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Hari T. Vigneswaran, Zachary J. Grabel, Craig P. Eberson, Mark A. Palumbo and Alan H. Daniels

OBJECT

Adolescent idiopathic scoliosis (AIS) can cause substantial morbidity and may require surgical intervention. In this study, the authors aimed to evaluate US trends in operative AIS as well as patient comorbidities, operative approach, in-hospital complications, hospital length of stay (LOS), and hospital charges in the US for the period from 1997 to 2012.

METHODS

Patients with AIS (ICD-9-CM diagnosis codes 737.30) who had undergone spinal fusion (ICD-9-CM procedure codes 81.xx) from 1997 to 2012 were identified from the Kids' Inpatient Database. Parameters of interest included patient comorbidities, operative approach (posterior, anterior, or combined anteroposterior), in-hospital complications, hospital LOS, and hospital charges.

RESULTS

The authors identified 20, 346 patients in the age range of 0–21 years who had been admitted for AIS surgery in the defined study period. Posterior fusions composed 63.4% of procedures in 1997 and 94.1% in 2012 (r = 0.95, p < 0.01). The mean number of comorbidities among all fusion groups increased from 3.0 in 1997 to 4.2 in 2012 (r = 0.92, p = 0.01). The percentage of patients with complications increased from 15.6% in 1997 to 22.3% in 2012 (r = 0.78, p = 0.07). The average hospital LOS decreased from 6.5 days in 1997 to 5.6 days in 2012 (r = -0.86, p = 0.03). From 1997 to 2012, the mean hospital charges (adjusted to 2012 US dollars) for surgical treatment of AIS more than tripled from $55,495 in 1997 to $177,176 in 2012 (r = 0.99, p < 0.01).

CONCLUSIONS

Over the 15-year period considered in this study, there was an increasing trend toward using posterior-based techniques for AIS corrective surgery. The number of comorbid conditions per patient and thus the medical complexity of patients treated for AIS have increased. The mean charges for the treatment of AIS have increased, with a national bill over $1.1 billion per year in 2012.

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J. Mason DePasse, Roy Ruttiman, Adam E. M. Eltorai, Mark A. Palumbo and Alan H. Daniels

OBJECTIVE

Spinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists.

METHODS

The VerdictSearch database, a large legal-claims database, was queried for “epidural abscess”–related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed.

RESULTS

In total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000–$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000–$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]).

CONCLUSIONS

This investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.

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J. Mason DePasse, Mauricio Valdes, Mark A. Palumbo, Alan H. Daniels and Craig P. Eberson

Spinopelvic fixation provides an important anchor for long fusions in spinal deformity surgery, and it is also used in the treatment of other spine pathologies. Iliac screws are known to sometimes require reoperation due to pain resulting from hardware prominence and skin injury. S-2 alar/iliac (S2AI) screws do not often require removal, but they may provide inadequate fixation in select cases. In this paper the authors describe a technique for S-1 alar/iliac screws that may be used independently or as a supplement to S2AI screws. A preliminary biomechanical analysis and 2 clinical case examples are also provided.

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Saisanjana Kalagara, Adam E. M. Eltorai, Wesley M. Durand, J. Mason DePasse and Alan H. Daniels

OBJECTIVE

Hospital readmission contributes substantial costs to the healthcare system. The purpose of this investigation was to create a predictive machine learning model to identify lumbar laminectomy patients at risk for postoperative hospital readmission.

METHODS

Patients who had undergone a lumbar laminectomy procedure in the period from 2011 to 2014 were isolated from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Demographic characteristics and clinical factors, including complications, comorbidities, length of stay, age, and body mass index, were analyzed in relation to whether or not the patients had been readmitted to the hospital within 30 days after their procedure by utilizing independent-samples t-tests. Supervised gradient boosting machine learning was then used to create two models to predict readmission—one with all collected patient variables and one with only the variables known prior to hospital discharge.

RESULTS

A total of 26,869 patients were evaluated, 5.59% (1501 patients) of whom had an unplanned readmission to the hospital within 30 days of their procedure. Readmitted patients were older and had a greater number of complications and comorbidities, longer operative time, longer hospital stay, higher BMI, and higher work relative value unit (RVU) operation score (p < 0.01). They also had a worse health status prior to surgery (p < 0.01) and were more likely to be sent to a skilled discharge destination postoperatively (p < 0.01). The model with all patient variables accurately identified 49.6% of readmissions with an overall accuracy of 95.33% (area under the curve [AUC] = 0.8059), with postdischarge complications and comorbidities as the most important predictors. The predictive model built with only clinical information known predischarge identified 40.5% of readmitted patients with an accuracy of 79.55% (AUC = 0.6901), with discharge destination, comorbidities, and American Society of Anesthesiologists (ASA) classification as the most influential factors in identifying readmitted patients.

CONCLUSIONS

In this study, the authors analyzed hospital readmissions following laminectomy and developed predictive models to identify readmitted patients with an accuracy of over 95% using all variables and over 79% when using only predischarge variables. Using only the variables available predischarge, the authors created a model capable of predicting 40% of the readmitted patients. This study provides data that will assist in the development of predictive models for readmission and the creation of interventions to prevent readmission in high-risk patients.

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Umut Safer, Mustafa Kaplan and Vildan Binay Safer

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Alan H. Daniels, Roy Ruttiman, Adam E. M. Eltorai, J. Mason DePasse, Bielinsky A. Brea and Mark A. Palumbo

OBJECTIVE

Adverse events related to spine surgery sometimes lead to litigation. Few studies have evaluated the association between spine surgical complications and medical malpractice proceedings, outcomes, and awards. The aim of this study was to identify the most frequent causes of alleged malpractice in spine surgery and to gain insight into patient demographic and clinical characteristics associated with medical negligence litigation.

METHODS

A search for “spine surgery” spanning February 1988 to May 2015 was conducted utilizing the medicolegal research service VerdictSearch (ALM Media Properties, LLC). Demographic data for the plaintiff and defendant in addition to clinical data for the procedure and legal outcomes were examined. Spinal cord injury, anoxic/hypoxic brain injury, and death were classified as catastrophic complications; all other complications were classified as noncatastrophic. Both chi-square and t-tests were used to evaluate the effect of these variables on case outcomes and awards granted.

RESULTS

A total of 569 legal cases were examined; 335 cases were excluded due to irrelevance or insufficient information. Of the 234 cases included in this investigation, 54.2% (127 cases) resulted in a defendant ruling, 26.1% (61) in a plaintiff ruling, and 19.6% (46) in a settlement. The awards granted for plaintiff rulings ranged from $134,000 to $38,323,196 (mean $4,045,205 ± $6,804,647). Awards for settlements ranged from $125,000 to $9,000,000 (mean $1,930,278 ± $2,113,593), which was significantly less than plaintiff rulings (p = 0.022). Compared with cases without a delay in diagnosis of the complication, the cases with a diagnostic delay were more likely to result in a plaintiff verdict or settlement (42.9% vs 72.7%, p = 0.007) than a defense verdict, and were more likely to settle out of court (17.5% vs 40.9%, p = 0.008). Similarly, compared with cases without a delay in treatment of the complication, those with a therapeutic delay were more likely to result in a plaintiff verdict or settlement (43.7% vs 68.4%, p = 0.03) than a defense verdict, and were more likely to settle out of court (18.1% vs 36.8%, p = 0.04). Overall, 28% of cases (66/234) involved catastrophic complications. Physicians were more likely to lose cases (plaintiff verdict or settlement) with catastrophic complications (66.7% vs 37.5%, p < 0.001). In cases with a plaintiff ruling, catastrophic complications resulted in significantly larger mean awards than noncatastrophic complications ($6.1M vs $2.9M, p = 0.04). The medical specialty of the provider and the age or sex of the patient were not associated with the case outcome or award granted (p > 0.05). The average time to a decision for defendant verdicts was 5.1 years; for plaintiff rulings, 5.0 years; and for settlements, 3.4 years.

CONCLUSIONS

Delays in the diagnosis and the treatment of a surgical complication predict legal case outcomes favoring the plaintiff. Catastrophic complications are linked to large sums awarded to the plaintiff and are predictive of rulings against the physician. For physician defendants, the costs of settlements are significantly less than those of losing in court. Although this study provides potentially valuable data from a large series of postoperative litigation cases, it may not provide a true representation of all jurisdictions, each of which has variable malpractice laws and medicolegal environments.

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Alan H. Daniels, Satoshi Kawaguchi, Alec G. Contag, Farbod Rastegar, Garrett Waagmeester, Paul A. Anderson, Melanie Arthur and Robert A. Hart

OBJECTIVE

Beginning in 2008, the Centers for Medicare and Medicaid Service (CMS) determined that certain hospital-acquired adverse events such as surgical site infection (SSI) following spine surgery should never occur. The following year, they expanded the ruling to include deep vein thrombosis (DVT) and pulmonary embolism (PE) following total joint arthroplasty. Due to their ruling that “never events” are not the payers' responsibility, CMS insists that the costs of managing these complications be borne by hospitals and health care providers, rather than billings to health care payers for additional care required in their management. Data comparing the expected costs of such adverse events in patients undergoing spine and orthopedic surgery have not previously been reported.

METHODS

The California State Inpatient Database (CA-SID) from 2008 to 2009 was used for the analysis. All patients with primary procedure codes indicating anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), lumbar laminectomy (LL), total knee replacement (TKR), and total hip replacement (THR) were analyzed. Patients with diagnostic and/or treatment codes for DVT, PE, and SSI were separated from patients without these complication codes. Patients with more than 1 primary procedure code or more than 1 complication code were excluded. Median charges for treatment from primary surgery through 3 months postoperatively were calculated.

RESULTS

The incidence of the examined adverse events was lowest for ACDF (0.6% DVT, 0.1% PE, and 0.03% SSI) and highest for TKA (1.3% DVT, 0.3% PE, 0.6% SSI). Median inpatient charges for uncomplicated LL was $51,817, compared with $73,432 for ACDF, $143,601 for PLIF, $74,459 for THR, and $70,116 for TKR. Charges for patients with DVT ranged from $108,387 for TKR (1.5 times greater than index) to $313,536 for ACDF (4.3 times greater than index). Charges for patients with PE ranged from $127,958 for TKR (1.8 times greater than index) to $246,637 for PLIF (1.7 times greater than index). Charges for patients with SSI ranged from $168,964 for TKR (2.4 times greater than index) to $385,753 for PLIF (2.7 times greater than index).

CONCLUSIONS

Although incidence rates are low, adverse events of spinal procedures substantially increase the cost of care. Charges for patients experiencing DVT, PE, and SSI increased in this study by factors ranging from 1.8 to 4.3 times those for patients without such complications across 5 common spinal and orthopedic procedures. Cost projections by health care providers will need to incorporate expected costs of added care for patients experiencing such complications, assuming that the cost burden of such events continues to shift from payers to providers.

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Steven L. Bokshan, Alex Han, J. Mason DePasse, Stephen E. Marcaccio, Adam E. M. Eltorai and Alan H. Daniels

OBJECTIVE

Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery.

METHODS

Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization.

RESULTS

Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs.

CONCLUSIONS

This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.