Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database

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  • 1 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 2 Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 3 Atlantic Neurosurgical Specialists, Morristown, New Jersey;
  • | 4 Department of Neurosurgery, University of Tennessee, Memphis, Tennessee;
  • | 5 Geisinger Health System, Danville, Pennsylvania;
  • | 6 Goodman Campbell Brain and Spine, Indianapolis, Indiana;
  • | 7 Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia;
  • | 8 Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, North Carolina;
  • | 9 Department of Neurological Surgery, Weill Cornell Medical College, New York City, New York;
  • | 10 Department of Neurologic Surgery, University of Miami, Florida;
  • | 11 Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan;
  • | 12 Marion Bloch Neuroscience Institute’s Spine Program; Saint Luke Health System, Kansas City, Missouri;
  • | 13 Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
  • | 14 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
  • | 15 Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
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OBJECTIVE

Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.

METHODS

The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.

RESULTS

Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38–5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00–4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17–4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0–11 vs moderate 12–14, OR 2, 95% CI 1.07–3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12–48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2–3 levels, OR 0.3, 95% CI 0.1–0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25–0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).

CONCLUSIONS

The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

ABBREVIATIONS

ACDF = anterior cervical discectomy and fusion; ASA = American Society of Anesthesiologists; CSM = cervical spondylotic myelopathy; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PRO = patient-reported outcome.

Supplementary Materials

    • Supplemental Tables 1 and 2 (PDF 427 KB)
Illustrations from Walker et al. (pp 80–90). © Barrow Neurological Institute, Phoenix, Arizona.

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Contributor Notes

Correspondence Mohamad Bydon: Mayo Clinic, Rochester, MN. bydon.mohamad@mayo.edu.

INCLUDE WHEN CITING Published online May 7, 2021; DOI: 10.3171/2020.11.SPINE201442.

Disclosures Dr. Chan receives non–study-related research support from Orthofix Medical Inc. Dr. Mummaneni is a consultant for DePuy Synthes, Globus, and Stryker; owns stock in Spinicity/ISD; receives royalties from DePuy Synthes, Thieme Publishers, and Springer Publishers; and receives grants from AO Spine and ISSG. Dr. Knightly has a nonfinancial relationship with NPA. Dr. Asher is a director of Quality Outcomes Database and co-chairman of the American Spine Registry and receives study-related compensation from Stryker. Dr. Foley is a consultant for Medtronic; owns stock in Discgenics, DuraStat, Medtronic, NuVasive, Practical Navigation/Fusion Robotics, RevBio, SpineWave, Tissue Differentiation Intelligence, Triad Life Sciences, and True Digital Surgery; holds patents with Medtronic and NuVasive; and receives royalties from Medtronic. Dr. Slotkin is a consultant for Stryker and Medtronic. Dr. C. I. Shaffrey is a consultant for Medtronic, NuVasive, and SI Bone; owns stock in NuVasive; holds patents with Medtronic, Zimmer Biomet, and NuVasive; and receives royalties from Medtronic and NuVasive. Dr. Fu is a consultant for SI Bone, Globus, DePuy Synthes, and Atlas. Dr. Wang is a consultant for Globus Medical, Spineology, Medtronic, Stryker, and DePuy Synthes Spine; owns stock in ISD and Medical Device Partners; and holds a patent with DePuy Synthes Spine. Dr. Park is a consultant for Globus and NuVasive; receives royalties from Globus; and receives non–study-related support from DePuy and ISSG. Dr. Tumialan is a consultant for Medtronic. Dr. Bisson is a consultant for Stryker and MiRus and owns stock in MiRus and nView.

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