Outcomes of Cervical Spine Surgery in Teaching and Non-Teaching Hospitals
ABSTRACT Study Design. Retrospective national database analysis.Objective. A national population-based database was analyzed to characterize cervical spine procedures performed at teaching and non-teaching hospitals with regards to patient demographics, clinical outcomes/complications, resource utilization and costs.Summary of Background Data. There are mixed reports in the literature regarding the quality and costs of healthcare provided by teaching hospitals in the United States. However, outcomes of cervical spine surgery based upon teaching-status remains largely unknown.Methods. Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing elective anterior or posterior cervical fusion (ACF, PCF), or posterior cervical decompression (PCD; i.e. laminoforaminotomy, laminectomy, laminoplasty) for a diagnosis of cervical myelopathy and/or radiculopathy were identified and separated into two cohorts (teaching and non-teaching hospitals). Patient demographics, co-morbidities, complications, length of hospitalization, costs, and mortality were compared for both groups. Regression analysis was performed to assess independent predictors of mortality.Results. A total of 212,385 cervical procedures were identified from 2002-2009 in the United States, with 54.6% performed at teaching hospitals. More multilevel fusions and posterior approaches were performed in teaching hospitals (p<0.0005). Patients treated in teaching hospitals trended towards male gender, increased costs, and hospitalizations. Overall, procedure-related complications and in-hospital mortality were increased in teaching hospitals. Regression analysis revealed that significant predictors of mortality were age ≥ 65 (O.R. = 3.0) and multiple co-morbidities. Teaching status was not a significant predictor of mortality (p = 0.07).Conclusion. Patients treated in teaching hospitals for cervical spine surgery demonstrated longer hospitalizations, increased costs, and mortality over patients treated in non-teaching hospitals. Incidences of post-operative complications were identified as higher in teaching hospitals. Possible explanations for these findings are an increased complexity of procedures performed at teaching hospitals. Older age and presence of co-morbidities were more significant predictors of in-hospital mortality than teaching-status. Future studies should identify long-term complications and costs beyond an in-patient setting to assess if differences extend beyond the peri-operative period.
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ABSTRACT: Background Context: The frequency of anterior cervical fusion (ACF) surgery as well as total hospital costs in spine surgery has substantially increased in the last several years. Purpose: To determine which patient comorbidities are associated with increased total hospital costs following elective one or two-level ACFs.Study Design/Setting: retrospective cohort analysis Patient Sample: Individuals who have undergone elective one or two-level ACFs at our single institution. 1082 total patients. Outcome measure: Total hospital costs during single admission. Methods: Multivariate linear regression models were used to analyze independent effects of preoperative patient characteristics on total hospital costs. Univariate analysis was utilized to examine association of these characteristics on operative time, length of stay (LOS), and complications. Results: Age, obesity, and diabetes were independently associated with increased average hospital costs of $1404 [Confidence Interval (CI) $857 - $1951, p<0.001], $681 (CI $285 - $1076, p=0.001), and $1877 (CI $726 - $3072, p=0.001), respectively. Age was associated with increased LOS (p<0.001) and complications (p<0.001), but not operative time (p=0.431). Diabetes was associated with increased LOS (<0.001) and complications (p=0.042), but not operative time (p=0.234). Obesity was not associated with increased LOS (p=0.164), complications (p=0.890), or operative time (p=0.067). Conclusions: This study highlights the patient comorbidities associated with increased hospital costs following one or two-level ACFs and the potential drivers of these costs.The Spine Journal 01/2015; Accepted in Press(5). DOI:10.1016/j.spinee.2015.01.022 · 2.80 Impact Factor
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ABSTRACT: Operative skills are key to neurosurgical resident training. They should be acquired in a structured manner and preferably starting early in residency. The aim of this study was to test the hypothesis that the outcome and complication rate of anterior cervical discectomy and fusion with or without instrumentation (ACDF(I)) is not inferior for supervised residents as compared to board-certified faculty neurosurgeons (BCFN). This was a retrospective single-center study of all consecutive patients undergoing ACDF(I)-surgery between January 2011 and August 2014. All procedures were dichotomized into two groups according to the surgeon's level of experience: teaching cases (postgraduate year (PGY)-2 to PGY-6 neurosurgical residents) and non-teaching cases operated by BCFN. The primary study endpoint was patients' clinical outcome 4 weeks after surgery, categorized into a binary responder and non-responder variable. Secondary endpoints were complications, need for re-do surgery, and clinical outcome until the last follow-up. After exclusion of six cases because of incomplete data, a total of 287 ACDF(I) operations were enrolled into the study, of which 82 (29.2 %) were teaching cases and 199 (70.8 %) were non-teaching cases. Teaching cases required a longer operation time (131 min (95 % confidence interval (CI) 122-141 min) vs. 102 min (95-108 min; p < 0.0001) and were associated with a slightly higher estimated blood loss (84 ml (95 % CI 56-111 ml) vs. 57 ml (95 % CI 47-66 ml); p = 0.0017), while there was no difference in the rate of intraoperative complications (2.4 vs. 1.5 %; p = 0.631). Four weeks after surgery, 92.7 and 93 % of the patients had a positive response to surgery (p = 1.000), respectively. There was no difference in the postoperative complication rate (4.9 vs. 3.0 %; p = 0.307). Around 30 % of the study patients were followed up in outpatient clinics for more than once up until a mean period of 6.4 months (95 % CI 5.3-7.6 months). At the last follow-up, the clinical outcome was similar with a 90 % responder rate for both groups (p = 0.834). In total, five patients from the teaching group and eight patients from the non-teaching group required re-do surgery (p = 0.602). Short- and mid-term outcomes and complication rates following microscopic ACDF(I) were comparable for patients operated on by supervised neurosurgical residents or by senior surgeons. Our data thus indicate that a structured neurosurgical education of operative skills does not lead to worse outcomes or increase the complication rates after ACDF(I). Confirmation of the results by a prospective study is desired.Acta Neurochirurgica 03/2015; DOI:10.1007/s00701-015-2396-6 · 1.79 Impact Factor
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ABSTRACT: Study Design. Retrospective analysis of prospectively collected data from the 2001-2010 Nationwide Inpatient Sample (NIS) database.Objective. To assess complication rates in adolescent spinal deformity by surgeon operative volume for procedures with a range of complexity.Summary of Background Data. Surgeons performing higher volumes of lumbar spinal fusion have been associated with improved surgical outcomes, according to studies using the NIS. This relationship has not been shown in adolescent spinal deformity surgery.Methods. The NIS was queried for patients age 10-18 with in-hospital stays including spinal arthrodesis for scoliosis [adolescent idiopathic, neuromuscular (NMS) and congenital scoliosis (CS)]. The primary endpoint was hospital stay morbidity: database-defined surgical, mechanical, major medical and neurological complications. Length of stay (LOS) and hospital charges were also analyzed. Annual surgeon volumes were stratified into quartiles based on number of cases (Q1:1, Q2: 2-7, Q3:8-19, Q4: 20-97). To account for variation in surgical invasiveness, an operative complexity index was used. One-way ANOVA was used to assess differences between quartiles for continuous measures, chi-square for categorical measures.Results. 6,100 spine fusion cases met inclusion criteria for adolescent scoliosis. All complications categories were less frequent for higher volume surgeons after a primary fusion for all diagnoses. This pattern held for increasing surgical invasiveness, such as fusing ≥9 levels and became more distinct for neurologic complications when comparing surgeons performing combined anterior-posterior procedures. Including all adolescent scoliosis fusions, higher surgical volume was associated with decreased LOS and hospital charges.Conclusion. Perioperative complications after adolescent scoliosis fusion surgery are more frequent in lower volume settings. This may reflect a learning curve required for more complex cases as the trends are magnified in NMS/CS cases or simply that higher volume surgeons are more adept at these fusions. The impact of volume on reduced LOS and hospital charges has implications for future healthcare economics measures.Spine 11/2014; 40(3). DOI:10.1097/BRS.0000000000000710 · 2.45 Impact Factor