Dysfunction of the aging female mouse urethra is associated with striated muscle loss and increased fibrosis: an initial report.

The decline of urethral function with advancing age plays a major role in urinary incontinence in women, impairing quality of life and economically burdening the health care system. However, none of the current urinary incontinence treatments address the declining urethral function with aging, and the mechanisms by which aging impacts urethra physiology remain little known or explored. Here, we have compared functional, morphometric, and global gene expression of urethral tissues between young and old female mice. Bladder leak point pressure (LPP) measurement showed that the aged female mice had 26.55% lower LPP compared to younger mice. Vectorized Scale-Invariant Pattern Recognition (VIPR) analysis of the relative abundance of different tissue components revealed that the mid-urethra of old female mice contains less striated muscle, more extracellular matrix/fibrosis, and diminished elastin fibers ratio compared to young mice. Gene expression profiling analysis (bulk RNA-seq of the whole urethra) showed more down-regulated genes in aged than young mice. Immune response and muscle-related (striated and smooth) pathways were predominantly enriched. In contrast, keratinization, skin development, and cell differentiation pathways were significantly downregulated in aged urethral tissues compared to those from young female mice. These results suggest that molecular pathways (i.e., ACVR1/FST signaling and CTGF/TGF-ß signaling) leading to a decreased striated muscle mass and an increase in fibrous extracellular matrix in the process of aging deserve further investigation for their roles in the declined urethral function.

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model.

STUDY DESIGN/SETTING: Retrospective. OBJECTIVE: To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. SUMMARY OF BACKGROUND DATA: Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. METHODS: The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. RESULTS: A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. CONCLUSIONS: Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

Is Outpatient Anterior Lumbar Fusion (ALIF) Safe? An Analysis of 30-day Outcomes.

STUDY DESIGN: Review of publicly available database. OBJECTIVE: To compare 30-day outcomes of single-level ALIF procedures performed in outpatient and inpatient settings. SUMMARY OF BACKGROUND DATA: Despite a growing interest in performing standalone anterior lumbar interbody fusions (ALIFs) as an outpatient procedure, no study has evaluated the safety or efficacy of this procedure outside an inpatient setting. METHODS: The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was queried using CPT code 22558 to identify patients undergoing a single-level ALIF. Patients receiving concurrent posterior lumbar surgery/fusion/instrumentation, pelvic fixation, or surgery due to tumor, trauma and/or deformity were excluded to capture an isolated cohort of patients receiving single-level standalone ALIFs. A total of 3728 single-level standalone ALIFs were included in the study. Multivariate regression analyses were used to compare 30-day adverse events and readmissions while controlling for baseline clinical characteristics. RESULTS: Out of a total of 3728 ALIFs, 149 (4.0%) were performed as outpatient procedure. Following adjustment, outpatient ALIFs versus inpatient ALIFs had lower odds of experiencing any 30-day adverse event (2.0% vs. 9.2%, OR 0.24 [95% CI 0.08-0.76]; P =0.015). No significant differences were noted with regard to severe adverse events 9p=0.261), minor adverse events 9p=0.995), and readmission rates ( P =0.95). CONCLUSION: On the basis of the results of the study, it appears that ALIFs may be carried out safely in an outpatient setting in an appropriately selected patient population.

Comparison of Lumbar Fusion With and Without Interbody Fusion for Lumbar Stenosis Using Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing (CAT).

Study design This was a retrospective analysis of patient-reported outcomes across a two-year period. Summary of background data Patients suffering from lumbar stenosis may experience low back pain, neurogenic claudication, and weakness. Patients can benefit from surgical intervention, including decompression with or without fusion. However, the superiority of any single fusion construct remains controversial. Objective The goal of this study was to compare Patient-Reported Outcomes Measurement Information System (PROMIS®) Computer Adaptive Testing (CAT) measures in patients with lumbar spinal stenosis treated surgically with lumbar decompression and fusion with or without interbody fusion. Methods A retrospective review of patients with lumbar stenosis undergoing lumbar decompression and one-level fusion was performed. PROMIS® CAT Physical Function (PF) and Pain Interference (PI) assessments were administered using a web-based platform pre and postoperatively. Results Sixty patients with lumbar stenosis undergoing one-level lumbar fusion were identified. Twenty-seven patients underwent posterior lumbar fusion (PSF) alone and 33 underwent one-level lumbar interbody fusion (IF). Patients undergoing IF had better absolute PF scores compared to patients undergoing PSF at one-year postoperatively (48.9 v 41.6, p=0.002) and greater relative improvement in PF scores from baseline at one-year postoperatively (D13.6 v D8.6, p=0.02). A subgroup analysis of patients undergoing TLIF v PSF showed better absolute PF scores at the one-year follow-up in the TLIF group (47.1 v 42.3, p=0.04). No differences were found in PI scores at any time point between the PSF and IF groups. Patients undergoing IF had significantly shorter hospital stays (2.5 v 3.3 days, p=0.02) compared to patients undergoing PSF. Conclusions Patients with lumbar spinal stenosis treated with one-level IF reported higher absolute PF scores and experienced greater relative improvement in PF scores from baseline at one-year follow-up compared to patients treated with PSF alone. Additionally, IF is associated with a decreased length of hospital stay as compared to PSF.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS).

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients: Executive summary.

Guidelines for the implantation of cardiac implantable electronic devices (CIEDs) have evolved since publication of the initial ACC/AHA pacemaker guidelines in 1984 [1]. CIEDs have evolved to include novel forms of cardiac pacing, the development of implantable cardioverter defibrillators (ICDs) and the introduction of devices for long term monitoring of heart rhythm and other physiologic parameters. In view of the increasing complexity of both devices and patients, practice guidelines, by necessity, have become increasingly specific. In 2018, the ACC/AHA/HRS published Guidelines on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay [2], which were specific recommendations for patients >18 years of age. This age-specific threshold was established in view of the differing indications for CIEDs in young patients as well as size-specific technology factors. Therefore, the following document was developed to update and further delineate indications for the use and management of CIEDs in pediatric patients, defined as ≤21 years of age, with recognition that there is often overlap in the care of patents between 18 and 21 years of age. This document is an abbreviated expert consensus statement (ECS) intended to focus primarily on the indications for CIEDs in the setting of specific disease/diagnostic categories. This document will also provide guidance regarding the management of lead systems and follow-up evaluation for pediatric patients with CIEDs. The recommendations are presented in an abbreviated modular format, with each section including the complete table of recommendations along with a brief synopsis of supportive text and select references to provide some context for the recommendations. This document is not intended to provide an exhaustive discussion of the basis for each of the recommendations, which are further addressed in the comprehensive PACES-CIED document [3], with further data easily accessible in electronic searches or textbooks.

2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.

Robotic-Assisted Versus Conventional Posterior Lumbar Fusion-An Analysis of 90-Day Complications and Readmissions.

OBJECTIVE: To evaluate medical and surgical complication rates between robotic-assisted versus conventional elective posterior lumbar fusions. METHODS: The Symphony Integrated DataVerse was queried using International Classification of Diseases, 10th Edition, Clinical Modification procedure codes to identify patients undergoing elective posterior lumbar fusions for degenerative spine pathologies between 2015 and 2018. International Classification of Diseases, 10th Edition, Clinical Modification procedure codes (8E0W4CZ, 8E0W0CZ, 8E0W3CZ) were used to identify patients undergoing a robotic-assisted spinal fusion. Outcome measures were 90-day medical and surgical complications, 1-year pseudarthrosis, and 1-year revision surgery rates. Multivariate logistic regression analyses were used to assess whether undergoing a robotic-assisted fusion (vs. conventional fusion) was associated with differences in wound complications, medical complications, pseudarthrosis, revision surgery, and readmissions within 90 days of surgery. RESULTS: A total of 39,387 patients undergoing elective posterior lumbar fusions were included in the cohort-of whom 245 (0.62%) patients underwent a robotic-assisted fusion. Multivariate analysis showed that robotic-assisted fusion (vs. conventional fusion) was not associated with significant differences in 90-day rates of wound complications (P = 0.299), urinary tract infections (P = 0.648), acute myocardial infarctions (P = 0.209), acute renal failure (P = 0.461), pneumonia (P = 0.214), stroke (P = 0.917), deep venous thrombosis (P = 0.562), pulmonary embolism (P = 0.401), and readmissions (P = 0.985). In addition, there were no significant differences in the 1-year rates of revision fusions (P = 0.316) and pseudarthrosis (P = 0.695). CONCLUSIONS: Patients who underwent a robotic-assisted fusion had similar rates of surgical and medical complications compared with those who underwent a conventional fusion. Further studies are warranted to better understand the future role of robots in spine surgery.

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.

Understanding the Trends and Variability in Procedures Performed During Orthopedic Spine Surgery Fellowship Training: An Analysis of ACGME Case Log Data.

OBJECTIVE: To understand trends and variability of procedures performed by orthopedic spine surgery fellows during training. DESIGN: Cross-sectional survey. SETTING: Accreditation Council on Graduate Medical Education (ACGME) case logs. PARTICIPANTS: Fellows enrolled in ACGME-accredited "Orthopaedic Surgery of the Spine" fellowships from 2010 to 2015. RESULTS: The 2010 to 2015 ACGME fellowship case logs for "Orthopaedic Surgery of the Spine" were retrieved. Spine cases in case logs are grouped into the following categories: (1) Excision, (2) Osteotomy, (3) Fracture and/or Dislocation, (4) Decompression, (5) Anterior fusion/arthrodesis, (6) Posterior fusion, (7) Deformity surgery, (8) Exploration, (9) Instrumentation, and (10) other/uncategorized. The total number of spine cases logged by each fellow increased from 821 in 2010 to 1134 in 2015 (38.2% increase). The greatest increases were noted from fracture/dislocation cases (77.9%), followed by posterior fusions (62.2%), anterior fusions (43.6%), decompressions (36.3%), and instrumentation (29.5%). The average number of deformity cases decreased from 23 in 2010 to 19 in 2016 (18.6% decrease). The average number of adult-only cases increased from 770 in 2010 to 1100 in 2015 (42.8% increase), whereas the average number of pediatric-only cases declined from 51 in 2010 to 35 in 2015 (32.1% decrease). Based on case logs from 2015, the greatest variation in case volume between the 10th centile and 90th centile of fellows was noted for deformity cases, followed by decompressions and posterior fusions. CONCLUSIONS: Even though there has been a 38% increase in the overall number of spine cases performed by fellows during training, a large amount of variation in type of case exposure exists between fellowships. The findings of our study call for the establishment of minimal case volumes and/or uniformity of training spectrums across the nation to ensure appropriate surgical care is made accessible to all patients.

Hospital network participation and outcomes following elective posterior lumbar fusions - are mergers effective?

BACKGROUND CONTEXT: Due to financial pressures associated with healthcare reforms, an increasing number of hospitals are now merging (or consolidating) into networks (or systems). However, it remains unclear how these mergers or network participations affect quality of care and/or costs. PURPOSE: The current study aims to evaluate the impact of hospital network participation on 90-day complications, charges, and costs following elective posterior lumbar fusions (PLFs). STUDY DESIGN: Retrospective review of a 100% national sample of Medicare claims from 2010 to 2014 (SAF100). STUDY SAMPLE: All Medicare-eligible patients undergoing elective 1-to-3 level PLFs for degenerative lumbar pathology from 2010 to 2014. OUTCOME MEASURES: Ninety-day complications, charges, and costs. METHODS: The 2010 to 2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1- to 3-level PLFs for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network (or system) between 2010 and 2014. The study sample was divided into 2 cohorts (network hospitals and non-network hospitals) for analyses. Multivariate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location, and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs. RESULTS: A total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study, out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were more prevalent in the South or West regions of the United States. Patients in network hospitals had a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1- to 3-level PLFs, greater number of beds, be located in an urban location, and have a voluntary/nonprofit or proprietary/profit ownership model. Multivariate analyses showed that even though patients undergoing surgery at network hospitals (vs non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs 7.4%, odds ratio [OR] 1.07 [95% confidence interval {CI} 1.02-1.12]; p=.010), thromboembolic complications (2.4% vs 2.2%, OR 1.12 [95% CI 1.01-1.20]; p=.025) and emergency department visits (16.4% vs 16.0%, OR 1.06 [95% CI 1.02-1.09]; p=.002), the differences would not be considered clinically significant. Despite a slight decrease in risk-adjusted 90-day reimbursements (-$272), the risk-adjusted 90-day charges were actually significantly higher (+$9,959; p<.001) at network hospitals. CONCLUSIONS: Even though hospitals that are part of a network do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks.

Intensive Care Unit Admission Following Surgery for Pediatric Spinal Deformity: An Analysis of the ACS-NSQIP Pediatric Spinal Fusion Procedure Targeted Dataset.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To understand which patient and surgical factors are predictive of an increased odds of undergoing an admission and a prolonged stay >2 days in an intensive care unit (ICU) following corrective surgery for pediatric deformity. METHODS: The 2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric Spinal Fusion Procedure Targeted database records, merged with original 2016 ACS-NSQIP Pediatric file variables, were used for this study. Univariate and multivariate analyses were used to identify independent risk factors associated with admission, as well as a prolonged length of stay in the ICU following surgery. RESULTS: A total of 1398 (39.5%) patients required an ICU admission following the procedure-out of whom 416 (29.8%) stayed for more than 2 days. Following adjusted analysis, patient and surgical factors independently associated with an ICU admission were black/African American versus white race, anterior fusion, combined fusion, nonidiopathic scoliosis, preoperative ventilator dependence, asthma, having structural pulmonary abnormality, developmental delay, having a neuromuscular disorder, requiring nutritional support and a total operative time >270 minutes. The only significant factors associated with a prolonged length of ICU stay >2 days were preoperative ventilator dependence, nutritional support requirement, and undergoing anterior or combined fusion. CONCLUSIONS: This study is the first of its kind to identify significant patient- and procedure-level factors associated with an ICU admission, and also explores predictors for a prolonged stay in the ICU. Surgeons can use this data to preoperatively counsel families and ensure postoperative course of care is appropriately planned ahead of time.

Costs Associated With a 90-Day Episode of Care After Single-Level Anterior Lumbar Interbody Fusion.

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is a commonly performed surgical procedure for the management of degenerative lumbar spine pathologic entities. Despite an increasing number of ALIFs performed nationally, to the best of our knowledge, no study has evaluated the costs associated with the 90-day episode of care postoperatively. METHODS: The 2007-2016 Humana Administrative Claims data set, a national database of commercial and Medicare Advantage (MA) beneficiaries, was queried using Current Procedural Terminology code 22558 for patients who had undergone single-level ALIF. The 90-day costs were defined using the following categories: facility, surgeon, anesthesia, other hospitalization costs and services, radiology, office visits, physical therapy/rehabilitation, emergency department visits, and readmissions. RESULTS: A total of 365 ALIF procedures (MA, n = 244; commercial, n = 121) were included in the analysis. The average 90-day cost of single-level ALIF was $25,568 and $51,741 for the MA and commercial enrollees, respectively. The major proportion of 90-day costs was attributable to facility reimbursement (74%-76%), followed by surgeon costs (9%-11%). Postacute care (i.e., office visits and physical therapy/rehabilitation) was not a major driver of the 90-day costs, consisting of only 0.7%-1.3% of the total 90-day reimbursement. Of patients who had required readmission, the costs of the readmission increased the average 90-day costs by 65%-66%. CONCLUSIONS: Facility costs were the major drivers of a stipulated 90-day reimbursement for patients undergoing single-level ALIF. Health policy makers and providers can use these data to better understand the distribution of costs in a stipulated bundled-payment model for ALIFs and allow them to identify areas in which cost reduction strategies can be performed.

Does Increasing Body Mass Index Correlate with Adverse Outcomes Following Posterior Cervical Fusions?

BACKGROUND: Obesity has been shown to be associated with higher rates of complications after lumbar spine surgery. However, the evidence regarding the impact of body mass index (BMI) on outcomes following posterior cervical fusions (PCFs) remains limited. METHODS: The 2012-2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 22600 to identify PCFs. Patients undergoing anterior cervical spine surgery and surgery for deformity, malignancy, or infection were excluded. Patients with missing data with regard to weight, height, and 30-day outcomes were excluded. BMI (kg/m2) was categorized into 4 groups: 1) <25.0, 2) 25.0-29.9, 3) 30.0-34.9, and 4) ≥35.0. Multivariate regression analyses were constructed to assess independent impact of BMI on 30-day outcomes while controlling for baseline clinical characteristics. RESULTS: Of 2786 patients with PCFs, 710 (25.5%) had BMI <25.0, 919 (33.0%) had BMI between 25.0 and 29.9, 655 (23.5%) had BMI between 30.0 and 34.9, and 502 (18.0%) had BMI ≥35.0. Following adjustment for baseline demographics and clinical characteristics, increased BMI was not associated with a higher risk of any adverse events, severe adverse events, minor adverse events, bleeding requiring transfusion, or readmissions within 30 days of surgery. BMI ≥35.0 versus BMI <25.0 was associated only with a higher risk of deep surgical site infections (odds ratio 4.61; P = 0.009). CONCLUSIONS: With the exception of a higher rate of deep surgical site infections seen in obese patients, increased BMI does not seem to have a major impact on 30-day outcomes following PCFs.

30-Day Postoperative Morbidity and Readmission Following Revision Anterior Cervical Discectomy and Fusion (ACDF).

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. METHODS: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. RESULTS: Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). CONCLUSIONS: Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. LEVEL OF EVIDENCE: Level III-retrospective.