The Association of "U.S. News & World Report" Hospital Rankings and Outcomes Following Anterior Cervical Fusions: Do Rankings Even Matter?

STUDY DESIGN: Retrospective observational study. OBJECTIVE: The aim of this study was to evaluate whether there are any differences in outcomes and costs for elective one- to three-level anterior cervical fusions (ACFs) performed at US News and World Report (USNWR) ranked and unranked hospitals. SUMMARY OF BACKGROUND DATA: Although the USNWR rankings are advertised by media and are routinely used by patients as a guide in seeking care, evidence regarding whether these rankings are reflective of actual clinical outcome remains limited. METHODS: The 2010-2014 USNWR hospital rankings were used to identify ranked hospitals in "Neurosurgery" and "Orthopedics." The 2010-2014 100% Medicare Standard Analytical Files (SAF100) were used to identify patients undergoing elective ACFs at ranked and unranked hospitals. Multivariable logistic regression and generalized linear regression analyses were used to assess for differences in 90-day outcomes and costs between ranked and unranked hospitals. RESULTS: A total of 110,520 patients undergoing elective one- to three-level ACFs were included in the study, of which 10,289 (9.3%) underwent surgery in one of the 100 ranked hospitals. Following multivariate analysis, there were no significant differences between ranked versus unranked hospitals with regards to wound complications (1.2% vs. 1.1%; P = 0.907), cardiac complications (12.9% vs. 11.9%; P = 0.055), pulmonary complications (3.7% vs. 6.7%; P = 0.654), urinary tract infections (7.3% vs. 5.8%; P = 0.120), sepsis (9.3% vs. 7.9%; P = 0.847), deep venous thrombosis (1.9% vs. 1.3%; P = 0.077), revision surgery (0.3% vs. 0.3%; P = 0.617), and all-cause readmissions (4.7% vs. 4.4%; P = 0.266). Ranked hospitals, as compared to unranked hospitals, had a slightly lower odds of experiencing renal complications (7.0% vs. 4.9%; P = 0.047), but had significantly higher risk-adjusted 90-day charges (+$17,053; P < 0.001) and costs (+ $1695; P < 0.001). CONCLUSION: Despite the higher charges and costs of care at ranked hospitals, these facilities appear to have similar outcomes as compared to unranked hospitals following elective ACFs.Level of Evidence: 3.

Primary single-level lumbar microdisectomy/decompression at a free-standing ambulatory surgical center vs a hospital-owned outpatient department-an analysis of 90-day outcomes and costs.

BACKGROUND CONTEXT: While free-standing ambulatory surgical centers (ASCs) have been extolled as lower cost settings than hospital outpatient facilities/departments (HOPDs) for performing routine elective spine surgeries, differences in 90-day costs and complications have yet to be compared between the two types of treatment facilities. PURPOSE: We carried a comprehensive analysis to report the differences on payments to providers and facilities as a reflection of true costs to patients, employers and health plans for patients undergoing primary, single-level lumbar microdiscectomy/decompression at ASC versus HOPD. STUDY DESIGN: Retrospective review of Medicare advantage and commercially insured enrollees from the Humana dataset from 2007 to 2017Q1. OUTCOME MEASURES: To understand the differences in 90-day complications, readmissions, emergency department visits and costs for patients undergoing primary, single-level lumbar microdiscectomy/decompressions at an ASC versus HOPD. METHODS: The Humana 2007 to 2017Q1 was queried using Current Procedural Terminology codes to identify patients undergoing primary, single-level lumbar microdiscectomy/decompressions. Patients undergoing two-level surgery, open laminectomies, fusions, revision discectomies, and/or deformities were excluded. Service Location codes for HOPD (Location Code 22) and free-standing ASC (Location Code 24) were used to determine surgery treatment facilities. Using propensity scoring, we matched two groups who had surgery performed in ASCs or HOPDs based on age, gender, race, region and Elixhauser comorbidity index. Multivariable logistic regression analyses were performed on matched cohorts to assess for differences in 90-day outcomes between facilities, while controlling for age, gender, race, region, plan, and Elixhauser comorbidity index. RESULTS: A total of 1,077 and 10,475 primary single-level decompressions were performed in ASCs and HOPDs, respectively. Following a matching algorithm with propensity scoring, the two cohorts were comprised of 990 patients each. Observed differences in 90-day complication rates were not statistically or clinically significant (ASC=9.1% vs. HOPD=10.3%; p=.362) nor were readmissions (ASC=4.5% vs. HOPD=5.3%; p=.466). On average, performing surgery in an ASC versus HOPD resulted in significant cost savings of over $2,000/case in Medicare Advantage ($5,814 vs. $7,829) and over $3,500/case ($10,116 vs. $13,623) in commercial beneficiaries. CONCLUSION: Performing single-level decompression surgeries in an ASC compared with HOPDs was associated with approximately $2,000 to $3,500 cost-savings per case with no statistically significant impact on complication or readmission rates.

The Impact of Metabolic Syndrome on 30-Day Outcomes Following ORIF for Ankle Fractures.

Introduction: Metabolic syndrome (MetS) is associated with significant postoperative morbidity. Despite an increasing prevalence of MetS in the US population, its impact on postoperative outcomes following ankle fractures remains limited. Materials and Methods: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program database was queried for patients undergoing open reduction with internal fixation (ORIF) for ankle fractures using Current Procedural Terminology codes: 27766, 27769, 27792, 27814, 27822, and 27823. The study cohort was divided into 2 groups: MetS versus No MetS. MetS was identified using a predefined criteria as the coexistence of (1) diabetes mellitus, (2) hypertension, and (3) body mass index ≥30 kg/m2. Results: A total of 1013 (6.7%) MetS underwent ORIF for ankle fractures. Following adjustment for baseline differences, MetS was an independent predictor of experiencing any 30-day complication (odds ratio [OR] = 1.35; P = .020), wound complications (OR = 1.67; P = .024), renal complications (OR = 3.54; P = .022), 30-day readmissions (OR = 1.66; P = .001), 30-day unplanned reoperations (OR = 1.69; P = .009) and decreased odds of home discharge (OR = 0.66; P < .001). Conclusion: Patients with MetS undergoing ORIF for ankle fractures are at an increased risk of experiencing adverse 30-day complications, readmissions, and reoperations. Providers should understand the need of appropriate postoperative surveillance in this high-risk group to minimize the risk of poor outcomes. Level of Evidence: Level III.

Risk factors for post-discharge complications and readmissions in home-discharges after elective posterior lumbar fusions.

OBJECTIVES: Previous literature has studied overall post-operative outcomes following lumbar fusions. We examined the rates and risk factors for adverse outcomes in patients who are being discharged home. PATIENTS AND METHODS: The 2012-2016 ACS-NSQIP database was used to query for patients undergoing 1- to 2-level posterior lumbar fusions (PLFs) for degenerative spinal pathology. Patients discharged to a destination other than home were removed from the database. RESULTS: Out of a total of 19,179 home-discharge patients, 546 (2.8%) experienced any adverse event (AAE), 276 experienced a severe adverse event (SAE) and 321 (1.7%) experienced a minor adverse event (MAE). Overall re-admission and re-operation rate in home-discharged patients was 4.4% and 2.5%. Multivariate analysis identified the following predictors for experiencing an AAE - Bleeding disorder (OR 2.25), BMI ≥ 35.0 vs. BMI < 25 (OR 1.96), chronic steroid use (OR 1.89), a LOS > 3 days (OR 1.53), insulin-dependent diabetes mellitus (OR 1.44), hypertension (OR 1.28) and female gender (OR 1.24). Patients with a pre-discharge complication (OR 2.12), bleeding disorders (OR 1.84), chronic steroid use (OR 1.55), age>75 (OR 1.49), age>65 (OR 1.26), history of severe COPD (OR 1.43), total operative time >210 min. (OR 1.26), ASA > II (OR 1.26) and undergoing a 2-level fusion (OR 1.21) were likely to be re-admitted from home. CONCLUSIONS: Providers should utilize the data to risk-stratify and better understand the need of provision of supplemental health-care services, in home-discharged patients, and/or regular clinic follow-up to minimize the rate of adverse events and reduce costs in a bundled-payment environment.

Impact of Sarcopenia on Adverse Outcomes After Allogeneic Hematopoietic Cell Transplantation.

BACKGROUND: High intensity treatments such as hematopoietic cell transplantation (HCT) can be curative for patients with hematologic malignancies, but this needs to be balanced by the high risk of nonrelapse mortality (NRM) during the first 2 years after HCT. Sarcopenia (low muscle mass) is associated with physical disability and premature mortality in individuals with nonmalignant diseases and may be a predictor of NRM and poor overall survival in patients undergoing HCT. METHODS: This was a retrospective cohort study of 859 patients with acute leukemia or myelodysplastic syndrome who underwent a first HCT as adults (≥18 years) between 2007 and 2014. Sarcopenia was assessed from pre-HCT abdominal computed tomography scans. Two-year cumulative incidence of NRM was calculated, with relapse/progression considered as a competing risk event. Fine-Gray subdistribution hazard ratio estimates and 95% confidence intervals (CI) were obtained and adjusted for relevant covariates. Kaplan-Meier method was used to examine overall survival. All statistical tests were two-sided. RESULTS: Median age at HCT was 51 years (range = 18-74 years); 52.5% had a high [≥3] HCT-comorbidity index; 33.7% had sarcopenia pre-HCT. Sarcopenia was an independent predictor of higher NRM risk (hazard ratio = 1.58, 95% CI = 1.16 to 2.16) compared with patients who were not. The 2-year incidence of NRM approached 30% in patients with sarcopenia and high (≥3) HCT-comorbidity index. Patients with sarcopenia had on average a longer hospitalization (37.2 days vs 31.5 days, P < .001) and inferior overall survival at 2 years (55.2%, 95% CI = 49.5% to 61.0% vs 66.9%, 95% CI = 63.0% to 70.8%, P < .001). CONCLUSIONS: Sarcopenia is an important and independent predictor of survival after HCT, with potential additional downstream impacts on health-economic outcomes. This information can be used to facilitate treatment decisions prior to HCT and guide interventions to decrease the risk of treatment-related complications after HCT.

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis.

OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

Characterization of SNARE cleavage products generated by formulated botulinum neurotoxin type-a drug products.

The study evaluated substrate cleavage product(s) generated by three botulinum neurotoxin serotype A (BoNT/A) medicinal drug products utilizing a novel and highly specific, light-chain activity, high-performance liquid chromatography (LCA-HPLC) method. Samples were reacted with a commercially available BoNT/A fluorescent substrate derived from the SNAP-25 sequence. Reaction products were separated by reversed-phase HPLC. The method detected an atypical cleavage pattern by one of the formulated drug products. IncobotulinumtoxinA produced two cleavage fragments rather than the single fragment typically generated by BoNT/A. Identification confirmed the secondary cleavage at a position corresponding to SNAP-25 Arg198-Ala199 (normal BoNT/A cleavage is Gln197-Arg198). Arg198-Ala199 is also the cleavage site for trypsin and serotype C toxin. Normal cleavage was observed for all other BoNT/A drug product samples, as well as 900-kD and 150-kD bulk toxin BoNT/A. The reason for this unexpected secondary cleavage pattern by one formulated BoNT/A drug product is unknown. Possible explanations include a contaminating protease and/or damage to the 150-kD type-A toxin causing nonspecific substrate recognition and subsequent cleavage uncharacteristic of type-A toxin. The BoNT/A drug products were also analyzed via the LCA-HPLC assay using a commercial BoNT/C fluorescent substrate derived from the syntaxin sequence. Cleavage of the serotype C substrate by incobotulinumtoxinA was also confirmed whilst neither of the other drug products cleaved the syntaxin substrate.