Browsing by Subject "Length of Stay"

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Open Access
Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury.
(Critical care medicine, 2019-11) Jiang, Fan; Jaja, Blessing NR; Kurpad, Shekar N; Badhiwala, Jetan H; Aarabi, Bizhan; Grossman, Robert G; Harrop, James S; Guest, Jim D; Schär, Ralph T; Shaffrey, Chris I; Boakye, Max; Toups, Elizabeth G; Wilson, Jefferson R; Fehlings, Michael G; North American Clinical Trials Network Collaborators
Objectives
There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome.
Design
Multicenter prospective registry.
Setting
Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network.
Patients
Eight-hundred one spinal cord injury patients enrolled by participating centers.
Interventions
Appropriate spinal cord injury treatment at individual centers.
Measurements and main results
A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores.
Conclusions
Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.
Open Access
Adult Scoliosis Deformity Surgery: Comparison of Outcomes Between One Versus Two Attending Surgeons.
(Spine, 2017-07) Gomez, Jaime A; Lafage, Virginie; Sciubba, Daniel M; Bess, Shay; Mundis, Gregory M; Liabaud, Barthelemy; Hanstein, Regina; Shaffrey, Christopher; Kelly, Michael; Ames, Christopher; Smith, Justin S; Passias, Peter G; Errico, Thomas; Schwab, Frank; International Spine Study Group
Study design
Retrospective review of prospectively collected data.
Objective
Assess outcomes of adult spinal deformity (ASD) surgery performed by one versus two attending surgeons.
Summary of background data
ASD centers have developed two attending teams to improve efficiency; their effects on complications and outcomes have not been reported.
Methods
Patients with ASD with five or more levels fused and more than 2-year follow-up were included. Estimated blood loss (EBL), length of stay (LOS), operating room (OR) time, complications, quality of life (Health Related Quality of Life), and x-rays were analyzed. Outcomes were compared between one-surgeon (1S) and two-surgeon (2S) centers. A deformity-matched cohort was analyzed.
Results
A total of 188 patients in 1S and 77 in 2S group were included. 2S group patients were older and had worse deformity based on the Scoliosis Research Society-Schwab classification (P < 0.05). There were no significant differences in levels fused (P = 0.57), LOS (8.7 vs 8.9 days), OR time (445.9 vs 453.2 min), or EBL (2008 vs 1898 cm; P > 0.05). 2S patients had more three-column osteotomies (3CO; P < 0.001) and used less bone morphogenetic protein 2 (BMP-2; 79.9% vs 15.6%; P < 0.001). The 2S group had fewer intraoperative complications (1.3% vs 11.1%; P = 0.006). Postoperative (6 wk to 2 yr) complications were more frequent in the 2S group (4.8% vs 15.6%; P < 0.002). After matching for deformity, there were no differences in (9.1 vs 10.1 days), OR time (467.8 vs 508.4 min), or EBL (3045 vs 2247 cm; P = 0.217). 2S group used less BMP-2 (20.6% vs 84.8%; P < 0.001), had fewer intraoperative complications (P = 0.015) but postoperative complications due to instrumentation failure/pseudarthrosis were more frequent (P < 0.01).
Conclusion
No significant differences were found in LOS, OR time, or EBL between the 1S and 2S groups, even when matching for severity of deformity. 2S group had less BMP-2 use, fewer intraoperative complications but more postoperative complications.
Level of evidence
2.
Open Access
Association between Dysphagia and Surgical Outcomes across the Continuum of Frailty.
(Journal of nutrition in gerontology and geriatrics, 2021-04) Cohen, Seth M; Porter Starr, Kathryn N; Risoli, Thomas; Lee, Hui-Jie; Misono, Stephanie; Jones, Harrison; Raman, Sudha
This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. A retrospective cohort analysis of surgical hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample among patients ≥50 years of age undergoing intermediate/high risk surgery not involving the larynx, pharynx, or esophagus. Of 3,298,835 weighted surgical hospitalizations, dysphagia occurred in 1.2% of all hospitalizations and was higher in frail patients ranging from 5.4% to 11.7%. Dysphagia was associated with greater length of stay, higher total costs, increased non-routine discharges, and increased medical/surgical complications among both frail and non-frail patients. Dysphagia may be an independent risk factor for poor postoperative outcomes among surgical patients ≥50 years of age across frailty conditions and is an important consideration for providers seeking to reduce risk in vulnerable surgical populations.
Open Access
Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock.
(Anesthesiology, 2015-12) Raghunathan, Karthik; Bonavia, Anthony; Nathanson, Brian H; Beadles, Christopher A; Shaw, Andrew D; Brookhart, M Alan; Miller, Timothy E; Lindenauer, Peter K
BACKGROUND: Currently, guidelines recommend initial resuscitation with intravenous (IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative. However, fluid mixtures are often used in practice, and it is unclear whether the specific mixture of IV fluids used impacts outcomes. The objective of this study is to test the hypothesis that the specific mixture of IV fluids used during initial resuscitation, in severe sepsis, is associated with important in-hospital outcomes. METHODS: Retrospective cohort study includes patients with severe sepsis who were resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2, patients who had not undergone any major surgical procedures, and patients who had a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting, propensity score matching, and hierarchical regression methods were used for risk adjustment. Patients were grouped into four exposure categories: recipients of isotonic saline alone ("Sal" exclusively), saline in combination with balanced crystalloids ("Sal + Bal"), saline in combination with colloids ("Sal + Col"), or saline in combination with balanced crystalloids and colloids ("Sal + Bal + Col"). In-hospital mortality was the primary outcome, and hospital LOS and costs per day (among survivors) were secondary outcomes. RESULTS: In risk-adjusted Inverse Probability Weighting analyses including 60,734 adults admitted to 360 intensive care units across the United States between January 2006 and December 2010, in-hospital mortality was intermediate in the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%, P = 0.401). In pairwise propensity score-matched comparisons, the administration of balanced crystalloids by hospital day 2 was consistently associated with lower mortality, whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not (relative risk, 0.79; 95% CI, 0.70 to 0.89). The association between colloid use and in-hospital mortality was inconsistent, and survival was not uniformly affected, whereas LOS and costs per day were uniformly increased. Results were robust in sensitivity analyses. CONCLUSIONS: During the initial resuscitation of adults with severe sepsis/septic shock, the types of IV fluids used may impact in-hospital mortality. When compared with the administration of isotonic saline exclusively during resuscitation, the coadministration of balanced crystalloids is associated with lower in-hospital mortality and no difference in LOS or costs per day. When colloids are coadministered, LOS and costs per day are increased without improved survival. A large randomized controlled trial evaluating crystalloid choice is warranted. Meanwhile, the use of balanced crystalloids seems reasonable. (Anesthesiology 2015; 123:1385-93).
Open Access
Autonomic cardiovascular dysregulation as a potential mechanism underlying depression and coronary artery bypass grafting surgery outcomes.
(J Cardiothorac Surg, 2010-05-13) Dao, Tam K; Youssef, Nagy A; Gopaldas, Raja R; Chu, Danny; Bakaeen, Faisal; Wear, Emily; Menefee, Deleene
BACKGROUND: Coronary artery bypass grafting (CABG) is often used to treat patients with significant coronary heart disease (CHD). To date, multiple longitudinal and cross-sectional studies have examined the association between depression and CABG outcomes. Although this relationship is well established, the mechanism underlying this relationship remains unclear. The purpose of this study was twofold. First, we compared three markers of autonomic nervous system (ANS) function in four groups of patients: 1) Patients with coronary heart disease and depression (CHD/Dep), 2) Patients without CHD but with depression (NonCHD/Dep), 3) Patients with CHD but without depression (CHD/NonDep), and 4) Patients without CHD and depression (NonCHD/NonDep). Second, we investigated the impact of depression and autonomic nervous system activity on CABG outcomes. METHODS: Patients were screened to determine whether they met some of the study's inclusion or exclusion criteria. ANS function (i.e., heart rate, heart rate variability, and plasma norepinephrine levels) were measured. Chi-square and one-way analysis of variance were performed to evaluate group differences across demographic, medical variables, and indicators of ANS function. Logistic regression and multiple regression analyses were used to assess impact of depression and autonomic nervous system activity on CABG outcomes. RESULTS: The results of the study provide some support to suggest that depressed patients with CHD have greater ANS dysregulation compared to those with only CHD or depression. Furthermore, independent predictors of in-hospital length of stay and non-routine discharge included having a diagnosis of depression and CHD, elevated heart rate, and low heart rate variability. CONCLUSIONS: The current study presents evidence to support the hypothesis that ANS dysregulation might be one of the underlying mechanisms that links depression to cardiovascular CABG surgery outcomes. Thus, future studies should focus on developing and testing interventions that targets modifying ANS dysregulation, which may lead to improved patient outcomes.
Open Access
Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study.
(World neurosurgery, 2023-05) Sykes, David AW; Tabarestani, Troy Q; Chaudhry, Nauman S; Salven, David S; Shaffrey, Christopher I; Bullock, W Michael; Guinn, Nicole R; Gadsden, Jeffrey; Berger, Miles; Abd-El-Barr, Muhammad M
Objective
There is increasing interest in awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA vs general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration.
Methods
The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA vs GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents (MME), TTA, and LOS.
Results
10 SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m², and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA vs GA patients (12.87 vs 50.79 hours, p=0.001). Opioid utilization was reduced in SA vs GA patients (10.76 vs 31.43 MME, p=0.006). TTA was reduced in SA vs GA patients (7.22 vs 29.87 hours, p=0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs 188.2 minutes, p=0.089).
Conclusion
These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.
Open Access
Bleeding outcomes of inpatients receiving therapeutic plasma exchange: A propensity-matched analysis of the National Inpatient Sample.
(Transfusion, 2022-02) Soares Ferreira Júnior, Alexandre; Boyle, Stephen H; Kuchibhatla, Maragatha; Onwuemene, Oluwatoyosi A
Background
Although therapeutic plasma exchange (TPE) is associated with hemostatic abnormalities, its impact on bleeding outcomes is unknown. Therefore, the main study objective was to determine bleeding outcomes of inpatients treated with TPE.
Study design and methods
In a cross-sectional analysis of the National Inpatient Sample (NIS), discharges were identified with 10 common TPE-treated conditions. A 1:3 propensity-matched analysis of TPE- to non-TPE-treated discharges was performed. The primary outcome was major bleeding and secondary outcomes were packed red blood cell (PRBC) transfusion, mortality, disposition, hospital length of stay (LOS), and charges. Multivariable regression analyses were used to examine the association between TPE and study outcomes.
Results
The study population was 15,964 discharges, of which 3991 were TPE- treated. The prevalence of major bleeding was low (5.4%). When compared to non-TPE discharges, TPE had a significant and positive association with major bleeding (OR = 1.37, 95% CI: 1.16-1.63, p = .0003). TPE was also associated with PRBC transfusion (OR = 1.66, 95% CI: 1.42-1.94, p < .0001), in-hospital mortality (OR = 1.45, 95% CI: 1.10-1.90, p = .0008), hospital length of stay (12.45 [95% CI: 11.95-12.97] vs. 7.38 [95% CI: 7.12-7.65] days, p < .0001) and total charges, ($125,123 [95% CI: $119,220-$131,317] vs. $61,953 [95% CI: $59,391-$64,625], p < .0001), and disposition to non-self-care (OR = 1.29, 95% CI: 1.19-1.39, p < .0001).
Discussion
The use of TPE in the inpatient setting is positively associated with bleeding; however, with low prevalence. Future studies should address risk factors that predispose patients to TPE-associated bleeding.
Open Access
Comparison of Outcomes Following Anterior vs Posterior Fusion Surgery for Patients With Degenerative Cervical Myelopathy: An Analysis From Quality Outcomes Database.
(Neurosurgery, 2019-04) Asher, Anthony L; Devin, Clinton J; Kerezoudis, Panagiotis; Chotai, Silky; Nian, Hui; Harrell, Frank E; Sivaganesan, Ahilan; McGirt, Matthew J; Archer, Kristin R; Foley, Kevin T; Mummaneni, Praveen V; Bisson, Erica F; Knightly, John J; Shaffrey, Christopher I; Bydon, Mohamad
BACKGROUND:The choice of anterior vs posterior approach for degenerative cervical myelopathy that spans multiple segments remains controversial. OBJECTIVE:To compare the outcomes following the 2 approaches using multicenter prospectively collected data. METHODS:Quality Outcomes Database (QOD) for patients undergoing surgery for 3 to 5 level degenerative cervical myelopathy was analyzed. The anterior group (anterior cervical discectomy [ACDF] or corpectomy [ACCF] with fusion) was compared with posterior cervical fusion. Outcomes included: patient reported outcomes (PROs): neck disability index (NDI), numeric rating scale (NRS) of neck pain and arm pain, EQ-5D, modified Japanese Orthopedic Association score for myelopathy (mJOA), and NASS satisfaction questionnaire; hospital length of stay (LOS), 90-d readmission, and return to work (RTW). Multivariable regression models were fitted for outcomes. RESULTS:Of total 245 patients analyzed, 163 patients underwent anterior surgery (ACDF-116, ACCF-47) and 82 underwent posterior surgery. Patients undergoing an anterior approach had lower odds of having higher LOS (P < .001, odds ratio 0.16, 95% confidence interval 0.08-0.30). The 12-mo NDI, EQ-5D, NRS, mJOA, and satisfaction scores as well as 90-d readmission and RTW did not differ significantly between anterior and posterior groups. CONCLUSION:Patients undergoing anterior approaches for 3 to 5 level degenerative cervical myelopathy had shorter hospital LOS compared to those undergoing posterior decompression and fusion. Also, patients in both groups exhibited similar long-term PROs, readmission, and RTW rates. Further investigations are needed to compare the differences in longer term reoperation rates and functional outcomes before the clinical superiority of one approach over the other can be established.
Open Access
Contemporary trends and predictors of postacute service use and routine discharge home after stroke.
(J Am Heart Assoc, 2015-02-23) Prvu Bettger, Janet; McCoy, Lisa; Smith, Eric E; Fonarow, Gregg C; Schwamm, Lee H; Peterson, Eric D
BACKGROUND: Returning home after the hospital is a primary aim for healthcare; however, additional postacute care (PAC) services are sometimes necessary for returning stroke patients to their pre-event status. Recent trends in hospital discharge disposition specifying PAC use have not been examined across age groups or health insurance types. METHODS AND RESULTS: We examined trends in discharge to inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home with home health (HH), and home without services for 849 780 patients ≥18 years of age with ischemic or hemorrhagic stroke at 1687 hospitals participating in Get With The Guidelines-Stroke. Multivariable analysis was used to identify factors associated with discharge to any PAC (IRF, SNF, or HH) versus discharge home without services. From 2003 to 2011, there was a 2.1% increase (unadjusted P=0.001) in PAC use after a stroke hospitalization. Change was greatest in SNF use, an 8.3% decrease over the period. IRF and HH increased 6.9% and 3.6%, respectively. The 2 strongest clinical predictors of PAC use after acute care were patients not ambulating on the second day of their hospital stay (ambulation odds ratio [OR], 3.03; 95% confidence interval [CI], 2.86 to 3.23) and those who failed a dysphagia screen or had an order restricting oral intake (OR, 2.48; 95% CI, 2.37 to 2.59). CONCLUSIONS: Four in 10 stroke patients are discharged home without services. Although little has changed overall in PAC use since 2003, further research is needed to explain the shift in service use by type and its effect on outcomes.
Open Access
Developing nonlinear k-nearest neighbors classification algorithms to identify patients at high risk of increased length of hospital stay following spine surgery.
(Neurosurgical focus, 2023-06) Shahrestani, Shane; Chan, Andrew K; Bisson, Erica F; Bydon, Mohamad; Glassman, Steven D; Foley, Kevin T; Shaffrey, Christopher I; Potts, Eric A; Shaffrey, Mark E; Coric, Domagoj; Knightly, John J; Park, Paul; Wang, Michael Y; Fu, Kai-Ming; Slotkin, Jonathan R; Asher, Anthony L; Virk, Michael S; Michalopoulos, Giorgos D; Guan, Jian; Haid, Regis W; Agarwal, Nitin; Chou, Dean; Mummaneni, Praveen V
Objective
Spondylolisthesis is a common operative disease in the United States, but robust predictive models for patient outcomes remain limited. The development of models that accurately predict postoperative outcomes would be useful to help identify patients at risk of complicated postoperative courses and determine appropriate healthcare and resource utilization for patients. As such, the purpose of this study was to develop k-nearest neighbors (KNN) classification algorithms to identify patients at increased risk for extended hospital length of stay (LOS) following neurosurgical intervention for spondylolisthesis.
Methods
The Quality Outcomes Database (QOD) spondylolisthesis data set was queried for patients receiving either decompression alone or decompression plus fusion for degenerative spondylolisthesis. Preoperative and perioperative variables were queried, and Mann-Whitney U-tests were performed to identify which variables would be included in the machine learning models. Two KNN models were implemented (k = 25) with a standard training set of 60%, validation set of 20%, and testing set of 20%, one with arthrodesis status (model 1) and the other without (model 2). Feature scaling was implemented during the preprocessing stage to standardize the independent features.
Results
Of 608 enrolled patients, 544 met prespecified inclusion criteria. The mean age of all patients was 61.9 ± 12.1 years (± SD), and 309 (56.8%) patients were female. The model 1 KNN had an overall accuracy of 98.1%, sensitivity of 100%, specificity of 84.6%, positive predictive value (PPV) of 97.9%, and negative predictive value (NPV) of 100%. Additionally, a receiver operating characteristic (ROC) curve was plotted for model 1, showing an overall area under the curve (AUC) of 0.998. Model 2 had an overall accuracy of 99.1%, sensitivity of 100%, specificity of 92.3%, PPV of 99.0%, and NPV of 100%, with the same ROC AUC of 0.998.
Conclusions
Overall, these findings demonstrate that nonlinear KNN machine learning models have incredibly high predictive value for LOS. Important predictor variables include diabetes, osteoporosis, socioeconomic quartile, duration of surgery, estimated blood loss during surgery, patient educational status, American Society of Anesthesiologists grade, BMI, insurance status, smoking status, sex, and age. These models may be considered for external validation by spine surgeons to aid in patient selection and management, resource utilization, and preoperative surgical planning.
Open Access
Does improved access to diagnostic imaging results reduce hospital length of stay? A retrospective study.
(BMC Health Serv Res, 2010-09-06) Hurlen, Petter; Østbye, Truls; Borthne, Arne S; Gulbrandsen, Pål
BACKGROUND: One year after the introduction of Information and Communication Technology (ICT) to support diagnostic imaging at our hospital, clinicians had faster and better access to radiology reports and images; direct access to Computed Tomography (CT) reports in the Electronic Medical Record (EMR) was particularly popular. The objective of this study was to determine whether improvements in radiology reporting and clinical access to diagnostic imaging information one year after the ICT introduction were associated with a reduction in the length of patients' hospital stays (LOS). METHODS: Data describing hospital stays and diagnostic imaging were collected retrospectively from the EMR during periods of equal duration before and one year after the introduction of ICT. The post-ICT period was chosen because of the documented improvement in clinical access to radiology results during that period. The data set was randomly split into an exploratory part used to establish the hypotheses, and a confirmatory part. The data was used to compare the pre-ICT and post-ICT status, but also to compare differences between groups. RESULTS: There was no general reduction in LOS one year after ICT introduction. However, there was a 25% reduction for one group - patients with CT scans. This group was heterogeneous, covering 445 different primary discharge diagnoses. Analyses of subgroups were performed to reduce the impact of this divergence. CONCLUSION: Our results did not indicate that improved access to radiology results reduced the patients' LOS. There was, however, a significant reduction in LOS for patients undergoing CT scans. Given the clinicians' interest in CT reports and the results of the subgroup analyses, it is likely that improved access to CT reports contributed to this reduction.
Open Access
Dysphagia following combined anterior-posterior cervical spine surgeries.
(Journal of neurosurgery. Spine, 2013-09) Chen, Ching-Jen; Saulle, Dwight; Fu, Kai-Ming; Smith, Justin S; Shaffrey, Christopher I
Object
This study was undertaken to evaluate the incidence of and risk factors associated with the development of dysphagia following same-day combined anterior-posterior cervical spine surgeries.
Methods
The records of 30 consecutive patients who underwent same-day combined anterior-posterior cervical spine surgery were reviewed. The presence of dysphagia was assessed by a formalized screening protocol using history/clinical presentation and a bedside swallowing test, followed by formal evaluation by speech and language pathologists and/or fiberoptic endoscopic evaluation of swallowing/modified barium swallow when necessary. Age, sex, previous cervical surgeries, diagnoses, duration of procedure, specific vertebral levels and number of levels operated on, degree of sagittal curve correction, use of anterior plate, estimated blood loss, use of recombinant human bone morphogenetic protein-2 (rhBMP-2), and length of hospital stay following procedures were analyzed.
Results
In the immediate postoperative period, 13 patients (43.3%) developed dysphagia. Outpatient follow-up data were available for 11 patients with dysphagia, and within this subset, all cases of dysphagia resolved subjectively within 12 months following surgery. The mean numbers of anterior levels surgically treated in patients with and without dysphagia were 5.1 and 4.0, respectively (p = 0.004). All patients (100%) with dysphagia had an anterior procedure that extended above C-4, compared with 58.8% of patients without dysphagia (p = 0.010). Patients with dysphagia had significantly greater mean correction of C2-7 lordosis than patients without dysphagia (p = 0.020). The postoperative sagittal occiput-C2 angle and the change in this angle were not significantly associated with the occurrence of dysphagia (p = 0.530 and p = 0.711, respectively). Patients with postoperative dysphagia had significantly longer hospital stays than those who did not develop dysphagia (p = 0.004). No other significant difference between the dysphagia and no-dysphagia groups was identified; differences with respect to history of previous anterior cervical surgery (p = 0.141), use of an anterior plate (p = 0.613), and mean length of anterior cervical operative time (p = 0.541) were not significant.
Conclusions
The incidence of dysphagia following combined anterior-posterior cervical surgery in this study was comparable to that of previous reports. The risk factors for dysphagia that were identified in this study were increased number of anterior levels exposed, anterior surgery that extended above C-4, and increased surgical correction of C2-7 lordosis.
Open Access
Effect of Resident and Fellow Involvement in Adult Spinal Deformity Surgery.
(World neurosurgery, 2019-02) Zuckerman, Scott L; Lim, Jaims; Lakomkin, Nikita; Than, Khoi D; Smith, Justin S; Shaffrey, Christopher I; Devin, Clinton J
Background
Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications.
Methods
Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation.
Results
A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82-96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81-4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18-3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34-3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications.
Conclusion
RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist.
Open Access
Effective Implementation of Enhanced Recovery Pathway Programs: The Key to Disseminating Evidence into Practice.
(Jt Comm J Qual Patient Saf, 2015-10) Hopkins, Thomas J; Miller, Timothy E
Open Access
External Validation of the Adult Spinal Deformity (ASD) Frailty Index (ASD-FI) in the Scoli-RISK-1 Patient Database.
(Spine, 2018-10) Miller, Emily K; Lenke, Lawrence G; Neuman, Brian J; Sciubba, Daniel M; Kebaish, Khaled M; Smith, Justin S; Qiu, Yong; Dahl, Benny T; Pellisé, Ferran; Matsuyama, Yukihiro; Carreon, Leah Y; Fehlings, Michael G; Cheung, Kenneth M; Lewis, Stephen; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Mehdian, Hossein; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P; AOSpine Knowledge Forum Deformity, the International Spine Study Group
Study design
Analysis of a prospective multicenter database.
Objective
To assess the ability of the recently created Adult Spinal Deformity (ASD) Frailty Index (ASD-FI) to predict odds of major complications and length of hospital stay for patients who had more severe preoperative deformity and underwent more invasive ASD surgery compared with patients in the database used to create the index.
Summary of background data
Accurate preoperative estimates of risk are necessary given the high complication rates currently associated with ASD surgery.
Methods
Patients were enrolled by participating institutions in Europe, Asia, and North America from 2009 to 2011. ASD-FI scores were used to classify 267 patients as not frail (NF) (<0.3), frail (0.3-0. 5), or severely frail (SF) (>0.5). Multivariable logistic regression, adjusted for preoperative and surgical covariates such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and incidence of major complications, overall incidence of complications, and length of hospital stay.
Results
The mean ASD-FI score was 0.3 (range, 0-0.7). We categorized 105 patients as NF, 103 as frail, and 59 as SF. The adjusted odds of developing a major complication were higher for SF patients (odds ratio = 4.4; 95% CI 2.0, 9.9) compared with NF patients. After adjusting for covariates, length of hospital stay for SF patients increased by 19% (95% CI 1.4%, 39%) compared with NF patients. The odds of developing a major complication or having increased length of stay were similar between frail and NF patients.
Conclusion
Greater patient frailty, as measured by the ASD-FI, is associated with a longer hospital stay and greater risk of major complications among patients who have severe preoperative deformity and undergo invasive surgical procedures.
Level of evidence
2.
Open Access
Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)
(Canadian Journal of Anesthesia, 2016-01-01) Miller, Timothy Ellis; Roche, Anthony Michael; Mythen, Michael Gerard
Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.
Open Access
Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.
(British journal of anaesthesia, 2016-10) International Surgical Outcomes Study group
Background
As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care.
Methods
We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries.
Results
A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries.
Conclusions
Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care.
Study registration
ISRCTN51817007
Open Access
Grading of Complications After Cervical Deformity-corrective Surgery: Are Existing Classification Systems Applicable?
(Clinical spine surgery, 2019-07) Bortz, Cole A; Passias, Peter G; Segreto, Frank A; Horn, Samantha R; Lafage, Renaud; Smith, Justin S; Line, Breton G; Mundis, Gregory M; Kelly, Michael P; Park, Paul; Sciubba, Daniel M; Hamilton, D Kojo; Gum, Jeffrey L; Burton, Douglas C; Hart, Robert A; Schwab, Frank J; Bess, Shay; Shaffrey, Christopher; Klineberg, Eric O; International Spine Study Group
Study design
This is a retrospective review of prospective multicenter cervical deformity (CD) database.
Objective
Assess the impact of complication type and Clavien complication (Cc) grade on clinical outcomes of surgical CD patients BACKGROUND:: Validated for general surgery, the Clavien-Dindo complication classification system allows for broad comparison of postoperative complications; however, the applicability of this system is unclear in CD-specific populations.
Methods
Surgical CD patients above 18 years with baseline and postoperative clinical data were included. Primary outcomes were complication type (renal, infection, cardiac, pulmonary, gastrointestinal, neurological, musculoskeletal, implant-related, radiographic, operative, wound) and Cc grade (I, II, III, IV, V). Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), reoperation, and health-related quality of life (HRQL) score. The univariate analysis assessed the impact of complication type and Cc grade on improvement markers and 1-year postoperative HRQL outcomes.
Results
In total, 153 patients (61±10 y, 61% female) underwent surgery for CD (8.1±4.6 levels fused; surgical approach included 48% posterior, 18% anterior, 34% combined). Overall, 63% of patients suffered at least 1 complication. Complication breakdown by type: renal (2.0%), infection (5.2%), cardiac (7.2%), pulmonary (3.9%), gastrointestinal (2.0%), neurological (26.1%), musculoskeletal (0.0%), implant-related (3.9%), radiographic (16.3%), operative (7.8%), and wound (5.2%). Of complication types, only operative complications were associated with increased EBL (P=0.004), whereas renal, cardiac, pulmonary, gastrointestinal, neurological, radiographic, and wound infections were associated with increased LOS (P<0.050). Patients were also assessed by Cc grade: I (28%), II (14.3%), III (16.3%), IV (6.5%), and V (0.7%). Grades I and V were associated with increased EBL (both P<0.050); Cc grade V was the only complication not associated with increased LOS (P=0.610). Increasing complication severity was correlated with increased risk of reoperation (r=0.512; P<0.001), but not inferior 1-year HRQL outcomes (all P>0.05).
Conclusions
Increasing complication severity, assessed by the Clavien-Dindo classification system, was not associated with increased EBL, inpatient LOS, or inferior 1-year postoperative HRQL outcomes. Only operative complications were associated with increased EBL. These results suggest a need for modification of the Clavien system to increase applicability and utility in CD-specific populations.
Open Access
Hospital mortality of patients aged 80 and older after surgical repair for type A acute aortic dissection in Japan.
(Medicine, 2016-08) Ohnuma, Tetsu; Shinjo, Daisuke; Fushimi, Kiyohide
To evaluate whether patients aged 80 and older have higher risk of hospital mortality after repair of type A acute aortic dissection (TAAAD).Emergency surgery for TAAAD in patients aged 80 and older remains a controversial issue because of its high surgical risk.Data from patients who underwent surgical repair of TAAAD between April 2011 and March 2013 were retrospectively extracted from the Japanese Diagnosis Procedure Combination database. The effect of age on hospital mortality was evaluated using multivariate logistic regression analysis.A total of 5175 patients were enrolled. The mean age of patients was 67.1 ± 13.0 years, and the male:female ratio was 51:49. Patients aged 80 and older more frequently received tracheostomy than their younger counterparts (9.5% vs 5.4%, P <0.001). Intensive care unit and hospital stays were significantly longer in the elderly cohort versus the younger cohort (7.6 vs 6.7 days, P <0.001, and 42.2 vs 35.8 days, P <0.001, respectively). Logistic regression analysis showed that age ≥80 years was significantly associated with a higher risk of hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 1.28-2.06; P <0.001). In linear regression analysis, age ≥80 years was also significantly associated with longer hospital stay (P = 0.007).In a large, nationwide, Japanese database, patients aged 80 and older were at increased risk of hospital mortality and length of hospital stay.
Open Access
Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.
(Neurosurgical focus, 2017-12) Nunley, Pierce D; Mundis, Gregory M; Fessler, Richard G; Park, Paul; Zavatsky, Joseph M; Uribe, Juan S; Eastlack, Robert K; Chou, Dean; Wang, Michael Y; Anand, Neel; Frank, Kelly A; Stone, Marcus B; Kanter, Adam S; Shaffrey, Christopher I; Mummaneni, Praveen V; International Spine Study Group
OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

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