Predicting nonroutine discharge in patients undergoing surgery for vertebral column tumors

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  • Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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OBJECTIVE

More than 8000 patients are treated annually for vertebral column tumors, of whom roughly two-thirds will be discharged to an inpatient facility (nonroutine discharge). Nonroutine discharge is associated with increased care costs as well as delays in discharge and poorer patient outcomes. In this study, the authors sought to develop a prediction model of nonroutine discharge in the population of vertebral column tumor patients.

METHODS

Patients treated for primary or metastatic vertebral column tumors at a single comprehensive cancer center were identified for inclusion. Data were gathered regarding surgical procedure, patient demographics, insurance status, and medical comorbidities. Frailty was assessed using the modified 5-item Frailty Index (mFI-5) and medical complexity was assessed using the modified Charlson Comorbidity Index (mCCI). Multivariable logistic regression was used to identify independent predictors of nonroutine discharge, and multivariable linear regression was used to identify predictors of prolonged length of stay (LOS). The discharge model was internally validated using 1000 bootstrapped samples.

RESULTS

The authors identified 350 patients (mean age 57.0 ± 13.6 years, 53.1% male, and 67.1% treated for metastatic vs primary disease). Significant predictors of prolonged LOS included higher mCCI score (β = 0.74; p = 0.026), higher serum absolute neutrophil count (β = 0.35; p = 0.001), lower hematocrit (β = −0.34; p = 0.001), use of a staged operation (β = 4.99; p < 0.001), occurrence of postoperative pulmonary embolism (β = 3.93; p = 0.004), and surgical site infection (β = 9.93; p < 0.001). Significant predictors of nonroutine discharge included emergency admission (OR 3.09; p = 0.001), higher mFI-5 score (OR 1.90; p = 0.001), lower serum albumin level (OR 0.43 per g/dL; p < 0.001), and operations with multiple stages (OR 4.10; p < 0.001). The resulting statistical model was deployed as a web-based calculator (https://jhuspine4.shinyapps.io/Nonroutine_Discharge_Tumor/).

CONCLUSIONS

The authors found that nonroutine discharge of patients with surgically treated vertebral column tumors was predicted by emergency admission, increased frailty, lower serum albumin level, and staged surgical procedures. The resulting web-based calculator tool may be useful clinically to aid in discharge planning for spinal oncology patients by preoperatively identifying patients likely to require placement in an inpatient facility postoperatively.

ABBREVIATIONS ACIR = acute care inpatient rehabilitation; ACS-NSQIP = American College of Surgeons National Surgical Quality Improvement Program; ANC = absolute neutrophil count; ASA = American Society of Anesthesiologists; AUC = area under the ROC curve; DVT = deep vein thrombosis; INR = international normalized ratio; KPS = Karnofsky Performance Status; LOS = length of stay; mCCI = modified Charlson Comorbidity Index; MCHgb = mean corpuscular hemoglobin; MCV = mean corpuscular volume; mFI-5 = modified 5-item Frailty Index; OT = occupational therapy; PE = pulmonary embolism; PT = physical therapy; RDW = red blood cell distribution width; ROC = receiver operating characteristic; SAR = subacute rehabilitation; SIZE = Surgical Invasiveness; SNF = skilled nursing facility; SSI = surgical site infection; WBC = white blood cell.

Supplementary Materials

    • Supplementary Tables 1 and 2 (PDF 400 KB)

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Contributor Notes

Correspondence Daniel M. Sciubba: Johns Hopkins University School of Medicine, Baltimore, MD. dsciubb1@jhmi.edu.

INCLUDE WHEN CITING Published online November 20, 2020; DOI: 10.3171/2020.6.SPINE201024.

J.E. and Z.P. contributed equally to this work.

Disclosures Dr. Sciubba reports being a consultant for Baxter, DePuy-Synthes, Globus Medical, K2M, Medtronic, NuVasive, and Stryker and receiving grant support unrelated to this study from Baxter Medical, the North American Spine Society, and Stryker.

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