Impact of surgeon and hospital factors on surgical decision-making for grade 1 degenerative lumbar spondylolisthesis: a Quality Outcomes Database analysis

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  • 1 Department of Neurological Surgery, University of Miami, Florida;
  • 2 Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota;
  • 3 Department of Neurological Surgery, University of California, San Francisco, California;
  • 4 Department of Neurological Surgery, University of Utah, Salt Lake City, Utah;
  • 5 Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
  • 6 Atlantic Neurosurgical Specialists, Morristown, New Jersey;
  • 7 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;
  • 8 Department of Neurological Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts;
  • 9 Goodman Campbell Brain and Spine, Indianapolis, Indiana;
  • 10 University of Tennessee Health Science Center, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee;
  • 11 Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan;
  • 12 Department of Neurological Surgery, Weill Cornell Medical Center, New York City, New York;
  • 13 Geisinger Health, Danville, Pennsylvania; and
  • 14 Norton Leatherman Spine Center, Louisville, Kentucky
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OBJECTIVE

Surgical treatment for degenerative spondylolisthesis has been proven to be clinically challenging and cost-effective. However, there is a range of thresholds that surgeons utilize for incorporating fusion in addition to decompressive laminectomy in these cases. This study investigates these surgeon- and site-specific factors by using the Quality Outcomes Database (QOD).

METHODS

The QOD was queried for all cases that had undergone surgery for grade 1 spondylolisthesis from database inception to February 2019. In addition to patient-specific covariates, surgeon-specific covariates included age, sex, race, years in practice (0–10, 11–20, 21–30, > 30 years), and fellowship training. Site-specific variables included hospital location (rural, suburban, urban), teaching versus nonteaching status, and hospital type (government, nonfederal; private, nonprofit; private, investor owned). Multivariable regression and predictor importance analyses were performed to identify predictors of the treatment performed (decompression alone vs decompression and fusion). The model was clustered by site to account for site-specific heterogeneity in treatment selection.

RESULTS

A total of 12,322 cases were included with 1988 (16.1%) that had undergone decompression alone. On multivariable regression analysis clustered by site, adjusting for patient-level clinical covariates, no surgeon-specific factors were found to be significantly associated with the odds of selecting decompression alone as the surgery performed. However, sites located in suburban areas (OR 2.32, 95% CI 1.09–4.84, p = 0.03) were more likely to perform decompression alone (reference = urban). Sites located in rural areas had higher odds of performing decompression alone than hospitals located in urban areas, although the results were not statistically significant (OR 1.33, 95% CI 0.59–2.61, p = 0.49). Nonteaching status was independently associated with lower odds of performing decompression alone (OR 0.40, 95% CI 0.19–0.97, p = 0.04). Predictor importance analysis revealed that the most important determinants of treatment selection were dominant symptom (Wald χ2 = 34.7, accounting for 13.6% of total χ2) and concurrent diagnosis of disc herniation (Wald χ2 = 31.7, accounting for 12.4% of total χ2). Hospital teaching status was also found to be relatively important (Wald χ2 = 4.2, accounting for 1.6% of total χ2) but less important than other patient-level predictors.

CONCLUSIONS

Nonteaching centers were more likely to perform decompressive laminectomy with supplemental fusion for spondylolisthesis. Suburban hospitals were more likely to perform decompression only. Surgeon characteristics were not found to influence treatment selection after adjustment for clinical covariates. Further large database registry experience from surgeons at high-volume academic centers at which surgically and medically complex patients are treated may provide additional insight into factors associated with treatment preference for degenerative spondylolisthesis.

ABBREVIATIONS DLS = degenerative lumbar spondylolisthesis; NPA = NeuroPoint Alliance; ODI = Oswestry Disability Index; QOD = Quality Outcomes Database.

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Contributor Notes

Correspondence Michael Wang: University of Miami, FL. mwang2@med.miami.edu.

INCLUDE WHEN CITING Published online February 19, 2021; DOI: 10.3171/2020.8.SPINE201015.

Disclosures Dr. Huang is a consultant for Integrity Implants. Dr. Buccholz is a consultant for Medtronic, NuVasive, and Siemens Healthcare. Dr. Bisson is a consultant for Stryker and MiRus and has stock ownership with MiRus and nView. Dr. Potts is a consultant for and receives royalties from Medtronic. Dr. Knightly serves on the board of directors of NPA. Dr. Coric is a consultant for and receives royalties from Integrity Implants, Medtronic, Globus Medical, and Spine Wave; receives royalties from Stryker, RTI Surgical, and Premia Spine; and has stock ownership with Spine Wave and Premia Spine. Dr. Asher is the treasurer for NeuroPoint Alliance and chairman of the American Spine Registry. Dr. Foley is a consultant for Medtronic; has direct stock ownership in Digital Surgery Systems, Discgenics, DuraStat, LaunchPad Medical (RevBio), Medtronic, NuVasive, Practical Navigation/Fusion Robotics, SpineWave, TDi, and Triad Life Sciences; holds patents with Medtronic and NuVasive; receives royalties from Medtronic; and serves on the boards of directors of Digital Surgery Systems, Discgenics, DuraStat, LaunchPad Medical, Practical Navigation/Fusion Robotics, TDi, and Triad Life Sciences. Dr. Mummaneni is a consultant for DePuy Synthes, Globus, and Stryker; has direct stock ownership in Spinicity/ISD; receives support from ISSG and AO Spine for non–study-related clinical or research effort that he oversees; and receives royalties from Thieme Publishing, Springer Publishing, and DePuy Synthes. Dr. Park is a consultant for Globus and NuVasive; receives royalties from Globus; and receives support from the ISSG and DePuy Synthes for non–study-related clinical or research effort that he oversees. Dr. Fu is a consultant for SI Bone, Globus, DePuy Synthes, and Atlas Spine. Dr. Glassman is an employee of Norton Healthcare; is a patent holder with Medtronic, from whom he also receives royalties; receives clinical or research support from NuVasive, Integra, Intellirod Spine Inc., Pfizer, ISSG, Norton Healthcare, Texas Scottish Rite Hospital, Cerapedics Inc., and Medtronic; and is the past president of the Scoliosis Research Society and the chair of the American Spine Registry. Dr. Wang serves as a consultant to DePuy Synthes Spine, Stryker, Spineology, Medtronic, Globus, ISD, Aesculap Spine, JoiMax, and K2M for the study described; receives royalties from Children’s Hospital of Los Angeles, DePuy Synthes Spine, Springer Publishing, and Quality Medical Publishing; holds stock in Innovative Surgical Devices, Medical Device Partners, and Spinicity; and holds a patent with DePuy Synthes.

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