Hospital and Surgeon Variation in Complications and Repeat Surgery Following Incident Lumbar Fusion for Common Degenerative Diagnoses.

The Geisel School of Medicine at Dartmouth, Hanover, NH
Health Services Research (Impact Factor: 2.49). 06/2012; DOI: 10.1111/j.1475-6773.2012.01434.x
Source: PubMed

ABSTRACT OBJECTIVE: To identify factors that account for variation in complication rates across hospitals and surgeons performing lumbar spinal fusion surgery. DATA SOURCES: Discharge registry including all nonfederal hospitals in Washington State from 2004 to 2007. STUDY DESIGN: We identified adults (n = 6,091) undergoing an initial inpatient lumbar fusion for degenerative conditions. We identified whether each patient had a subsequent complication within 90 days. Logistic regression models with hospital and surgeon random effects were used to examine complications, controlling for patient characteristics and comorbidity. PRINCIPAL FINDINGS: Complications within 90 days of a fusion occurred in 4.8 percent of patients, and 2.2 percent had a reoperation. Hospital effects accounted for 8.8 percent of the total variability, and surgeon effects account for 14.4 percent. Surgeon factors account for 54.5 percent of the variation in hospital reoperation rates, and 47.2 percent of the variation in hospital complication rates. The discretionary use of operative features, such as the inclusion of bone morphogenetic proteins, accounted for 30 and 50 percent of the variation in surgeons' reoperation and complication rates, respectively. CONCLUSIONS: To improve the safety of lumbar spinal fusion surgery, quality improvement efforts that focus on surgeons' discretionary use of operative techniques may be more effective than those that target hospitals.

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    ABSTRACT: Object Large administrative databases have assumed a major role in population-based studies examining health care delivery. Lumbar fusion surgeries specifically have been scrutinized for rising rates coupled with ill-defined indications for fusion such as stenosis and spondylosis. Administrative databases classify cases with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9-CM discharge codes are not designated by surgeons, but rather are assigned by trained hospital medical coders. It is unclear how accurately they capture the surgeon's indication for fusion. The authors first sought to compare the ICD-9-CM code(s) assigned by the medical coder according to the surgeon's indication based on a review of the medical chart, and then to elucidate barriers to data fidelity. Methods A retrospective review was undertaken of all lumbar fusions performed in the Department of Neurosurgery at the authors' institution between August 1, 2011, and August 31, 2013. Based on this review, the indication for fusion in each case was categorized as follows: spondylolisthesis, deformity, tumor, infection, nonpathological fracture, pseudarthrosis, adjacent-level degeneration, stenosis, degenerative disc disease, or disc herniation. These surgeon diagnoses were compared with the primary ICD-9-CM codes that were generated by the medical coders and submitted to administrative databases. A follow-up interview with the hospital's coders and coding manager was undertaken to review causes of error and suggestions for future improvement in data fidelity. Results There were 178 lumbar fusion operations performed in the course of 170 hospital admissions. There were 44 hospitalizations in which fusion was performed for tumor, infection, or nonpathological fracture. Of these, the primary diagnosis matched the surgical indication for fusion in 98% of cases. The remaining 126 hospitalizations were for degenerative diseases, and of these, the primary ICD-9-CM diagnosis matched the surgeon's diagnosis in only 61 (48%) of 126 cases of degenerative disease. When both the primary and all secondary ICD-9-CM diagnoses were considered, the indication for fusion was identified in 100 (79%) of 126 cases. Still, in 21% of hospitalizations, the coder did not identify the surgical diagnosis, which was in fact present in the chart. There are many different causes of coding inaccuracy and data corruption. They include factors related to the quality of documentation by the physicians, coder training and experience, and ICD code ambiguity. Conclusions Researchers, policymakers, payers, and physicians should note these limitations when reviewing studies in which hospital claims data are used. Advanced domain-specific coder training, increased attention to detail and utilization of ICD-9-CM diagnoses by the surgeon, and improved direction from the surgeon to the coder may augment data fidelity and minimize coding errors. By understanding sources of error, users of these large databases can evaluate their limitations and make more useful decisions based on them.
    Neurosurgical FOCUS 06/2014; 36(6):E2. DOI:10.3171/2014.3.FOCUS1459 · 2.14 Impact Factor
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    ABSTRACT: Study Design. Multicenter retrospective cohort study.Objective. To investigate the impact of spine surgeon specialty on 30-day complication rates in patients undergoing single-level lumbar fusion.Summary of Background Data. Operative care of the spine is delivered by surgeons who undergo either orthopaedic or neurosurgical training. It is currently unknown whether surgeon specialty has an impact on 30-day complication rates in patients undergoing single-level lumbar fusion.Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed to identify all patients who underwent single-level lumbar fusion procedures during 2006-2011. Propensity-score matching analysis was employed to reduce baseline differences in patient characteristics. Univariate and multivariate analyses were performed to assess the impact of spine surgeon specialty on 30-day complication rates.Results. A total of 2,970 patients were included for analysis. After propensity matching, 1,264 pairs of well-matched patients remained. Overall complication rates in the unadjusted dataset were 7.3% and 7.1% for the neurosurgery (NS) and orthopaedic surgery (OS) cohort, respectively. Our multivariate analysis revealed that compared to the NS cohort, the OS cohort did not have statistically significant differences in odds ratios (OR) for development of any complication (OR 0.95, 95% CI 0.69-1.30, p = 0.740). Similarly, spine surgeon specialty was not a risk factor in any of the specific complications studiedincluding medical complications (OR 1.11, 95% CI 0.77-1.60, p = 0.583), surgical complications (OR 0.76, 95% CI 0.46-1.26, p = 0.287), or re-operation (OR 1.10, 95% CI 0.76-1.60, p = 0.618).Conclusion. Our analysis demonstrates that spine surgeon specialty is not a risk factor for any of the reported 30-day complications in patients undergoing single-level lumbar fusion. This data supports the currently dichotomous paradigm of training for spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.
    Spine 05/2014; 39(15). DOI:10.1097/BRS.0000000000000394 · 2.45 Impact Factor
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    ABSTRACT: Study Design. Retrospective analysis of Medicare claims linked to a multi-center clinical trial.Objective. The Spine Patient Outcomes Research Trial (SPORT) provided a unique opportunity to examine the validity of a claims-based algorithm for grouping patients by surgical indication. SPORT enrolled patients for lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis. We compared the surgical indication derived from Medicare claims to that provided by SPORT surgeons, the "gold standard".Summary of Background Data. Administrative data are frequently used to report procedure rates, surgical safety outcomes, and costs in the management of spinal surgery. However, the accuracy of using diagnosis codes to classify patients by surgical indication has not been examined.Methods. Medicare claims were link to beneficiaries enrolled in SPORT. The sensitivity and specificity of three claims-based approaches to group patients based on surgical indications were examined: 1) using the first listed diagnosis; 2) using all diagnoses independently; and 3) using a diagnosis hierarchy based on the support for fusion surgery.Results. Medicare claims were obtained from 376 SPORT participants, including 21 with disc herniation, 183 with spinal stenosis, and 172 with degenerative spondylolisthesis. The hierarchical coding algorithm was the most accurate approach for classifying patients by surgical indication, with sensitivities of 76.2%, 88.1%, and 84.3% for disc herniation, spinal stenosis, and degenerative spondylolisthesis cohorts, respectively. The specificity was 98.3% for disc herniation, 83.2% for spinal stenosis, and 90.7% for degenerative spondylolisthesis. Misclassifications were primarily due to codes attributing more complex pathology to the case.Conclusion. Standardized approaches for using claims data to accurately group patients by surgical indications has widespread interest. We found that a hierarchical coding approach correctly classified over 90% of spine patients into their respective SPORT cohorts. Therefore, claims data appears to be a reasonably valid approach to classifying patients by surgical indication.
    Spine 02/2014; 39(9). DOI:10.1097/BRS.0000000000000275 · 2.45 Impact Factor


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May 31, 2014

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