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  • Author or Editor: Mitchell G. Maltenfort x
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Sanjay Yadla, Mitchell G. Maltenfort, John K. Ratliff and James S. Harrop

Object

Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements.

Methods

A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: “adult scoliosis surgery,” “adult spine deformity surgery,” “outcomes,” and “complications.” Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major curve (coronal scoliosis or lumbar lordosis Cobb angle as reported), major curve correction, Oswestry Disability Index (ODI) scores, Scoliosis Research Society (SRS) instrument scores, complications, and pseudarthroses were recorded.

Results

Forty-nine articles were obtained and included in this review; 3299 patient data points were analyzed. The mean age was 47.7 years, and the mean follow-up period was 3.6 years. The average major curve correction was 26.6° (for 2188 patients); for 2129 patients, it was possible to calculate average curve reduction as a percentage (40.7%). The mean total ODI was 41.2 (for 1289 patients), and the mean postoperative reduction in ODI was 15.7 (for 911 patients). The mean SRS-30 equivalent score was 97.1 (for 1700 patients) with a mean postoperative decrease of 23.1 (for 999 patients). There were 897 reported complications for 2175 patients (41.2%) and 319 pseudarthroses for 2469 patients (12.9%).

Conclusions

Surgery for adult scoliosis is associated with improvement in radiographic and clinical outcomes at a minimum 2-year follow-up. Perioperative morbidity includes an approximately 13% risk of pseudarthrosis and a greater than 40% incidence of perioperative adverse events. Incidence of perioperative complications is substantial and must be considered when deciding optimal disease management. Although the quality of published studies in this area has improved, particularly in the last few years, the current review highlights the lack of routine use of standardized outcomes measures and assessment in the adult scoliosis literature.

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Sonia G. Teufack, Peter Campbell, Pascal Jabbour, Mitchell Maltenfort, James Evans and John K. Ratliff

Object

The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for “never events” (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility.

Methods

Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events.

Results

A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 ± 11.5 vs 5.9 ± 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician).

Conclusions

The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

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Cheerag D. Upadhyaya and Praveen V. Mumaneni

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Peter G. Campbell, Sanjay Yadla, Rani Nasser, Jennifer Malone, Mitchell G. Maltenfort and John K. Ratliff

Object

Present attempts to control health care costs focus on reducing the incidence of complications and hospital-acquired conditions (HACs). One approach uses restriction or elimination of hospital payments for HACs. Present approaches assume that all HACs are created equal and that payment restrictions should be applied uniformly. Patient factors, and especially patient comorbidities, likely impact complication incidence. The relationship of patient comorbidities and complication incidence in spine surgery has not been prospectively reported.

Methods

The authors conducted a prospective assessment of complications in spine surgery during a 6-month period; an independent auditor and a validated definition of perioperative complications were used. Initial demographics captured relevant patient comorbidities. The authors constructed a model of relative risk assessment based on the presence of a variety of comorbidities. They examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence.

Results

Two hundred forty-nine patients undergoing 259 procedures at a tertiary care facility were evaluated during the 6-month duration of the study. Eighty percent of the patients underwent fusion procedures. One hundred thirty patients (52.2%) experienced at least 1 complication, with major complications occurring in 21.4% and minor complications in 46.4% of the cohort. Major complications doubled the median duration of hospital stay, from 6 to 12 days in cervical spine patients and from 7 to 14 days in thoracolumbar spine patients. At least 1 comorbid condition was present in 86% of the patients. An increasing number of comorbidities strongly correlated with increased risk of major, minor, and any complications (p = 0.017, p < 0.0001, and p < 0.0001, respectively). Patient factors correlating with increased risk of specific complications included systemic malignancy and cardiac conditions other than hypertension.

Conclusions

Comorbidities significantly increase the risk of perioperative complications. An increasing number of comorbidities in an individual patient significantly increases the risk of a perioperative adverse event. Patient factors significantly impact the relative risk of HACs and perioperative complications.

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Sanjay Yadla, Jennifer Malone, Peter G. Campbell, Mitchell G. Maltenfort, James S. Harrop, Ashwini D. Sharan and John K. Ratliff

Object

The reported incidence of complications in spine surgery varies widely. Variable study methodologies may open differing avenues for potential bias, and unclear definitions of perioperative complication make analysis of the literature challenging. Although numerous studies have examined the morbidity associated with specific procedures or diagnoses, no prospective analysis has evaluated the impact of preoperative diagnosis on overall early morbidity in spine surgery. To accurately assess perioperative morbidity in patients undergoing spine surgery, a prospective analysis of all patients who underwent spine surgery by the neurosurgical service at a large tertiary care center over a 6-month period was conducted. The correlation between preoperative diagnosis and the incidence of postoperative complications was assessed.

Methods

Data were prospectively collected on 248 consecutive patients undergoing spine surgery performed by the neurosurgical service at the Thomas Jefferson University Hospital from May to December 2008. A standardized definition of minor and major complications was applied to all adverse events occurring within 30 days of surgery. Data on diagnosis, complications, and length of stay were retrospectively assessed using stepwise multivariate analysis. Patients were analyzed by preoperative diagnosis (neoplasm, infection, degenerative disease, trauma) and level of surgery (cervical or thoracolumbar).

Results

Total early complication incidence was 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%. Preoperative diagnosis correlated only with the occurrence of minor complications in the overall cohort (p = 0.02). In patients undergoing surgery of the thoracolumbar spine, preoperative diagnosis correlated with presence of a complication and the number of complications (p = 0.003). Within this group, patients with preoperative diagnoses of infection and neoplasm were more often affected by isolated and multiple complications (p = 0.05 and p = 0.02, respectively). Surgeries across the cervicothoracic and thoracolumbar junctions were associated with higher incidences of overall complication than cervical or lumbar surgery alone (p = 0.04 and p = 0.03, respectively). Median length of stay was 5 days for patients without a complication. Length of stay was significantly greater for patients with a minor complication (10 days, p < 0.0001) and even greater for patients with a major complication (14 days, p < 0.0001).

Conclusions

The incidence of complications found in this prospective analysis is higher than that reported in previous studies. This association may be due to a greater accuracy of record-keeping, absence of recall bias via prospective data collection, high complexity of pathology and surgical approaches, or application of a more liberal definition of what constitutes a complication. Further large-scale prospective studies using clear definitions of complication are necessary to ascertain the true incidence of early postoperative complications in spine surgery.

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Peter G. Campbell, Sanjay Yadla, Jennifer Malone, Mitchell G. Maltenfort, James S. Harrop, Ashwini D. Sharan and John K. Ratliff

Object

Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications.

Methods

Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis.

Results

Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications.

Conclusions

Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

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Sanjay Yadla, George M. Ghobrial, Peter G. Campbell, Mitchell G. Maltenfort, James S. Harrop, John K. Ratliff and Ashwini D. Sharan

OBJECT

Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates.

METHODS

Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS.

RESULTS

The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n = 2), UTI (n = 2), and neurological deficit (n = 1). Complications affecting LOS were not found to be predictive of readmission (p = 0.029).

CONCLUSIONS

Postoperative complications in patients who have undergone spine surgery are not uncommon and are associated with prolonged hospital stays. In the current cohort, the occurrence of pulmonary complications, UTI, and new neurological deficit had the greatest effect on overall LOS. Further study is required to determine the causative factors affecting readmission. These specific complications may be high-yield targets for cost reduction and/or prevention efforts.

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Gabriel A. Smith, Phillip Dagostino, Mitchell G. Maltenfort, Aaron S. Dumont and John K. Ratliff

Object

Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed.

Methods

The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored.

Results

The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%–92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations.

Conclusions

The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.

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Peter G. Campbell, Olatilewa O. Awe, Mitchell G. Maltenfort, Darius M. Moshfeghi, Theodore Leng, Andrew A. Moshfeghi and John K. Ratliff

Object

Factors determining choice of an academic career in neurological surgery are unclear. This study seeks to evaluate the graduates of medical schools and US residency programs to determine those programs that produce a high number of graduates remaining within academic programs and the contribution of these graduates to academic neurosurgery as determined by h-index valuation.

Methods

Biographical information from current faculty members of all accredited neurosurgery training programs in the US with departmental websites was obtained. Any individual who did not have an American Board of Neurological Surgery certificate (or was not board eligible) was excluded. The variables collected included medical school attended, residency program completed, and current academic rank. For each faculty member, Web of Science and Scopus h-indices were also collected.

Results

Ninety-seven academic neurosurgery departments with 986 faculty members were analyzed. All data regarding training program and medical school education were compiled and analyzed by center from which each faculty member graduated. The 20 medical schools and neurosurgical residency training programs producing the greatest number of graduates remaining in academic practice, and the respective individuals' h-indices, are reported. Medical school graduates of the Columbia University College of Physicians and Surgeons chose to enter academics the most frequently. The neurosurgery training program at the University of Pittsburgh produced the highest number of academic neurosurgeons in this sample.

Conclusions

The use of quantitative measures to evaluate the academic productivity of medical school and residency graduates may provide objective measurements by which the subjective influence of training experiences on choice of an academic career may be inferred. The top 3 residency training programs were responsible for 10% of all academic neurosurgeons. The influence of medical school and residency experiences on choice of an academic career may be significant.

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Peter G. Campbell, Jennifer Malone, Sanjay Yadla, Rohan Chitale, Rani Nasser, Mitchell G. Maltenfort, Alex Vaccaro and John K. Ratliff

Object

Large studies of ICD-9–based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9–based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9–based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9–based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well.

Methods

A prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9–based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9–based, and retrospective assessments.

Results

Ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9–based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9–based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9–based assessment (p = 0.05).

Conclusions

An ICD-9–based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9–based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9–based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.