Drivers of Variability in 90-day Cost for Primary Single-level Microdiscectomy.

BACKGROUND: The healthcare reimbursement models are rapidly transitioning to pay-per-performance episode of care payment models. These models, if designed well, must account for the variability in the cost of index surgeries during the global period. OBJECTIVE: To analyze the variability in 90-d cost and determine the drivers of the variability in total 90-d cost associated with single-level microdiscectomy. METHODS: A total of 203 patients undergoing primary microdiscectomy for degenerative lumbar conditions were included in the study. The total 90-d cost was derived as the sum of cost of surgery, cost associated with postdischarge utilization. A multivariable linear regression model for total 90-d cost was built. RESULTS: The mean total cost within 90-d after single-level primary microdiscectomy was $7962 ± $2092. In a multivariable linear regression model, obesity, history of myocardial infarction, factors that lengthen the time of surgery and hospital stay, complications and readmission within 90-d, postdischarge healthcare utilization including emergency room visits, time to opioid independence, number of days on nonopioid pain medications, diagnostic imaging, and the number of days in outpatient and inpatient rehabilitation contribute to the total 90-d cost. The model performance as measured by R2 is 0.76. CONCLUSION: Utilizing prospectively collected data, we highlight major drivers of variation in cost following a single-level primary microdiscectomy. Our model explains about three-quarters of the variation in cost. The risk-adjusted cost estimates powered by models such as the one presented here can be used to formulate a sustainable total 90-d episode of care bundle payment.

Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease.

BACKGROUND: Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period. OBJECTIVE: To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. METHODS: Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost. RESULTS: The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616. CONCLUSION: There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons' and institution-specific differences.

Surgeon-Level Variability in Outcomes, Cost, and Comorbidity Adjusted-Cost for Elective Lumbar Decompression and Fusion.

BACKGROUND: The costs and outcomes following degenerative spine surgery may vary from surgeon to surgeon. Patient factors such as comorbidities may increase the health care cost. These variations are not well studied. OBJECTIVE: To understand the variation in outcomes, costs, and comorbidity-adjusted cost for surgeons performing lumbar laminectomy and fusions surgery. METHODS: A total of 752 patients undergoing laminectomy and fusion, performed by 7 surgeons, were analyzed. Patient-reported outcomes and 90-d cost were analyzed. Multivariate regression model was built for high-cost surgery. A separate linear regression model was built to derive comorbidity-adjusted 90-d costs. RESULTS: No significant differences in improvement were found across all the patient-reported outcomes, complications, and readmission among the surgeons. In multivariable model, surgeons #4 (P < .0001) and #6 (P = .002) had higher odds of performing high-cost fusion surgery. The comorbidity-adjusted costs were higher than the actual 90-d costs for surgeons #1 (P = .08), #3 (P = .002), #5 (P < .0001), and #7 (P < .0001), whereas they were lower than the actual costs for surgeons #2 (P = .128), #4 (P < .0001), and #6 (P = .44). CONCLUSION: Our study provides valuable insight into variations in 90-d costs among the surgeons performing elective lumbar laminectomy and fusion at a single institution. Specific surgeons were found to have greater odds of performing high-cost surgeries. Adjusting for preoperative comorbidities, however, led to costs that were higher than the actual costs for certain surgeons and lower than the actual costs for others. Patients' preoperative comorbidities must be accounted for when crafting value-based payment models. Furthermore, designing intervention targeting "modifiable" factors tied to the way the surgeons practice may increase the overall value of spine care.

In-Toeing Is Often a Primary Care Orthopedic Condition.

OBJECTIVE: To evaluate in-toeing consults to a pediatric orthopedic clinic to determine the proportion that could be managed by a primary care physician. STUDY DESIGN: A prospective registry was created for 143 consecutive children referred to a pediatric orthopedic clinic for "in-toeing." Each patient underwent a careful history and physical examination, which included a rotational profile. We recorded the final diagnosis, treatment offered, follow-up visit results, and the source of the referral. RESULTS: After pediatric orthopedic evaluation, 85% of patients had a confirmed diagnosis of in-toeing, and 15% had a different final diagnosis. Seventy-four percent of patients had 1 consultation visit, 18% had 2, and 8% had >2 visits. None of the referred patients was a candidate for treatment by casting or surgery. CONCLUSION: In most cases, in-toeing is a normal variation of development that can be managed by counseling and observation by the primary care physician alone. Rare cases of severe in-toeing >2 standard deviations from the mean should likely still prompt referral to a pediatric orthopedic surgeon for potential intervention.

Does Obesity Correlate With Worse Patient-Reported Outcomes Following Elective Anterior Cervical Discectomy and Fusion?

BACKGROUND: Studies have investigated the impact of obesity in thoracolumbar surgery; however, the effect of obesity on patient-reported outcomes (PROs) following anterior cervical discectomy and fusion (ACDF) is unknown. OBJECTIVE: To examine the relationship between obesity and PROs following elective ACDF. METHODS: Consecutive patients undergoing ACDF for degenerative conditions were evaluated. Patients were divided into groups with a body mass index ≥35. The EuroQol-5D, Short-Form 12 (SF-12), modified Japanese Orthopaedic Association score, and Neck Disability Index were used. Correlations between PROs and obesity were calculated at baseline and 1 year. RESULTS: A total of 299 patients were included, with 80 obese (27%) and 219 nonobese (73%). patients At baseline, obesity was associated with worse myelopathy (modified Japanese Orthopaedic Association score: 10.7 vs 12.2, P = .01), general physical health (SF-12 physical component scale score: 28.7 vs 31.8, P = .02), and general mental health (SF-12 mental component scale score: 38.9 vs 42.3, P = .04). All PROs improved significantly following surgery in both groups. There was no difference in absolute scores and change scores for any PRO at 12 months following surgery. Furthermore, there was no difference in the percentage of patients achieving a minimal clinically important difference for the Neck Disability Index (52% vs 56%, P = .51) and no difference in patient satisfaction (85% vs 85%, P = .85) between groups. CONCLUSION: Obesity was not associated with less improvement in PROs following ACDF. There was no difference in the proportion of patients satisfied with surgery and those achieving a minimal clinically important difference across all PROs. Obese patients may therefore achieve meaningful improvement following elective ACDF. ABBREVIATIONS: ACDF, anterior cervical discectomy and fusionBMI, body mass indexEQ-5D, EuroQol-5DMCID, minimal clinically important differenceMCS, mental component scalemJOA, modified Japanese Orthopaedic AssociationNDI, Neck Disability IndexNRS, Numerical Rating ScalePCS, physical component scalePROs, patient-reported outcomesSF-12, Short Form 12.

Can facet joint fluid on MRI and dynamic instability be a predictor of improvement in back pain following lumbar fusion for degenerative spondylolisthesis?

PURPOSE: To investigate the relationship between lumbar facet fluid and dynamic instability in degenerative spondylolisthesis (DS), as well as the relationship between facet fluid and patient-reported outcomes following a posterior lumbar fusion. METHODS: We analyzed consecutive patients with degenerative spondylolisthesis undergoing single level posterior lumbar fusion from December 2010 to January 2013 at a single academic institution. We investigated the relationship between fluid in the facet joint as measured on axial MRI and the presence of dynamic instability. We investigated the impact of facet fluid, Modic changes, and dynamic instability on patient-reported outcomes. RESULTS: There was a significant association between the amount of facet joint fluid and the presence of dynamic instability (p = 0.03); as facet fluid increases, the probability of dynamic instability also increases. For every 1 mm of facet fluid, there was a 41.6 % increase (95 % CI 1.8-97) in the odds of dynamic instability. A facet fluid amount less than 0.5 mm gave a 90 % probability that there was no dynamic instability. The presence of facet fluid and dynamic instability were associated with achieving minimal clinical important difference (MCID) in low back pain following lumbar fusion (p = 0.04 and 0.05, respectively). CONCLUSION: Facet joint fluid is associated with the presence of dynamic instability in DS. The presence of facet fluid and dynamic instability may predict increased likelihood of achieving MCID for improvement in back pain following posterior lumbar fusion.

Is more lordosis associated with improved outcomes in cervical laminectomy and fusion when baseline alignment is lordotic?

BACKGROUND CONTEXT: In cervical spondylotic myelopathy (CSM), cervical sagittal alignment (CSA) is associated with disease severity. Increased kyphosis and C2-C7 sagittal vertical axis (SVA) correlate with worse myelopathy and poor outcomes. However, when alignment is lordotic, it is unknown whether these associations persist. PURPOSE: The study aimed to investigate the associations between CSA parameters and patient-reported outcomes (PROs) following posterior decompression and fusion for CSM when baseline lordosis is maintained. STUDY DESIGN/SETTING: This is an analysis of a prospective surgical cohort at a single academic institution. PATIENT SAMPLE: The sample includes adult patients undergoing primary cervical laminectomy and fusion for CSM over a 3-year period. OUTCOME MEASURES: The PROs included EuroQol-5D, Short-Form-12 (SF-12) physical composite (PCS) and mental composite scales (MCS), Neck Disability Index, and the modified Japanese Orthopaedic Association scores. Radiographic CSA parameters measured included C1-C2 Cobb, C2-C7 Cobb, C1-C7 Cobb, C2-C7 SVA, C1-C7 SVA, and T1 slope. METHODS: The PROs were recorded at baseline and at 3 and 12 months postoperatively. The CSA parameters were measured on standing radiographs in the neutral position at baseline and 3 months. Wilcoxon rank test was used to test for changes in PROs and CSA parameters, and Pearson correlation coefficients were calculated for CSA parameters and PROs preoperatively and at 12 months. No external sources of funding were used for this work. RESULTS: There were 45 patients included with an average age of 63 years who underwent posterior decompression and fusion of 3.7±1.3 levels. Significant improvements were found in all PROs except SF-12 MCS (p=.06). Small but statistically significant changes were found in C2-C7 Cobb (mean change: +3.6°; p=.03) and C2-C7 SVA (mean change: +3 mm; p=.01). At baseline, only C2-C7 SVA associated with worse SF-12 PCS scores (r=-0.34, p=.02). Postoperatively, there were no associations found between PROs and any CSA parameters. Similarly, no CSA parameters were associated with changes in PROs. CONCLUSIONS: Although creating more lordosis and decreasing SVA are associated with improved myelopathy and outcomes in patients with kyphosis, our study did not find such associationsin patients with lordosis undergoing posterior laminectomy and fusion for CSM. This suggests that any amount of lordosis may be sufficient.

Supply and Demand Analysis of the Orthopaedic Trauma Surgeon Workforce in the United States.

OBJECTIVE: To investigate recent trends in the orthopaedic trauma workforce and to assess whether supply of orthopaedic trauma surgeons (OTS) matches the demand for their skills. METHODS: Supply estimated using Orthopaedic Trauma Association (OTA) membership and American Academy of Orthopaedic Surgeons census data. The annual number of operative pelvic and acetabular fractures reported by American College of Surgeons verified trauma centers in the National Trauma Data Bank (NTDB) was used as a surrogate of demand. Because surrogates were used, the annual rate of change in OTA membership versus rate of change in operative injuries per NTDB center was compared. RESULTS: From 2002 to 2012, reported operative pelvic and acetabular injuries increased by an average of 21.0% per year. The number of reporting trauma centers increased by 27.2% per year. The number of OTA members increased each year except in 2009, with mean annual increase of 9.8%. The mean number of orthopaedic surgeons per NTDB center increased from 7.98 to 8.58, an average of 1.5% per year. The annual number of operative pelvic and acetabular fractures per NTDB center decreased from 27.1 in 2002 to 19.03 in 2012, down 2.0% per year. CONCLUSIONS: In the United States, from 2002 to 2012, the number of OTS trended upward, whereas operative pelvic and acetabular cases per reporting NTDB center declined. These trends suggest a net loss of such cases per OTS over this period.

Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973-2005.

OBJECTIVE: • To evaluate epidemiological and survival patterns of upper-tract urothelial carcinoma (UTUC) over the past 30 years through a review of a large, population-based database. PATIENTS AND METHODS: • Data from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2005 were reviewed in 10-year increments to evaluate disease trends. • Univariate and multivariate survival analyses identified prognostic variables for outcomes. RESULTS: •In total, 13,800 SEER-registered cases of UTUC were included. The overall incidence of UTUC increased from 1.88 to 2.06 cases per 100,000 person-years during the period studied, with an associated increase in ureteral disease (0.69 to 0.91) and a decrease in renal pelvic cancers (1.19 to 1.15). • The proportion of in situ tumours increased from 7.2% to 31.0% (P < 0.001), whereas local tumours declined from 50.4% to 23.6% (P < 0.001). • There was no change in the proportion of patients presenting with distant disease. • In multivariate analysis, increasing patient age (P < 0.001), male gender (P < 0.001), black non-Hispanic race (P < 0.001), bilateral UTUC (P = 0.001) and regional/distant disease (P < 0.001) were all associated with poorer survival outcomes. CONCLUSIONS: • The incidence of UTUC has slowly risen over the past 30 years. • Increased use of bladder cancer surveillance regimens and improved abdominal cross-sectional imaging may contribute to the observed stage migration towards more in situ lesions. • Although pathological disease characteristics impact cancer outcomes, certain sociodemographic factors also appear to portend worse prognosis.

Adrenergic mechanisms do not contribute to age-related decreases in calf venous compliance.

Limb venous compliance decreases with advancing age, even in healthy humans. To test the hypothesis that adrenergic mechanisms contribute to age-associated reductions in limb venous compliance, we measured calf venous compliance before and during acute systemic α- and ß-adrenergic blockade in eight young (27 ± 1 yr old, mean ± SE) and eight older healthy men (67 ± 2 yr old). Calf venous compliance was determined in supine subjects by inflating a thigh-collecting cuff to 60 mmHg for 8 min and then decreasing it (1 mmHg/s) to 0 mmHg while calf volume was indexed with a strain gauge. The slope (·10⁻³) of the pressure-compliance relation (compliance= ß1 + 2·ß2·cuff pressure), which is the first derivative of the quadratic pressure-volume relation [(Δlimb volume) = ß0+ ß1·(cuff pressure) + ß2·(cuff pressure)²] during reductions in cuff pressure, was used to quantify calf venous compliance. Calf venous compliance was ∼30% lower (P < 0.01) in older compared with young men before adrenergic blockade. In response to adrenergic blockade calf venous compliance did not increase in young (-2.62 ± 0.14 and -2.29 ± 0.18 ml·dl⁻¹·mmHg⁻¹, before and during blockade, respectively) or older men (-1.78 ± 0.27 and -1.68 ± 0.21 ml·dl⁻¹ ·mmHg⁻¹). Moreover, during adrenergic blockade differences in calf venous compliance between young and older men observed before adrenergic blockade persisted. Collectively, these data strongly suggest that adrenergic mechanisms neither directly restrain calf venous compliance in young or older men nor do they contribute to age-associated reductions in calf venous compliance in healthy men.