characterize preoperative risk factors for extended LOS and explain algorithm predictions. RESULTS: Gradient-boosted trees accurately predicted extended LOS across cohorts, achieving an AUROC of 0.87 (SD = 0.01) on the single-center validation set and an AUROC of 0.84 (SD = 0.00) on the nationwide National Inpatient Sample data set. Anterior approach only, elective admission status, age, and total number of Elixhauser comorbidities were important predictors that affected the likelihood of prolonged LOS. CONCLUSION: Machine learning algorithms accurately predict extended LOS across single-center and national patient cohorts and characterize key preoperative drivers of increased LOS after cervical spine surgery.

Robust Prediction of Non-home Discharge After Thoracolumbar Spine Surgery With Ensemble Machine Learning and Validation on a Nationwide Cohort.

BACKGROUND: Delays in postoperative referrals to rehabilitation or skilled nursing facilities contribute toward extended hospital stays. Facilitating more efficient referrals through accurate preoperative prediction algorithms has the potential to reduce unnecessary economic burden and minimize risk of hospital-acquired complications. We develop a robust machine learning algorithm to predict non-home discharge after thoracolumbar spine surgery that generalizes to unseen populations and identifies markers for prediction. METHODS: Retrospective electronic health records were obtained from our single-center data warehouse (SCDW) to identify patients undergoing thoracolumbar spine surgeries between 2008 and 2019 for algorithm development and internal validation. The National Inpatient Sample (NIS) database was queried to identify thoracolumbar surgeries between 2009 and 2017 for out-of-sample validation. Ensemble decision trees were constructed for prediction and area under the receiver operating characteristic curve (AUROC) was used to assess performance. Shapley additive explanations values were derived to identify drivers of non-home discharge for interpretation of algorithm predictions. RESULTS: A total of 5224 cases of thoracolumbar spine surgeries were isolated from the SCDW and 492,312 cases were identified from NIS. The model achieved an AUROC of 0.81 (standard deviation [SD] = 0.01) on the SCDW test set and 0.77 (SD = 0.01) on the nationwide NIS data set, thereby demonstrating robust prediction of non-home discharge across all diverse patient cohorts. Age, total Elixhauser comorbidities, Medicare insurance, weighted Elixhauser score, and female sex were among the most important predictors of non-home discharge. CONCLUSIONS: Machine learning algorithms reliably predict non-home discharge after thoracolumbar spine surgery across single-center and national cohorts and identify preoperative features of importance that elucidate algorithm decision-making.

Diabetes Is Predictive of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The present study analyzes complication rates and episode-based costs for patients with and without diabetes mellitus (DM) following posterior lumbar fusion (PLF). METHODS: PLF cases at a single institution from 2008 to 2016 were queried (n = 3226), and demographic and perioperative data were analyzed. Patients with and without the diagnosis of DM were compared using chi-square, Student's t test, and multivariable regression modeling. RESULTS: Patients with diabetes were older (63.10 vs 56.48 years, P < .001) and possessed a greater number of preoperative comorbidities (47.84% of patients had Elixhauser Comorbidity Index >0 vs 42.24%, P < .001) than did patients without diabetes. When controlling for preexisting differences, diabetes remained a significant risk factor for prolonged length of stay (OR = 1.59, 95% CI 1.26-2.01, P < .001), intensive care unit stay (OR = 1.52, 95% CI 1.07-2.17, P = .021), nonhome discharge (OR = 1.86, 95% CI 1.46-2.37, P < .001), 30-day readmission (OR = 2.15, 95% CI 1.28-3.60, P = .004), 90-day readmission (OR = 1.65, 95% CI 1.05-2.59, P = .031), 30-day emergency room visit (OR = 2.15, 95% CI 1.27-3.63, P = .004), and 90-day emergency room visit (OR = 2.27, 95% CI 1.41-3.65, P < .001). Cost modeling controlling for overall comorbidity burden demonstrated that diabetes was associated with a $1709 increase in PLF costs (CI $344-$3074, P = .014). CONCLUSIONS: The present findings indicate a correlation between diabetes and a multitude of postoperative adverse outcomes and increased costs, thus illustrating the substantial medical and financial burdens of diabetes for PLF patients. Future studies should explore preventive measures that may mitigate these downstream effects.

MIS-TLIF Procedure is Improving With Experience: Systematic Review of the Learning Curve Over the Last Decade.

STUDY DESIGN: This was a systematic review. OBJECTIVE: This review evaluates the minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) learning curve in the literature and compares outcomes during and after completing the curve. SUMMARY OF BACKGROUND DATA: MIS-TLIF are performed for various spine conditions. Proponents cite improved clinical outcomes while critics highlight the steep learning curve to attain proficiency. METHODS: Literature searches on Medline and Embase utilized relevant subject headings and keywords. Manuscripts reporting learning curve statistics were included. Monotonic trends of operative duration were assessed with Mann-Kendall nonparametric testing. RESULTS: Nine studies met inclusion criteria. Number of patients ranged from 26 to 150 (average 83.2, median of 86). Commonly reported metrics included number of procedures to complete the curve, operative duration, blood loss, ambulation time, length of stay, complication rate, follow-up visual analogue scale (VAS) for back and leg pain, and fusion rate. Various methods were employed to determine number of cases to complete the curve, all involving operative duration. Number of cases ranged from 14 to 44. A significant negative trend for operative duration of cases during the learning curve (τ=-0.733, P =0.039) was found over the years that studies were published. Initial complication rates varied from 6.8% to 23.8%. Initial VAS-back and VAS-leg ranged from 0.8 to 2.9 and 0.5 to 2.3, respectively. While definitions of "good" fusion varied, fusion rates meeting Bridwell grade I or II during the learning curve ranged from 84.0% to 95.2%. CONCLUSIONS: Surgeons in their learning curve have become faster at the MIS-TLIF procedure. Clinical outcomes including postoperative pain and fusion rates showed satisfactory results, but surgeons learning the procedure should take measures to minimize complications in early cases, such as utilizing novel navigation technology or supervision from more experienced surgeons. Learning curve research methodology could benefit from standardization.

Neurosurgical Performance in the First 2 Years of Merit-Based Incentive Payment System: A Descriptive Analysis and Predictors of Receiving Bonus Payments.

BACKGROUND: The merit-based incentive payment system (MIPS) program was implemented to tie Medicare reimbursements to value-based care measures. Neurosurgical performance in MIPS has not yet been described. OBJECTIVE: To characterize neurosurgical performance in the first 2 years of MIPS. METHODS: Publicly available data regarding MIPS performance for neurosurgeons in 2017 and 2018 were queried. Descriptive statistics about physician characteristics, MIPS performance, and ensuing payment adjustments were performed, and predictors of bonus payments were identified. RESULTS: There were 2811 physicians included in 2017 and 3147 in 2018. Median total MIPS scores (99.1 vs 90.4, P < .001) and quality scores (97.9 vs 88.5, P < .001) were higher in 2018 than in 2017. More neurosurgeons (2758, 87.6%) received bonus payments in 2018 than in 2017 (2013, 71.6%). Of the 2232 neurosurgeons with scores in both years, 1347 (60.4%) improved their score. Reporting through an alternative payment model (odds ratio [OR]: 32.3, 95% CI: 16.0-65.4; P < .001) and any practice size larger than 10 (ORs ranging from 2.37 to 10.2, all P < .001) were associated with receiving bonus payments. Increasing years in practice (OR: 0.99; 95% CI: 0.982-0.998, P = .011) and having 25% to 49% (OR: 0.72; 95% CI: 0.53-0.97; P = .029) or ≥50% (OR: 0.48; 95% CI: 0.28-0.82; P = .007) of a physician's patients eligible for Medicaid were associated with lower rates of bonus payments. CONCLUSION: Neurosurgeons performed well in MIPS in 2017 and 2018, although the program may be biased against surgeons who practice in small groups or take care of socially disadvantaged patients.

Intraoperative Navigation in Spine Surgery: Effects on Complications and Reoperations.

INTRODUCTION: Intraoperative navigation during spine surgery improves pedicle screw placement accuracy. However, limited studies have correlated the use of navigation with clinical factors, including operative time and safety. In the present study, we compared the complications and reoperations between surgeries with and without navigation. METHODS: The National Surgical Quality Improvement Project database was queried for posterior cervical and lumbar fusions and deformity surgeries from 2011 to 2018 and divided by navigation use. Patients aged >89 years, patients with deformity aged <25 years, and patients undergoing surgery for tumors, fractures, infections, or nonelective indications were excluded. The demographics and perioperative factors were compared via univariate analysis. The outcomes were compared using multivariable logistic regression adjusting for age, sex, body mass index, American Society of Anesthesiologists class, surgical region, and multiple treatment levels. The outcomes were also compared stratifying by revision status. RESULTS: Navigation surgery patients had had higher American Society of Anesthesiologists class (P < 0.0001), more multiple level surgeries (P < 0.0001), and longer operative times (P < 0.0001). The adjusted analysis revealed that navigated lumbar surgery had lower odds of complications (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.77-0.90; P < 0.0001), blood transfusion (OR, 0.79; 95% CI, 0.72-0.87; P < 0.0001), and wound debridement and/or drainage (OR, 0.66; 95% CI, 0.44-0.97; P = 0.04) compared with non-navigated lumbar surgery. Navigated cervical fusions had increased odds of transfusions (OR, 1.53; 95% CI, 1.06-2.23; P = 0.02). Navigated primary fusion had decreased odds of complications (OR, 0.91; 95% CI, 0.85-0.98; P = 0.01). However, no differences were found in revisions (OR, 0.89; 95% CI, 0.69-1.14; P = 0.34). CONCLUSIONS: Navigated surgery patients experienced longer operations owing to a combination of the time required for navigation, more multilevel procedures, and a larger comorbidity burden, without differences in the incidence of infection. Fewer complications and wound washouts were required for navigated lumbar surgery owing to a greater proportion percentage of minimally invasive cases. The combined use of navigation and minimally invasive surgery might benefit patients with the proper indications.

Seasonal Effects on Surgical Site Infections Following Spine Surgery.

BACKGROUND: Studies investigating seasonality as a risk factor for surgical site infections (SSIs) after spine surgery show mixed results. This study used national data to analyze seasonal effects on spine surgery SSIs. METHODS: National Surgical Quality Improvement Program data (2011-2018) were queried for posterior cervical fusions (PCFs), cervical laminoplasties, posterior lumbar fusions (PLFs), lumbar laminectomies, and deformity surgeries. Patients aged >89 and procedures for tumors, fractures, infections, and nonelective indications were excluded. Patients were divided into warm (admitted April-September) and cold (admitted October-March) seasonal groups. End points were SSIs and reoperations for wound débridement/drainage. Stratified analyses were performed by surgery type and pre-versus postdischarge infections. RESULTS: Overall (N = 208,291), SSIs were more likely in the warm season (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.08-1.23, P < 0.0001) and for PCFs (OR 1.40, 95% CI 1.08-1.80, P = 0.011), PLFs (OR 1.15, 95% CI 1.04-1.28, P = 0.006), and lumbar laminectomies (OR 1.13, 95% CI 1.03-1.25, P = 0.014). Postdischarge infections were also more likely in the warm season overall (OR 1.15, 95% CI 1.07-1.23, P < 0.0001) and for PCFs (OR 1.32, 95% CI 1.01-1.73, P = 0.041), PLFs (OR 1.14, 95% CI 1.03-1.27, P = 0.014), and lumbar laminectomies (OR 1.15, CI 1.04-1.27, P = 0.007). In-hospital infections were more likely during the warm season only for PCFs (OR 2.54, 95% CI 1.06-6.10, P = 0.037). Reoperations for infection were more likely during the warm season for PLFs (OR 1.29, 95% CI 1.08-1.54, P = 0.005). CONCLUSIONS: PCF, PLF, and lumbar laminectomy performed during the warm season had significantly higher odds of SSI, especially postdischarge SSIs. Reoperation rates for wound management were significantly increased during the warm season for PLFs. Identifying seasonal causes merits further investigation and may influence surgeon scheduling and expectations.

Clinical Trials in Spinal Tumors: A Two-Decade Review.

OBJECTIVE: Clinical trials are essential for assessing the advancements in spine tumor therapeutics. The purpose of the present study was to characterize the trends in clinical trials for primary and metastatic tumor treatment during the past 2 decades. METHODS: The ClinicalTrials.gov database was queried using the search term "spine" for all interventional studies from 1999 to 2020 with the categories of "cancer," "neoplasm," "tumor," and/or "metastasis." The tumor type, phase data, enrollment numbers, and home institution country were recorded. The sponsor was categorized as an academic institution, industry, government, or other and the intervention type as procedure, drug, device, radiation therapy, or other. The frequency of each category and the cumulative frequency during the 20-year period were calculated. RESULTS: A total of 106 registered trials for spine tumors were listed. All, except for 2, that had begun before 2008 had been completed. An enrollment of 51-100 participants (29.8%) was the most common, and most were phase II studies (54.4%). Most of the studies had examined metastatic tumors (58.5%), and the number of new trials annually had increased 3.4-fold from 2009 to 2020. Most of the studies had been conducted in the United States (56.4%). The most common intervention strategy was radiation therapy (32.1%), although from 2010 to 2020, procedural studies had become the most frequent (2.4/year). Most of the studies had been sponsored by academic institutions (63.2%), which during the 20-year period had sponsored 3.2-fold more studies compared with the industry partners. CONCLUSIONS: The number of clinical trials for spine tumor therapies has rapidly increased during the past 15 years, owing to studies at U.S. academic medical institutions investigating radiosurgery for the treatment of metastases. Targeted therapies for tumor subtypes and sequelae have updated international best practices.

The Impact of American Society of Anesthesiologists Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion.

BACKGROUND: Increased posterior cervical decompression and fusion (PCDF) procedures over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of health care costs, length of stay (LOS), and other postoperative outcomes in patients undergoing PCDF. METHODS: Low (I and II) versus high (III and IV) ASA class was used to evaluate 971 patients who underwent PCDF between 2008 and 2016 at a single institution. Demographics were compared using univariate analysis. Cost of care, LOS, and postoperative complications were compared using multivariable logistic and linear regression, controlling for sex, age, length of surgery, and number of segments fused. RESULTS: The high ASA class cohort was older (mean age 62 years vs. 55 years, P < 0.0001) and had higher Elixhauser comorbidity index scores (P < 0.0001). ASA class was independently associated with longer LOS (2.1 days, 95% confidence interval [CI] 1.3-2.9, P < 0.0001) and higher cost ($2936, 95% CI $1457-$4415, P < 0.0001). Patients with high ASA class were more likely to have a nonhome discharge (3.9, 95% CI 2.8-5.6, P < 0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, P = 0.006), intensive care unit stay (2.4, 95% CI 1.5 3.7, P = 0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, P = 0.03), and 30-day (3.2, 95% CI 1.5-6.8, P = 0.003) and 90-day (3.2, 95% CI 1.8-5.7, P = 0.0001) readmission. CONCLUSIONS: High ASA class is strongly associated with increased costs, LOS, and adverse outcomes following PCDF and could be useful for preoperative prediction of these outcomes.

The Impact of Diabetes on Outcomes and Health Care Costs Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Anterior cervical discectomy and fusion (ACDF) is commonly used to treat an array of cervical spine pathology and is associated with good outcomes and low complication rates. Diabetes mellitus (DM) is a common comorbidity for patients undergoing ACDF, but the literature is equivocal about the impact it has on outcomes. Because DM is a highly prevalent comorbidity, it is crucial to determine if it is an associated risk factor for outcomes after ACDF procedures. METHODS: Patients at a single institution from 2008 to 2016 undergoing ACDF were compared on the basis of having a prior diagnosis of DM versus no DM. The 2 cohorts were compared utilizing univariate tests and multivariate logistic and linear regressions. RESULTS: Data for 2470 patients was analyzed. Diabetic patients had significantly higher Elixhauser scores (P < .0001). Univariate testing showed diabetic patients were more likely to suffer from sepsis (0.82% vs 0.10%, P = .03) and bleeding complications (3.0% vs 1.5%, P = .04). In multivariate analyses, diabetic patients had higher rates of non-home discharge (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.07-1.75, P = .013) and prolonged length of stay (OR = 1.95, 95% CI = 1.25-3.05, P = .003), but similar complication (OR = 1.46, 95% CI = 0.85-2.52, P = .17), reoperation (OR = 0.77, 95% CI = 0.33-1.81, P = .55), and 90-day readmission (OR = 1.53, 95% CI = 0.97-2.43) rates compared to nondiabetic patients. Direct cost was also shown to be similar between the cohorts after adjusting for patient, surgical, and hospital-related factors (estimate = -$30.25, 95% CI = -$515.69 to $455.18, P = .90). CONCLUSIONS: Diabetic patients undergoing ACDF had similar complication, reoperation, and readmission rates, as well as similar cost of care compared to nondiabetic patients.

Anesthesia provider performance in the first two years of merit-based incentive payment system: Shifts in reporting and predictors of receiving bonus payments.

STUDY OBJECTIVE: The Merit-Based Incentive Payment System (MIPS) program was intended to align CMS quality and incentive programs. To date, no reports have described anesthesia clinician performance in the first two years of the program. DESIGN: Observational retrospective cohort study. SETTING: Centers for Medicare and Medicaid Services public datasets for their Quality Payment Program. PATIENTS: Anesthesia clinicians who participated in MIPS for 2017 and 2018 performance years. INTERVENTIONS: Descriptive statistics compared anesthesia clinician characteristics, practice setting, and MIPS performance between the two years to determine associations with MIPS-based payment adjustments. MEASUREMENTS: Logistic regression identified independent predictors of bonus payments for exceptional performance. MAIN RESULTS: Compared with participants in 2017 (n = 25,604), participants in 2018 (n = 54,381) had a higher proportion of reporting through groups and alternative payment models (APMs) than as individuals (p < 0.001). The proportion of clinicians earning performance bonuses increased from 2017 to 2018 except for those MIPS participants reporting as individuals. Median total MIPS scores were higher in 2018 than 2017 (84.6 vs. 82.4, p < 0.001), although median total scores fell for participants reporting as individuals (40.9 vs 75.5, p < 0.001). Among clinicians with scores in both years (n = 20,490), 10,559 (51.3%) improved their total score between 2017 and 2018, and 347 (1.7%) changed reporting from individual to APM. Reporting as an individual compared with group reporting (OR: 0.75; 95% CI: 0.71 to 0.80; p < 0.001) was associated with lower rates of bonus payments, as was having a greater proportion of patients dual-eligible for Medicaid and Medicare. Reporting through an APM (OR: 149.6; 95% CI: 110 to 203.4; p < 0.001) and increasing practice group size were associated with higher likelihood of bonus payments. CONCLUSIONS: Anesthesia clinician MIPS participation and performance were strong during 2017 and 2018 performance years. Providers who reported through groups or APMs have a higher likelihood of receiving bonus payments.

Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF). SUMMARY OF BACKGROUND DATA: While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated. METHODS: Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes. RESULTS: One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs. CONCLUSION: Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.Level of Evidence: 3.

Comparison of Anterior and Posterior Surgical Approaches for Treatment of Thoracic Myelopathy.

OBJECTIVE: To study a large multi-institutional sample of patients undergoing anterior versus posterior approaches for surgical decompression of thoracic myelopathy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent decompression for thoracic myelopathy between 2007 and 2015 via anterior or posterior approaches. Patients were excluded if they were undergoing surgery for tumors to isolate a degenerative cohort. Demographics, patient comorbidities, operative details, and postoperative complications were compared between the 2 cohorts. RESULTS: Although there were no differences in age (P = 0.06), sex (P = 0.72), or American Society of Anesthesiologists class (P = 0.59), there were higher rates of steroid use (P = 0.01) and hematologic disorders that predispose to bleeding (P = 0.04) at baseline in the posterior approach cohort. The posterior approach patients had longer operative times (P = 0.03), but there were no differences in length of stay (P = 0.64). Although there were no significant differences in the rates of major organ system complications or return to the operating room (P = 0.52), the posterior approach cohort displayed a trend toward increased severe adverse complications (29.8% vs. 17.6%, P = 0.28) compared with the anterior approach cohort. CONCLUSION: Although the anterior approach to surgical decompression of thoracic myelopathy demonstrated a lower complication rate, this result did not reach statistical significance. The anterior approach was associated with significantly shorter mean operative time, but otherwise there were no significant differences in operative or postoperative outcomes. These findings may support the favorability of the anterior approach but warrant further investigation in a larger study.

The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS: Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS: Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION: Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes.

STUDY DESIGN: Retrospective analysis of clinical data from a single institution. OBJECTIVE: The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy. SUMMARY OF BACKGROUND DATA: The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy. METHODS: Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates. RESULTS: Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts. CONCLUSION: The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.