Jonathan N Grauer

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (158)278.5 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: To identify factors associated with increased postoperative length of stay (LOS) and readmission after surgical repair of geriatric hip fractures.
    Journal of orthopaedic trauma. 09/2014;
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    ABSTRACT: Posterior spinal fusion (PSF) is commonly performed for patients with adolescent idiopathic scoliosis (AIS). Identifying factors associated with perioperative morbidity and PSF may lead to strategies for reducing the frequency of adverse events (AEs) in patients and total hospital costs.
    Clinical Orthopaedics and Related Research 09/2014; · 2.79 Impact Factor
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    ABSTRACT: : Study Design. Cross-sectionalObjective. To objectively evaluate the ability of International Classification of Diseases, Ninth Revision (ICD-9) codes, which are used as the foundation for administratively coded national databases, to identify preoperative anemia in spinal fusion patients.Summary of Background Data. National database research in spine surgery continues to rise. However, the validity of studies based on administratively coded data, such as the Nationwide Inpatient Sample (NIS), are dependent on the accuracy of ICD-9 coding. Such coding has previously been found to have poor sensitivity for conditions such as obesity and infection.Methods. A cross-sectional study was performed at an academic medical center. Hospital-reported anemia ICD-9 codes (those used for administratively coded databases) were directly compared to the chart-documented preoperative hematocrits (true laboratory values). A patient was deemed to have preoperative anemia if the preoperative hematocrit was less than the lower end of the normal range (36.0% for females and 41.0% for males).Results. The study included 260 patients. Of these, 37 patients (14.2%) were anemic; however, only 10 patients (3.8%) received an "anemia" ICD-9 code. Of those coded as anemic, 7 of these 10 patients were anemic by definition, while 3 were not, and thus were miscoded. This equates to an ICD-9 code sensitivity of 0.19, with a specificity of 0.99, and positive and negative predictive values of 0.70 and 0.88, respectively.Conclusions. The current study uses preoperative anemia to demonstrate the potential inaccuracies of ICD-9 coding. These results have implications for publications using databases that are compiled from ICD-9 coding data. Furthermore, the findings of the current investigation raise concerns regarding the accuracy of additional comorbidities. Although administrative databases are powerful resources that provide large sample sizes, it is crucial that we further consider the quality of the data source relative to its intended purpose.
    Spine 09/2014; · 2.16 Impact Factor
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    ABSTRACT: To identify factors that are associated with short-term outcomes following open reduction and internal fixation (ORIF) for tibial plateau fracture.
    Journal of orthopaedic trauma. 08/2014;
  • Jason O Toy, Bryce A Basques, Jonathan N Grauer
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    ABSTRACT: : Study Design. Retrospective cohort.Objective. To identify risk factors for poor short-term outcomes after vertebral augmentation procedures.Summary of Background Data. Vertebral compression fractures are the most common fractures of osteoporosis and are frequently treated with vertebroplasty or kyphoplasty. There is a shortage of information about risk factors for short-term, general health outcomes after vertebral augmentation in the literature.Methods. Patients aged 65 and over who underwent vertebroplasty or kyphoplasty in 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patient characteristics were tested for association with 30-day adverse events, mortality, and readmission using bivariate and multivariate analyses.Results. A total of 850 patients met inclusion criteria. The average age was 78.9 ± 11.7 years (mean ± standard deviation) and the cohort was 70.8% female. Of these patients, 9.5% had any adverse event (AAE), and 6.6% had a severe adverse event (SAE). Death occurred in 1.5% of patients, and 10.8% were readmitted within the first 30 postoperative days.On multivariate analysis, AAE and SAE were both significantly associated with American Society of Anesthesiologists (ASA) class 4 (AAE: odds ratio [OR] = 2.7, p = 0.013; SAE: OR = 2.5, p = 0.040) and inpatient status before procedure (AAE: OR = 2.7, p <0.001, SAE: OR = 2.4, p = 0.003). Increased postoperative mortality was associated with ASA class 4 (OR = 6.4, p = 0.024) and the use of non-general anesthesia (OR = 4.0, p = 0.022). Readmission was associated with history of pulmonary disease (OR = 2.0, p = 0.005) and inpatient status before procedure (OR = 1.9, p = 0.005).Conclusions. Adverse general health outcomes were relatively common, and the above-identified factors associated with patient outcomes after vertebral augmentation may be useful for preoperative discussions and counseling.
    Spine 08/2014; · 2.16 Impact Factor
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    ABSTRACT: : Study Design. Retrospective database review.Objective. To evaluate whether microscope use during spine procedures is associated with increased operating room times or increased risk of infection.Summary of Background Data. Operating microscopes are commonly used in spine procedures. It is debated whether the use of an operating microscope increases operating room time or confers increased risk of infection.Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, which includes data from over 370 participating hospitals, was used to identify patients undergoing elective spinal procedures with and without an operating microscope for the years 2011 and 2012. Bivariate and multivariate linear regressions were used to test the association between microscope use and operating room times. Bivariate and multivariate logistic regressions were similarly conducted to test the association between microscope use and infection occurrence within 30 days of surgery.Results. A total of 23,670 elective spine procedures were identified, of which 2,226 (9.4%) used an operating microscope. The average patient age was 55.1 ± 14.4 years. The average operative time (incision to closure) was 125.7 ± 82.0 minutes.Microscope use was associated with minor increases in preoperative room time (+2.9 minutes, p = 0.013), operative time (+13.2 minutes, p<0.001), and total room time (+18.6 minutes, p<0.001) on multivariate analysis.A total of 328 (1.4%) patients had an infection within 30 days of surgery. Multivariate analysis revealed no significant difference between the microscope and non-microscope groups for occurrence of any infection, superficial surgical site infection (SSI), deep SSI, organ space infection, or sepsis/septic shock, regardless of surgery type.Conclusions. We did not find operating room times or infection risk to be significant deterrents for use of an operating microscope during spine surgery.
    Spine 08/2014; · 2.16 Impact Factor
  • Jonathan N Grauer, Andrea Halim, Kristaps J Keggi
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    ABSTRACT: Total hip arthroplasty (THA) and revision total hip arthroplasty are among the most commonly performed orthopedic procedures. There are many reported complications of THA, but intrapelvic complications are a rare subset. Bladder injuries have infrequently been described in association with this common procedure. We present an unusual case of a bladder tear occurring intraoperatively during a revision THA. It is suspected that the patient's history of multiple prior hip procedures caused adhesions of the bladder to the pelvic floor and predisposed the bladder to injury during acetabular revision. Previous reports of bladder injury relating to THA have described thermal necrosis, component migration, and occasional direct perforation. There are no prior case reports describing bladder tears related to adhesions occurring intraoperatively during revision THA. This case report highlights the importance of surgeon awareness of an unusual complication. In this case, intraoperative and postoperative recognition of a hematuria diagnosis led to the appropriate treatment, and this patient had an acceptable outcome.
    American journal of orthopedics (Belle Mead, N.J.) 08/2014; 43(8):E185-E188.
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    ABSTRACT: Study Design. Retrospective cohort.Objective. To determine the effect of non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) on postoperative complications following elective lumbar fusion surgery.Summary of Background Data. Diabetes mellitus (DM) is a common chronic disease. The effects of NIDDM and IDDM on rates of postoperative complications, extended length of stay, and readmission after lumbar fusion surgery are not well established.Methods. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing lumbar fusion between 2005 and 2012 were identified and characterized as having NIDDM, IDDM, or neither. Bivariate and multivariate analyses were used to test NIDDM and IDDM patients for increased risk of adverse postoperative outcomes over the initial 30 postoperative days.Results. 15,480 patients who underwent lumbar fusion were identified (13,043 were non-DM patients, 1,650 patients had NIDDM, and 787 patients had IDDM).NIDDM was independently associated with an increased risk of wound dehiscence (Relative Risk = 2.3; p = 0.033) and extended length of stay (1.2; p < 0.003).IDDM was independently associated with an increased risk of death (2.7; p = 0.020), sepsis (2.2; p = 0.002), septic shock (3.3; p = 0.032), unplanned intubation (2.8; p = 0.003), ventilator-assisted respiration > 48 hours postoperatively (2.8; p = 0.005), wound-related infection (1.9; p = 0.001), urinary tract infection (1.6, p = 0.011), pneumonia (3.1; p < 0.001), extended length of stay (1.5; p < 0.001), and readmission within 30 days (1.5, p = 0.036).Conclusions. Compared to non-DM patients, IDDM was associated with an increased risk of a considerably higher number of postoperative complications than NIDDM. These complications were also of greater severity. This important designation may improve preoperative risk stratification and counseling of diabetic patients prior to lumbar fusion surgery.
    Spine 07/2014; · 2.16 Impact Factor
  • Andrea Halim, Jonathan Grauer
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    ABSTRACT: We report a case of a C7 pars fracture subadjacent to C7 pedicle screw instrumentation at the caudal end of posterior cervical instrumentation construct. To date, posterior cervical instrumentation has been "off label"; however, the US Food and Drug Administration is considering approving label indication of such instrumentation for this common surgical practice. Complications related to the techniques are reported to be relatively low. We know of no previous reports of pars fractures occurring subadjacent to such instrumentation. A 43-year-old man underwent posterior C5-C7 instrumented fusion. Postoperatively, the patient experienced cervical spine injury after a mechanical fall down stairs. Work-up detected bilateral C7 pars fractures subadjacent to the posterior instrumentation construct. After we treated the pars fracture with distal extension of the posterior fusion to the level of T2, the patient progressed to union and marked improvement of initial clinical symptoms that was maintained 2.5 years after posterior instrumentation. To our knowledge, a C7 pars fracture subadjacent to posterior cervical instrumentation construct has not been reported. We hypothesize that the pars may have been vulnerable to fracture because of excessive bone resection during foraminotomy or decortication. This complication was successfully treated by extending the fusion caudally.
    American journal of orthopedics (Belle Mead, N.J.) 07/2014; 43(7):E137-E139.
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    ABSTRACT: : Study Design. Retrospective cohort study of 13,927 patients, 820 of whom received iliac crest bone graft (ICBG).Objective. To compare adverse events, length of stay (LOS), and readmission for patients receiving ICBG to those who did not using multivariate analysis to control for potentially confounding factors.Summary of Background Data. The use of ICBG in spinal fusion has been associated with increased surgical time, LOS, and donor site morbidity. Development of expensive bone graft substitutes has been predicated on these issues. Data on the effect of bone graft harvest on LOS and readmission rate is sparse, and multivariate analysis has not been used to control for confounding factors.Methods. Prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) 2010-2012 database was retrospectively reviewed. This includes demographics, comorbidities, surgical data, and hospital and 30-day follow-up outcomes data including adverse events, LOS, and readmission.Results. Only 5.9% of spinal fusions utilize ICBG.Bivariate logistic regression (used for categorical variables) found the ICBG cohort was more likely to have a postoperative blood transfusion (11.6% vs. 5.5%, p<0.001). Bivariate linear regression (used for continuous variables) found the ICBG cohort to have an extended operative time (+36.0 min, p<0.001) and extended LOS (+0.6 days, p<0.001).Multivariate analyses controlling for comorbidities, demographics, and approach determined postoperative blood transfusion (OR 1.5), extended operative time (+ 22.0 min, p<0.001) and LOS (+0.2 days, p = 0.037) to be significantly associated with ICBG use.No other adverse event was significantly associated with ICBG use. Readmission rates were not significantly different.Conclusion. This study used a large national database cohort and identified increased postoperative blood transfusion, extended operative time, and increased LOS as short-term outcomes associated with ICBG on multivariate analysis. Other short-term morbidities were not significantly associated with ICBG. Readmission rates were not affected.
    Spine 06/2014; · 2.16 Impact Factor
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    ABSTRACT: After lower extremity fracture or surgery, physicians often prescribe limited weight bearing. The current study was performed to evaluate teaching and compliance of touch-down weight bearing (defined as 25 lb) at a level I academic trauma center. A survey was distributed to physical therapists (PTs) from the orthopedic ward to gauge their training methods and their confidence in patients' ability to comply. Patients with recommended touch-down weight bearing were then evaluated on the day of discharge and again at their first follow-up appointment using the SmartStep weight-bearing measurement device (Andante Medical Devices, Inc, White Plains, New York). Fifteen PTs completed the survey (average of 14 years in practice). Inconsistency was observed in weight-bearing teaching methods: verbal cues were used 87% of the time, tactile methods were used 41%, demonstration was used 23%, and a scale was used only 1%. Limited confidence was found in the instruction efficacy by those surveyed. Twenty-one patients were seen the day of discharge and 18 of those were seen at first follow-up. At discharge, average minimum and maximum weight bearing were 3.2 and 30.2 lb, respectively. Only 31% of steps were within an acceptable range of 15 to 35 lb. At first follow-up, average minimum and maximum weight bearing were 12.2 and 50.8 lb, respectively. Only 27% of steps were within the acceptable range. The majority of steps were less than the prescribed weight at discharge, whereas the majority of steps were greater than the prescribed weight at first follow-up. These data suggest that more uniform and effective teaching methods for prescribed weight-bearing orders are warranted assuming compliance is an important clinical objective.
    Orthopedics 06/2014; 37(6):e552-6. · 1.05 Impact Factor
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    ABSTRACT: The use of national inpatient databases for spine surgery research has been increasing. Unfortunately, without firsthand knowledge of each specific database, it can be difficult to judge the validity of such studies. Large databases that rely on administrative data, such as International Classification of Diseases, Ninth Revision (ICD-9) codes, may misrepresent patient information and could thus affect the results of studies that use this data. The present study uses obesity, an easily quantified and objective variable, as an example comorbidity to assess the accuracy of ICD-9 codes in the setting of their continued use in spine database studies. A cross-sectional study at a large academic medical center. All patients spending at least one night in the hospital as an inpatient between April 1, 2013 and April 16, 2013. Obstetrics and gynecology, psychiatry, and pediatric patients were excluded. Proportion of patients for whom ICD-9 obesity diagnosis codes assigned at hospital discharge match chart-documented BMI. The medical record was reviewed for each patient, and obesity ICD-9 codes were directly compared to documented body mass index (BMI). No known conflicts of interest exist for this study. The study included 2,075 patients. Of 573 "obese" patients (calculated BMI 30-39.9), only 109 received the correct code (278.00), giving this ICD-9 code a sensitivity of 0.19. Of 174 "morbidly obese" patients (calculated BMI > 40), only 84 received the correct code (278.01), giving this ICD-9 code a sensitivity of 0.48. Using obesity as an example, this study highlights the potential errors inherent to using ICD-9-coded databases for spine surgery research. Should a study based on such data use "obesity" as a variable in any analyses, the reader should interpret these results with caution. We further suggest that obesity is likely not the only comorbidity to which these results apply. As database research continues to represent an increasing proportion of publications in the field of spine surgery, it is important to realize that study outcomes can be skewed by data accuracy, and thus should not be blindly accepted simply by virtue of large sample sizes.
    The spine journal: official journal of the North American Spine Society 04/2014; · 2.90 Impact Factor
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    ABSTRACT: : Study Design. Retrospective cohort study of 183 patients who underwent elective anterior cervical discectomy and fusion (ACDF) at a single institution over a two-year period.Objective. To determine which preoperative factors were independently associated with a prolonged hospital length of stay (LOS) following ACDF.Summary of Background Data. ACDF has become the most common treatment modality for addressing cervical spine pathology. Extended LOS following ACDF is associated with increased costs and complications. There is a lack of conclusive data for factors affecting LOS after ACDF. This study aims to create a multivariate model to determine the association of various patient and operative characteristics with LOS after ACDF.Methods. Patients who underwent elective ACDF at a single academic institution between January 2011 and February 2013 were identified using billing records. Their charts were reviewed to collect variables available preoperatively such as patient demographics, comorbidities, and surgery planned. Patients were categorized as normal or extended LOS, with extended LOS defined as LOS > 75th percentile. A multivariate logistic regression was used to determine which factors were independently associated with extended LOS.Results. A total of 183 ACDF patients were identified. The average LOS for this cohort was 2.0 ± 2.5 days (Mean ± Standard Deviation). Extended LOS was defined as ≥ 3 days. Multivariate analysis revealed that preoperative factors independently associated with extended LOS were history of non-spinal malignancy (Odds Ratio [OR] = 4.9), history of pulmonary disease (OR = 4.0), and procedures that included corpectomy (OR = 4.5).Conclusion. Patients with a history of non-spinal malignancy or pulmonary disease, as well as patients who underwent corpectomy, were more likely to have an extended LOS (ORs 4.0-4.9). Of significant note, other factors that one might expect to be associated with extended LOS did not independently predict extended LOS in this analysis.
    Spine 04/2014; · 2.16 Impact Factor
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    ABSTRACT: Retrospective cohort. To determine whether a genetic test is associated with successful Providence bracing for adolescent idiopathic scoliosis. Genetic factors have been defined that predict risk of progression of adolescent idiopathic scoliosis in a polygenic fashion. From these data, a commercially available genetic test, ScoliScore, was developed. It is now used in clinical practice for counseling and to guide clinical management. Bracing is a mainstay of treatment for adolescent idiopathic scoliosis. Large efforts have been made recently to reduce potential confounding across studies of different braces; however, none of these have considered genetics as a potential confounder. In particular, ScoliScore has not been evaluated in a population undergoing bracing. We conducted a retrospective cohort study in which we identified a population of adolescent idiopathic scoliosis patients who were initiated with Providence bracing and followed over time. While these patients did not necessarily fit the commercial indications for ScoliScore, we contacted the patients and obtained a saliva sample from each for genetic analysis. We then tested whether ScoliScore correlated with the outcome of their bracing therapy. We were able to contact and invite 25 eligible subjects, of whom 16 (64.0%) returned samples for laboratory analysis. Patients were followed for an average of 2.3 years (range 1.1 to 4) after initiation of the Providence brace. 8 patients (50.0%) progressed to more than 45 degrees, while 8 patients (50.0%) did not. The mean ScoliScore among those who progressed to more than 45 degrees was higher than that among those who did not (176 vs. 112, P=0.030). We demonstrate that a genetic test correlates with bracing outcome. It may be appropriate for future bracing studies to include analysis of genetic predisposition to limit potential confounding.
    Journal of spinal disorders & techniques 03/2014; · 1.21 Impact Factor
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    ABSTRACT: National databases are being used with increasing frequency to conduct orthopaedic research. However, there are important differences in these databases, which could result in different answers to similar questions; this important potential limitation pertaining to database research in orthopaedic surgery has not been adequately explored. The purpose of this study was to explore the interdatabase reliability of two commonly used national databases, the Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP), in terms of (1) demographics; (2) comorbidities; and (3) adverse events. In addition, using the NSQIP database, we identified (4) adverse events that had a higher prevalence after rather than before discharge, which has important implications for interpretation of studies conducted in the NIS. A retrospective cohort study of patients undergoing operative stabilization of transcervical and intertrochanteric hip fractures during 2009 to 2011 was performed in the NIS and NSQIP. Totals of 122,712 and 5021 patients were included from the NIS and NSQIP, respectively. Age, sex, fracture type, and lengths of stay were compared. Comorbidities common to both databases were compared in terms of more or less than twofold difference between the two databases. Similar comparisons were made for adverse events. Finally, adverse events that had a greater postdischarge prevalence were identified from the NSQIP database. Tests for statistical difference were thought to be of little value given the large sample size and the resulting fact that statistical differences would have been identified even for small, clinically inconsequential differences resulting from the associated high power. Because it is of greater clinical importance to focus on the magnitude of differences, the databases were compared by absolute differences. Demographics and hospital lengths of stay were not different between the two databases. In terms of comorbidities, the prevalences of nonmorbid obesity, coagulopathy, and anemia in found in the NSQIP were more than twice those in the NIS; the prevalence of peripheral vascular disease in the NIS was more than twice that in the NSQIP. Four other comorbidities had prevalences that were not different between the two databases. In terms of inpatient adverse events, the frequencies of acute kidney injury and urinary tract infection in the NIS were more than twice those in the NSQIP. Ten other inpatient adverse events had frequencies that were not different between the two databases. Because it does not collect data after patient discharge, it can be implied from the NSQIP data that the NIS does not capture more than ½ of the deaths and surgical site infections occurring during the first 30 postoperative days. This study shows that two databases commonly used in orthopaedic research can identify similar populations of operative patients but may generate very different results for specific commonly studied comorbidities and adverse events. The NSQIP identified higher rates of morbid obesity, coagulopathy, and anemia. The NIS identified higher rates of peripheral vascular disease, acute kidney injury, and urinary tract infection. Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
    Clinical Orthopaedics and Related Research 03/2014; · 2.79 Impact Factor
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    ABSTRACT: Retrospective review of the prospective American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database with 30-day follow-up of 2164 patients undergoing elective anterior cervical discectomy and fusion (ACDF). To determine factors independently associated with increased length of stay (LOS) and complications following ACDF in order to facilitate preoperative planning and setting of realistic expectations for patients and providers. The effect of individual preoperative factors on LOS and complications has been evaluated in small-scale studies. Large database analysis with multivariate analysis of these variables has not been reported. The ACS NSQIP database from 2005-2010 was queried for patients undergoing ACDF procedures. Pre and perioperative variables were collected. Multivariate regression determined significant predictors (P<0.05) of extended LOS and complications. Average LOS was 2.0±4.0 days (mean±SD) with a range of 0 to 103 days. By multivariate analysis, age≥65, functional status, transfer from facility, preoperative anemia, and diabetes were the preoperative factors predictive of extended LOS. Major complications, minor complications, and extended surgery time were the perioperative factors associated with increased LOS. The elongating effect of these variables was determined, and ranged from 0.5-5.0 days. 71 (3.3%) had a total of 92 major complications, including return to OR (40), venous thrombotic events (13), respiratory (21), cardiac (6), mortality (5), sepsis (4), and organ space infection (3). Multivariate analysis determined ASA score≥3, preoperative anemia, age≥65, extended surgery time and male gender to be predictive of major complications (odds ratios ranging between 1.756-2.609) No association found between levels fused and LOS or complications. Extended LOS following ACDF is associated with factors including age, anemia, and diabetes, as well as the development of postoperative complications. One in 33 patients develops a major complication post-operatively, which are associated with an increased LOS of 5 days.
    Journal of spinal disorders & techniques 02/2014; · 1.21 Impact Factor
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    ABSTRACT: Study Design. Retrospective cohort.Objective. To identify factors that were independently associated with increased postoperative length of stay (LOS) and readmission in patients who underwent elective laminectomy for lumbar spinal stenosis (LSS).Summary of Background Data. LSS is a common pathology that is traditionally treated with decompressive laminectomy. Risk factors associated with increased LOS and readmission have not been fully characterized for laminectomy.Methods. Patients who underwent laminectomy for LSS during 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patient characteristics were tested for association with LOS and readmission using bivariate and multivariate analyses. Patients with LOS > 10 days were excluded from the readmission analysis as the ACS-NSQIP only captures readmissions within 30 postoperative days, and the window for potential readmission was deemed too short for patients staying longer than 10 days.Results. A total of 2,358 laminectomy patients met inclusion criteria. The average age was 66.4 ± 11.7 years (mean ± standard deviation). Average postoperative LOS was 2.1 ± 2.6 days. Of those meeting criteria for readmission analysis, 3.7% of patients (86 of 2,339) were readmitted within 30 days postoperatively.Independent risk factors for prolonged LOS were increased age (p < 0.001), increased body mass index (p = 0.004), American Society of Anesthesiologists class 3-4 (p = 0.005), and preoperative hematocrit < 36.0 (p = 0.001). Independent risk factors for readmission were increased age (p = 0.013), increased body mass index (p = 0.040), ASA class 3-4 (p < 0.001), and steroid use (p = 0.001). The most common reason for readmission was surgical site-related infections (25.0% of patients readmitted in 2012).Conclusion. The identified factors associated with LOS and readmission following lumbar laminectomy may be useful for optimizing patient care.
    Spine 02/2014; · 2.16 Impact Factor
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    ABSTRACT: The "July effect" is the hypothetical increase in morbidity thought to be associated with the training of new residents during the first portion of the academic year. We evaluated for the presence of the July effect in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database among 21,434 patients who underwent primary total hip or knee arthroplasty. There was no association of an interaction term for academic quarter and resident involvement with "serious adverse events" (P=0.656) or "any adverse events" (P=0.578). As a result, this study could not demonstrate a July effect. Patients can be reassured that undergoing total joint arthroplasty during the first part of the academic year is without increased risk of adverse events related to the training of residents.
    The Journal of arthroplasty 02/2014; · 1.79 Impact Factor
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    ABSTRACT: Study Design. Retrospective cohort study.Objective. To identify factors that are independently associated with increased surgical drain output in patients who have undergone ACDF.Summary of Background Data. Surgical drains are typically placed following ACDF to reduce the risk of complications associated with neck hematoma. The orthopaedic literature has repeatedly challenged the use of surgical drains following many procedures, and there are currently no guidelines for determining which patients are most likely to benefit from drain placement after ACDF.Methods. Consecutive patients who underwent elective ACDF with surgical drain placement at a single academic institution between January 2011 and February 2013 were identified using billing records. Patient information was abstracted from the medical record. Patients were categorized based on normal or increased total drain output, with increased drain output defined as total drain output ≥ 50th percentile (30mL). A multivariate logistic regression was used to determine which factors were independently associated with increased drain output.Results. A total of 151 ACDF patients met inclusion criteria. Total drain output ranged from 0 mL to 265 mL. The average drain output for this cohort was 42.3 ± 45.5 mL (mean ± standard deviation). Among all patients in the study, 80 patients had increased drain output (drain output ≥ 50 percentile or 30 mL).Multivariate analysis identified three independent predictors of increased drain output: age ≥ 50 years (Odds Ratio [OR] = 3.9), number of levels (2 levels, OR = 2.7; 3-4 levels, OR = 17.0), and history of smoking (OR = 2.8). One patient developed a postoperative neck hematoma while a drain was in place.Conclusion. Patients with the above-identified factors associated with increased drain output may benefit most from surgical drain placement after ACDF. Nonetheless, neck hematoma is still possible even with drain use.
    Spine 01/2014; · 2.16 Impact Factor
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    ABSTRACT: Background Context The use of national inpatient databases for spine surgery research has been increasing. Unfortunately, without firsthand knowledge of each specific database, it can be difficult to judge the validity of such studies. Large databases that rely on administrative data, such as International Classification of Diseases, Ninth Revision (ICD-9) codes, may misrepresent patient information and could thus affect the results of studies that use this data. Purpose The present study uses obesity, an easily quantified and objective variable, as an example comorbidity to assess the accuracy of ICD-9 codes in the setting of their continued use in spine database studies. Study Design/Setting A cross-sectional study at a large academic medical center. Patient Sample All patients spending at least one night in the hospital as an inpatient between April 1, 2013 and April 16, 2013. Obstetrics and gynecology, psychiatry, and pediatric patients were excluded. Outcome Measures Proportion of patients for whom ICD-9 obesity diagnosis codes assigned at hospital discharge match chart-documented BMI. Methods The medical record was reviewed for each patient, and obesity ICD-9 codes were directly compared to documented body mass index (BMI). No known conflicts of interest exist for this study. Results The study included 2,075 patients. Of 573 “obese” patients (calculated BMI 30-39.9), only 109 received the correct code (278.00), giving this ICD-9 code a sensitivity of 0.19. Of 174 “morbidly obese” patients (calculated BMI > 40), only 84 received the correct code (278.01), giving this ICD-9 code a sensitivity of 0.48. Conclusions Using obesity as an example, this study highlights the potential errors inherent to using ICD-9-coded databases for spine surgery research. Should a study based on such data use “obesity” as a variable in any analyses, the reader should interpret these results with caution. We further suggest that obesity is likely not the only comorbidity to which these results apply. As database research continues to represent an increasing proportion of publications in the field of spine surgery, it is important to realize that study outcomes can be skewed by data accuracy, and thus should not be blindly accepted simply by virtue of large sample sizes.
    The Spine Journal. 01/2014;

Publication Stats

2k Citations
278.50 Total Impact Points

Institutions

  • 1997–2014
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 1997–2013
    • Yale University
      • Department of Orthopaedics and Rehabilitation
      New Haven, CT, United States
  • 2011
    • University Center Rochester
      Rochester, Minnesota, United States
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, MA, United States
  • 2009
    • Kansas City VA Medical Center
      Kansas City, Missouri, United States
    • University of Rochester
      • Department of Orthopaedics and Rehabilitation
      Rochester, NY, United States
  • 2008
    • University of New Haven
      New Haven, Connecticut, United States
  • 2003–2007
    • Thomas Jefferson University
      • • Rothman Institute
      • • Department of Orthopaedic Surgery
      Philadelphia, Pennsylvania, United States
  • 2003–2005
    • Rothman Institute
      Philadelphia, Pennsylvania, United States