Outpatient versus inpatient lumbar decompression surgery: a matched noninferiority study investigating clinical and patient-reported outcomes

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  • 1 Department of Neurosurgery, University of Alabama at Birmingham, Alabama;
  • | 2 Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 3 Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota;
  • | 4 School of Medicine, University of North Carolina at Chapel Hill, North Carolina;
  • | 5 Department of Neurological Surgery, University of Miami, Florida;
  • | 6 Neuroscience Institute, Carolinas Healthcare System, and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina;
  • | 7 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 8 Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah;
  • | 9 Atlanta Brain and Spine Care, Atlanta, Georgia;
  • | 10 Atlantic Neurosurgical Specialists, Morristown, New Jersey;
  • | 11 Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado; and
  • | 12 Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
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OBJECTIVE

Spine surgery represents an ideal target for healthcare cost reduction efforts, with outpatient surgery resulting in significant cost savings. With an increased focus on value-based healthcare delivery, lumbar decompression surgery has been increasingly performed in the outpatient setting when appropriate. The aim of this study was to compare clinical and patient-reported outcomes following outpatient and inpatient lumbar decompression surgery.

METHODS

The Quality Outcomes Database (QOD) was queried for patients undergoing elective one- or two-level lumbar decompression (laminectomy or laminotomy with or without discectomy) for degenerative spine disease. Patients were grouped as outpatient if they had a length of stay (LOS) < 24 hours and as inpatient if they stayed in the hospital ≥ 24 hours. Patients with ≥ 72-hour stay were excluded from the comparative analysis to increase baseline comparability between the two groups. To create two highly homogeneous groups, optimal matching was performed at a 1:1 ratio between the two groups on 38 baseline variables, including demographics, comorbidities, symptoms, patient-reported scores, indications, and operative details. Outcomes of interest were readmissions and reoperations at 30 days and 3 months after surgery, overall satisfaction, and decrease in Oswestry Disability Index (ODI), back pain, and leg pain at 3 months after surgery. Satisfaction was defined as a score of 1 or 2 in the North American Spine Society patient satisfaction index. Noninferiority of outpatient compared with inpatient surgery was defined as risk difference of < 1.5% at a one-sided 97.5% confidence interval.

RESULTS

A total of 18,689 eligible one- and two-level decompression surgeries were identified. The matched study cohorts consisted of 5016 patients in each group. Nonroutine discharge was slightly less common in the outpatient group (0.6% vs 0.3%, p = 0.01). The 30-day readmission rates were 4.4% and 4.3% for the outpatient and inpatient groups, respectively, while the 30-day reoperation rates were 1.4% and 1.5%. The 3-month readmission rates were 6.3% for both groups, and the 3-month reoperation rates were 3.1% for the outpatient cases and 2.9% for the inpatient cases. Overall satisfaction at 3 months was 88.8% for the outpatient group and 88.4% for the inpatient group. Noninferiority of outpatient surgery was documented for readmissions, reoperations, and patient-reported satisfaction from surgery.

CONCLUSIONS

Outpatient lumbar decompression surgery demonstrated slightly lower nonroutine discharge rates in comparison with inpatient surgery. Noninferiority in clinical outcomes at 30 days and 3 months after surgery was documented for outpatient compared with inpatient decompression surgery. Additionally, outpatient decompression surgery performed noninferiorly to inpatient surgery in achieving patient satisfaction from surgery.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; ASC = ambulatory surgical center; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; LOS = length of stay; MCID = minimal clinically important difference; NASS = North American Spine Society; NRS = numeric rating scale; ODI = Oswestry Disability Index; PRO = patient-reported outcome; QOD = Quality Outcomes Database; SMD = standardized mean difference.

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