Scott A. Meyer and Praveen V. Mummaneni
Christopher I. Shaffrey
John R. W. Kestle
Kaisorn Chaichana, Scott Parker, Alessandro Olivi and Alfredo Quiñones-Hinojosa
Glioblastoma multiforme (GBM) is the most common and aggressive type of primary brain tumor in adults. Although the average survival is ~ 12 months, individual survival is heterogeneous. The ability to predict short- and long-term survivors is limited. Therefore, the aims of this study were to ascertain preoperative risk factors associated with survival, develop a preoperative prognostic grading system, and evaluate the utility of this grading system in predicting survival for patients undergoing resection of a primary intracranial GBM.
Cases involving adult patients who underwent surgery for an intracranial primary (de novo) GBM between 1997 and 2007 at The Johns Hopkins Hospital, an academic tertiary-care institution, were retrospectively reviewed. Multivariate proportional hazards regression analysis was used to identify preoperative factors associated with survival, after controlling for extent of resection and adjuvant therapies. The identified associations with survival were then used to develop a grading system based on preoperative variables. Survival as a function of time was plotted using the Kaplan-Meier method, and survival rates were compared using Log-rank analysis. Associations with p < 0.05 were considered statistically significant.
Of the 393 patients in this study, 310 (79%) had died as of most recent follow-up (median time from surgery to death 11.9 months). The preoperative factors, independent of extent of resection and adjuvant therapies (carmustine wafers, temozolomide, and radiation), found to be negatively associated with survival were: age > 60 years (p < 0.0001), Karnofsky performance status score ≤ 80 (p < 0.0001), motor deficit (p = 0.02), language deficit (p = 0.001), and periventricular tumor location (p = 0.04). Patients possessing 0–1, 2, 3, and 4–5 of these variables were assigned a preoperative grade of 1, 2, 3, and 4, respectively. Patients with a preoperative grade of 1, 2, 3, and 4 had a median survival of 16.6, 10.2, 6.8, and 6.1 months, respectively.
The present study found that older age, poor performance status, motor deficit, language deficit, and periventricular tumor location independently predicted poorer survival in patients undergoing GBM resection. A grading system based on these factors was able to identify 4 distinct groups of patients with different survival rates. This grading system, based only on preoperative variables, may provide patients and physicians with prognostic information that may guide medical and surgical therapy before any intervention is pursued.
Scott L. Parker, David N. Shau, Stephen K. Mendenhall and Matthew J. McGirt
Revision lumbar fusion procedures are technically challenging and can be associated with tremendous health care resource utilization and cost. There is a paucity of data regarding specific factors that significantly contribute to increased cost of care. In light of this, the authors set out to identify independent risk factors predictive of increasing 2-year direct health care costs after revision lumbar fusion.
One hundred fifty patients undergoing revision instrument-assisted fusion for adjacent-segment disease (50 cases), pseudarthrosis (47 cases), or same-level stenosis (53 cases) were included in this study. Patient demographics, comorbidities, preoperative health states as assessed by patient-reported outcome questionnaires and perioperative complications were collected and analyzed. Two-year back-related medical resource utilization and direct health care costs were assessed. The independent association of all variables to increasing cost was assessed using multivariate linear regression analysis.
There was a wide range ($24,935–$63,769) in overall 2-year direct costs for patients undergoing revision lumbar fusion (mean $32,915 ± $8344 [± SD]). Preoperative variables independently associated with 2-year direct health care costs included diagnosis of congestive heart failure, more severe leg pain (visual analog scale), greater back-related disability (Oswestry Disability Index), and worse mental health (12-Item Short Form Health Survey Mental Component Summary score). There was a 1.1- to 1.2-fold increase in cost for patients in the greatest quartiles compared with those in the lowest quartiles for these variables. Surgical site infection, return to the operating room, and spine-related hospital readmission during the 90-day global health period were postoperative variables independently associated with 2-year cost. Patients in the greatest versus lowest quartiles had a 1.7- to 1.9-fold increase in cost for these variables.
Revision lumbar fusion can be associated with considerable 2-year health care costs. These costs can also vary widely among patients, as evidenced by the 2.6-fold overall cost range in this series. Although comorbidities and preoperative severity of disease states contribute to cost of care, the primary drivers of increased cost include perioperative complications such as surgical site infection, return to the operating room, and readmission during the global health period. Measures focused on health service improvement will be most successful in reducing the cost of care for patients undergoing revision lumbar fusion.
Kaisorn L. Chaichana, Scott L. Parker, Alessandro Olivi and Alfredo Quiñones-Hinojosa
Seizures are a common presenting symptom and cause of morbidity for patients with malignant astrocytomas. The authors set out to determine preoperative seizure characteristics, effects of surgery on seizure control, and factors associated with prolonged seizure control in patients with malignant astrocytomas.
Cases involving adult patients who underwent primary resection of a hemispheric anaplastic astrocytoma (AA) or glioblastoma multiforme (GBM) at the Johns Hopkins Medical Institutions between 1996 and 2006 were retrospectively reviewed. Multivariate logistical regression analysis was used to identify associations with pre-operative seizures, and multivariate proportional hazards regression analyses were used to identify associations with prolonged seizure control following resection.
Of the 648 patients (505 with GBM, 143 with AA) in this series, 153 (24%) presented with seizures. The factors more commonly associated with preoperative seizures were AA pathology (p = 0.03), temporal lobe involvement (p = 0.04), and cortical location (p = 0.04), while the factors less commonly associated with preoperative seizures were greater age (p = 0.03) and larger tumor size (p ≤ 0.001). Among those patients with a history of seizures, outcome 12 months after surgery was Engel Class I (seizure free) in 77%, Class II (rare seizures) in 12%, Class III (meaningful improvement) in 6%, and Class IV (no improvement) in 5%. Postoperative seizures were rare in patients without a history of preoperative seizures. The factor positively associated with prolonged seizure control was increased Karnofsky Performance Scale score (p = 0.002), while the factors negatively associated with seizure control were preoperative uncontrolled seizures (p = 0.03) and parietal lobe involvement (p = 0.005). Seizure recurrence in patients with postoperative seizure control was independently associated with tumor recurrence (p = 0.006).
The identification and consideration of factors associated with prolonged seizure control may help guide treatment strategies aimed at improving the quality of life for patients with malignant astrocytomas.
John R. W. Kestle
Scott L. Parker, Saniya S. Godil, David N. Shau, Stephen K. Mendenhall and Matthew J. McGirt
Treatment effectiveness following spine surgery is usually gauged with the help of patient-reported outcome (PRO) questionnaires. Although these questionnaires assess pain, disability, and general health state, their numerical scores lack direct, clinically significant meaning. Thus, the concept of minimum clinically important difference (MCID) has been introduced, which indicates the smallest change in an outcome measure that reflects clinically meaningful improvement to patients. The authors set out to determine anterior cervical discectomy and fusion (ACDF)–specific MCID values for the visual analog scale (VAS), Neck Disability Index (NDI), 12-Item Short-Form Health Survey (SF-12), and EQ-5D (the EuroQol health survey) in patients undergoing ACDF for cervical radiculopathy.
Data on 69 patients who underwent ACDF for cervical radiculopathy were collected in the authors' web-based, prospective registry during the study enrollment period. Patient-reported outcome questionnaires (VAS–neck pain [NP]), VAS–arm pain [AP], NDI, SF-12, and EQ-5D) were administered preoperatively and 3 months postoperatively, allowing 3-month change scores to be calculated. Four established calculation methods were used to calculate anchor-based MCID values using the North American Spine Society (NASS) patient satisfaction scale as the anchor: 1) average change, 2) minimum detectable change (MDC), 3) change difference, and 4) receiver operating characteristic (ROC) curve analysis.
Sixty-one patients (88%) were available at follow-up. At 3 months postoperatively, statistically significant improvement (p < 0.001) was observed for the following PROs assessed: VAS-NP (2.7 ± 3.3), VAS-AP (3.7 ± 3.6), NDI (23.2% ± 19.7%), SF-12 physical component score (PCS; 10.7 ± 9.7), and EQ-5D (0.20 ± 0.23 QALY). Improvement on the SF-12 mental component score (MCS) trended toward significance (3.4 ± 11.4, p = 0.07). The 4 MCID calculation methods generated a range of MCID values for each of the PROs: VAS-NP 2.6–4.0, VAS-AP 2.4–4.2, NDI 16.0%–27.6%, SF-12 PCS 7.0–12.2, SF-12 MCS 0.0–7.2, and EQ-5D 0.05–0.24 QALY. The maximum area under the curve (AUC) was observed for NDI (0.80), and the minimum AUC was observed for SF-12 MCS (0.66) and EQ-5D (0.67). Based on the MDC approach, the MCID threshold was 2.6 points for VAS-NP, 4.1 points for VAS-AP, 17.3% for NDI, 8.1 points for SF-12 PCS, 4.7 points for SF-12 MCS, and 0.24 QALY for EQ-5D. The mean improvement in patient scores at 3 months surpassed the MCID threshold for VAS-NP, NDI, and SF-12 PCS but not for VAS-AP, SF-12 MCS, and EQ-5D.
The ACDF-specific MCID is highly variable depending on the calculation technique used. The MDC approach seems to be most appropriate for MCID calculations in the ACDF population, as it provided a threshold value above the 95% confidence interval of nonresponders (greater than the measurement error) and was closest to the average change of most PROs reported by responders. When the MDC method was applied with the NASS patient satisfaction scale as the anchor, the MCID thresholds were 2.6 points for VAS-NP, 4.1 points for VAS-AP, 17.3% for NDI, 8.1 points for SF-12 PCS, 4.7 points for SF-12 MCS, and 0.24 QALY for EQ-5D.
Scott L. Parker, Ahilan Sivaganesan, Silky Chotai, Matthew J. McGirt, Anthony L. Asher and Clinton J. Devin
Hospital readmissions lead to a significant increase in the total cost of care in patients undergoing elective spine surgery. Understanding factors associated with an increased risk of postoperative readmission could facilitate a reduction in such occurrences. The aims of this study were to develop and validate a predictive model for 90-day hospital readmission following elective spine surgery.
All patients undergoing elective spine surgery for degenerative disease were enrolled in a prospective longitudinal registry. All 90-day readmissions were prospectively recorded. For predictive modeling, all covariates were selected by choosing those variables that were significantly associated with readmission and by incorporating other relevant variables based on clinical intuition and the Akaike information criterion. Eighty percent of the sample was randomly selected for model development and 20% for model validation. Multiple logistic regression analysis was performed with Bayesian model averaging (BMA) to model the odds of 90-day readmission. Goodness of fit was assessed via the C-statistic, that is, the area under the receiver operating characteristic curve (AUC), using the training data set. Discrimination (predictive performance) was assessed using the C-statistic, as applied to the 20% validation data set.
A total of 2803 consecutive patients were enrolled in the registry, and their data were analyzed for this study. Of this cohort, 227 (8.1%) patients were readmitted to the hospital (for any cause) within 90 days postoperatively. Variables significantly associated with an increased risk of readmission were as follows (OR [95% CI]): lumbar surgery 1.8 [1.1–2.8], government-issued insurance 2.0 [1.4–3.0], hypertension 2.1 [1.4–3.3], prior myocardial infarction 2.2 [1.2–3.8], diabetes 2.5 [1.7–3.7], and coagulation disorder 3.1 [1.6–5.8]. These variables, in addition to others determined a priori to be clinically relevant, comprised 32 inputs in the predictive model constructed using BMA. The AUC value for the training data set was 0.77 for model development and 0.76 for model validation.
Identification of high-risk patients is feasible with the novel predictive model presented herein. Appropriate allocation of resources to reduce the postoperative incidence of readmission may reduce the readmission rate and the associated health care costs.
Matthew J. McGirt, Saniya S. Godil, Anthony L. Asher, Scott L. Parker and Clinton J. Devin
In an era of escalating health care cost and universal pressure of improving efficiency and cost of care, ambulatory surgery centers (ASCs) have emerged as lower cost options for many surgical therapies. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and is rapidly increasing with an expanding aging population. While ASCs offer cost advantages for ACDF, there is a scarcity of evidence that ASCs allow for equivalent quality and thus superior health care value. Therefore, the authors analyzed a nationwide, prospective quality improvement registry (National Surgical Quality Improvement Program [NSQIP]) to compare the quality of ACDF surgery performed in the outpatient ASC versus the inpatient hospital setting.
Patients undergoing ACDF (2005-2011) were identified from the NSQIP database based on the primary Current Procedural Terminology codes. Patients were divided into 2 cohorts (outpatient vs inpatient) based on the acute care setting documented in the NSQIP database. All 30-day surgical morbidity and mortality rates were compared between the 2 groups. Propensity score matching and multivariate logistic regression analysis were used to adjust for confounding factors and to identify the independent association of outpatient ACDF with perioperative outcomes and morbidity.
A total of 7288 ACDF cases were identified (inpatient = 6120, outpatient = 1168). Unadjusted rates of major morbidity (0.94% vs 4.5%, p < 0.001) and return to the operating room (OR) within 30 days (0.3% vs 2.0%, p < 0.001) were significantly lower in outpatient versus inpatient ACDF. After propensity matching 1442 cases (inpatient = 650, outpatient = 792) based on baseline 32 covariates, rates of major morbidity (1.4% vs 3.1%, p = 0.03), and return to the OR (0.34% vs 1.4%, p = 0.04) remained significantly lower after outpatient ACDF. Adjusted comparison using multivariate logistic regression demonstrated that ACDF performed in the outpatient setting had 58% lower odds of having a major morbidity and 80% lower odds of return to the OR within 30 days.
An analysis of a nationwide, prospective quality improvement registry representing more than 250 hospitals demonstrates that 1- to 2-level ACDF can be safely performed in the outpatient ambulatory surgery setting in patients who are appropriate candidates. In an effort to decrease cost of care, surgeons can safely consider performing ACDF in an ASC environment.