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Yoji Ogura, Jeffrey L. Gum, Portia Steele, Charles H. Crawford III, Mladen Djurasovic, R. Kirk Owens II, Joseph L. Laratta, Morgan Brown, Christy Daniels, John R. Dimar II, Steven D. Glassman and Leah Y. Carreon

OBJECTIVE

Unexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.

METHODS

The electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.

RESULTS

A total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).

CONCLUSIONS

Increased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

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Michael D. Staudt, Ilknur Telkes and Julie G. Pilitsis

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Shyam J. Kurian, Yagiz Ugur Yolcu, Jad Zreik, Mohammed Ali Alvi, Brett A. Freedman and Mohamad Bydon

OBJECTIVE

The National Surgical Quality Improvement Program (NSQIP) and National Readmissions Database (NRD) are two widely used databases for research studies. However, they may not provide generalizable information in regard to individual institutions. Therefore, the objective of the present study was to evaluate 30-day readmissions following anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) procedures by using these two national databases and an institutional cohort.

METHODS

The NSQIP and NRD were queried for patients undergoing elective ACDF and PLF, with the addition of an institutional cohort. The outcome of interest was 30-day readmissions following ACDF and PLF, which were unplanned and related to the index procedure. Subsequently, univariable and multivariable analyses were conducted to determine the predictors of 30-day readmissions by using both databases and the institutional cohort.

RESULTS

Among all identified risk factors, only hypertension was found to be a common risk factor between NRD and the institutional cohort following ACDF. NSQIP and the institutional cohort both showed length of hospital stay to be a significant predictor for 30-day related readmission following PLF. There were no overlapping variables among all 3 cohorts for either ACDF or PLF. Additionally, the national databases identified a greater number of risk factors for 30-day related readmissions than did the institutional cohort for both procedures.

CONCLUSIONS

Overall, significant differences were seen among all 3 cohorts with regard to top predictors of 30-day unplanned readmissions following ACDF and PLF. The higher quantity of significant predictors found in the national databases may suggest that looking at single-institution series for such analyses may result in underestimation of important variables affecting patient outcomes, and that big data may be helpful in addressing this concern.

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Martin H. Weiss, Gabriel Zada, John D. Carmichael and William T. Couldwell

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Ben A. Strickland, Michelle Wedemeyer, Saman Sizdahkhani and Steven L. Giannotta

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Tyler S. Cole and Robert F. Spetzler

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Christian Iorio-Morin and Mathieu Levesque

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Christine Park, Rasheedat T. Zakare-Fagbamila, Wes Dickson, Alessandra N. Garcia and Oren N. Gottfried

OBJECTIVE

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey that assesses patient satisfaction, which is an important measure of the quality of hospital care and ultimately the overall hospital rating (OHR). However, the survey covers several elements of patient satisfaction beyond the patient-surgeon interaction. In this study, authors investigated which admission and experience factors had the highest impact on the OHR.

METHODS

This was a retrospective cohort analysis of HCAHPS surveys from patients who, in the period between August 1, 2016, and January 31, 2018, had been discharged from the neurosurgical or orthopedic service at three hospitals serving a single metropolitan area. The top-box score was defined as the highest rating obtainable for each survey question. Baseline admission attributes were obtained, and multivariate logistic regression was used to determine predictors of the top-box OHR.

RESULTS

After application of the inclusion and exclusion criteria, 1470 patients remained in the analysis. Categories on the HCAHPS included OHR, communication, education, environment, pain management, and responsiveness. After excluding identifying questions from the survey and adjusting for subspecialty and hospital, 7 of 17 HCAHPS survey items were significant predictors of OHR. Only 2 of these were related to the surgeon: 1) discharge, “Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” (OR 5.93, 95% CI 2.52–13.94); and 2) doctor, “Did doctors explain things in a way you could understand?” (OR 2.78, 95% CI 1.73–4.46). The top three strongest correlating items were 1) discharge; 2) nursing, “Did nurses treat you with courtesy and respect?” (OR 3.86, 95% CI 2.28–6.52); and 3) hospital environment, “Were your room and bathroom kept clean?” (OR 2.86, 95% CI 1.96–4.17).

CONCLUSIONS

The study findings demonstrated that there are several nonmodifiable factors (i.e., specialty, experience) and items that are not under the direct purview of the neurosurgeon (e.g., nursing communication, hospital environment) that are significant influences on overall inpatient satisfaction on the HCAHPS survey. Furthermore, components of the survey that ultimately influence the OHR vary across different hospitals. Hence, HCAHPS survey results should be broadly interpreted as a way to make health systems more aware of the overall hospital factors that can improve quality of care and patient experience.

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Jasmine A. T. DiCesare, Alexander M. Tucker, Irene Say, Kunal Patel, Todd H. Lanman, Frank J. Coufal, Justin Millard, Jeffrey E. Deckey, Siddharth Shetgeri and Duncan Q. McBride

Cervical spondylosis is one of the most commonly treated conditions in neurosurgery. Increasingly, cervical disc replacement (CDR) has become an alternative to traditional arthrodesis, particularly when treating younger patients. Thus, surgeons continue to gain a greater understanding of short- and long-term complications of arthroplasty. Here, the authors present a series of 4 patients initially treated with Mobi-C artificial disc implants who developed postoperative neck pain. Dynamic imaging revealed segmental kyphosis at the level of the implant. All implants were locked in the flexion position, and all patients required reoperation. This is the first reported case series of symptomatic segmental kyphosis after CDR.

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Joseph Piatt

OBJECTIVE

Social disparities in healthcare outcomes are almost ubiquitous, and trauma care is no exception. Because social factors cannot cause a trauma outcome directly, there must exist mediating causal factors related to the nature and severity of the injury, the robustness of the victim, access to care, or processes of care. Identification of these causal factors is the first step in the movement toward health equity.

METHODS

A noninferiority analysis was undertaken to compare mortality rates between Black children and White children after traumatic brain injury (TBI). Data were derived from the Trauma Quality Improvement Program (TQIP) registries for the years 2014 through 2017. Inclusion criteria were age younger than 19 years and head Abbreviated Injury Scale scores of 4, 5, or 6. A noninferiority margin of 10% was preselected. A logistic regression propensity score model was developed to distinguish Black and White children based on all available covariates associated with race at p < 0.10. Stabilized inverse probability weighting and a one-tailed 95% CI were used to test the noninferiority hypothesis.

RESULTS

There were 7273 observations of White children and 2320 observations of Black children. The raw mortality rates were 15.6% and 22.8% for White and Black children, respectively. The final propensity score model included 31 covariates. It had good fit (Hosmer-Lemeshow χ2 = 7.1604, df = 8; p = 0.5194) and good discrimination (c-statistic = 0.752). The adjusted mortality rates were 17.82% and 17.79% for White and Black children, respectively. The relative risk was 0.9986, with a confidence interval upper limit of 1.0865. The relative risk corresponding to the noninferiority margin was 1.1. The hypothesis of noninferiority was supported.

CONCLUSIONS

Data captured in the TQIP registries are sufficient to explain the observed racial disparities in mortality after TBI in childhood. Speculations about genetic or epigenetic factors are not supported by this analysis. Discriminatory care may still be a factor in TBI mortality disparities, but it is not occult. If it exists, evidence for it can be sought among the data included in the TQIP registries.