Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

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  • 1 Spine Research Unit, Vall d’Hebron Research Institute, Barcelona;
  • | 2 Spine Surgery Unit, Vall d’Hebron University Hospital, Barcelona, Spain;
  • | 3 Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland;
  • | 4 Norton Leatherman Spine Center, Louisville, Kentucky;
  • | 5 Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France;
  • | 6 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia;
  • | 7 Spine Center Division, Schulthess Klinik, Zurich, Switzerland;
  • | 8 Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado;
  • | 9 Spine Surgery Unit, La Paz University Hospital, Madrid, Spain;
  • | 10 Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;
  • | 11 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;
  • | 12 Department of Orthopedic Surgery, University of California, Davis, Sacramento, California;
  • | 13 Duke University Medical Center, Durham, North Carolina;
  • | 14 Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey; and
  • | 15 Department of Neurosurgery, University of California, San Francisco, California
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OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; ASD = adult spinal deformity; EBL = estimated blood loss; GAM = generalized additive model; HRQOL = health-related quality of life; ODI = Oswestry Disability Index; PI–LL = pelvic incidence–lumbar lordosis mismatch; SRS-22r = Scoliosis Research Society-22r; SVA = sagittal vertical axis; 3CO = 3-column osteotomy.

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