共查询到20条相似文献，搜索用时 31 毫秒
1.
Jeffrey L. Gum Richard Hostin Chessie Robinson Michael P. Kelly Leah Yacat Carreon David W. Polly R. Shay Bess Douglas C. Burton Christopher I. Shaffrey Justin S. Smith Virginie LaFage Frank J. Schwab Christopher P. Ames Steven D. Glassman 《The spine journal》2017,17(1):96-101
Background Context
Over the past decade, the number of adult spinal deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are associated with significant resource utilization and high cost, making them a primary target for increased scrutiny. Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness.Purpose
To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries.Study Design
Longitudinal cohort.Patient Sample
Consecutive patients enrolled in an ASD database from a single institution.Outcome Measures
Short Form (SF)-6D.Methods
Consecutive patients enrolled in an ASD database from a single institution from 2008 to 2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life years (QALY). Costs and QALYs were discounted at 3.5% annually.Results
Of 580 surgical ASD patients eligible for 2-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for the present study. Mean SF-6D gained is 0.10 during year 1 after surgery and 0.02 at year 2, resulting in a cumulative SF-6D gain of 0.12 over 2 years. Mean Medicare allowable rate over the 2 years is $82,050 (range $42,383 to $220,749) and mean direct cost is $99,114 (range $28,447 to $217,717). Mean cost per QALY over 2 years is $683,750 using Medicare allowable rates and $825,950 using direct costs. This difference of $17,181 between the 2 cost calculation represents a 17% difference, which was statistically significant (p<.001).Conclusions
There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost per QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost of ASD surgery, but it also creates inaccurate and unrealistic expectations for researchers and policymakers. 相似文献2.
Samuel Jang Meagan Mandabach Zviadi Aburjania Courtney J. Balentine Herbert Chen 《Surgery》2018,163(3):638-642
Background
Identifying hospital and provider variation in surgical cost is a potent method for controlling rising healthcare expenditure and delivering cost-effective care. The purpose of this study was to examine the variation of hospital cost by providers for parathyroidectomy in a single academic institution.Methods
We retrospectively evaluated 894 consecutive parathyroidectomies under 8 surgeons in our institution between September 2011 and July 2016. Total duration of stay and cost were evaluated using nonparametric tests. Categorical variables were evaluated with χ2.Results
The median total hospital cost for parathyroidectomy was $4,863.28 (interquartile range: 4,196–5,764), but the median costs per provider varied widely from $4,522.30 to $12,072.87. The median duration of stay was 0 days (IQR: 0–1) and demonstrated a wide variation among providers. Longer duration of practice was associated with lower cost. Despite the variation, only 2% was readmitted after discharge with no patient mortality.Conclusion
We found substantial variation in hospital cost among providers for parathyroidectomy despite practicing in the same academic institution, with some surgeons spending 4 time more for the same operation. Implementing institutional standards of practice could be a method to decrease variation and costs of surgical care. 相似文献3.
Peter G. Passias Gregory W. Poorman Cole A. Bortz Rabia Qureshi Bassel G. Diebo Justin C. Paul Samantha R. Horn Frank A. Segreto Alexandra Pyne Cyrus M. Jalai Virginie Lafage Shay Bess Frank J. Schwab Hamid Hassanzadeh 《The spine journal》2018,18(10):1845-1852
Background Context
With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators of adverse discharge disposition in ASD surgeries is paramount.Purpose
Using the nationwide and surgeon-created databases, the present study aimed to identify predictors of adverse discharge disposition after ASD surgeries and view the corresponding differences in charges.Study Design/Setting
This is a retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and of cost data from Medicare PearlDiver Database.Patient Sample
Patients undergoing thoracolumbar surgery for correction of ASD were included in the study.Outcome Measures
Primary analysis was performed to compare patients discharged to home with patients who either expired or were discharged to locations other than home. Secondary analysis was performed to determine the cost differences across discharge groups.Methods
Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x) and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30- and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.Results
A total of 1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. On multivariate regression analysis, age over 60 years (odds ratio [OR]: 0.28, confidence interval [CI]: 0.22–0.34) and female sex (p=.003) were independent predictors of adverse discharge status. Partially dependent preoperational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR: 0.57, CI: 0.35–0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR: 0.51, CI: 0.40–0.64), interbody device placement (OR: 0.80, CI: 0.64–0.98), and fixation to the iliac (OR: 0.54, CI: 0.41–0.70) increased the likelihood of adverse discharge. Complications most associated with adverse discharge were urinary tract infections (OR: 0.34, CI: 0.21–0.57) and blood transfusions (OR: 0.42, CI: 0.34–0.52). Relative to home discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=.177). The 90-day costs of care were $23,815 in rehab discharges (p<.001), but again not different from skilled nursing facility discharges (+$6,091, p=.212).Conclusions
Discharge destination to rehabilitation has a significant impact on the cost of thoracolumbar ASD surgeries. Patient selection can predict patients at higher risk of discharges to rehab or skilled nursing facility. 相似文献4.
Stephanie J. Tapp Brook I. Martin Tor D. Tosteson Jon D. Lurie Milton C. Weinstein Richard A. Deyo Sohail K. Mirza Anna N.A. Tosteson 《The spine journal》2018,18(4):584-592
Background Context
Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value.Purpose
This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices (“spacers”) relative to decompression surgery as a case study.Study Design
Model-based cost-effectiveness analysis.Patient Sample
The Medicare Provider Analysis and Review database for the years 2005–2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery.Outcome Measures
Costs, quality-adjusted life years (QALYs), and cost per QALY gained were the outcome measures.Methods
A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies: conservative care, spacer surgery, and decompression surgery. Incremental cost-effectiveness ratios (ICER) reported as cost per QALY gained included direct medical costsfor surgery. Medicare claims data were used to estimate complication rates, reoperation, and related costs within 3 years. Utilities and long-term reoperation rates for decompression were derived frompublished studies. Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4–10 (cumulative failure: 47%). In a “worst-case” analysis, the 10-year cumulative reoperation rate was increased steeply (to 90%). Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery.Results
The spacer strategy had an ICER of $89,500/QALY gained under base-case assumptions, and remained under $100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54%. Under worst-case assumptions, the spacer ICER was $482,000/QALY and fell below $100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of spacer surgery was $1,600 less than the cost of decompression surgery.Conclusions
Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis. Their value is expected to improve if procedure costs are lower in outpatient settings where these procedures are increasingly being performed. Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospective health utility assessment. 相似文献5.
Tej D. Azad Daniel Vail Chloe O&#x;Connell Summer S. Han Anand Veeravagu John K. Ratliff 《The spine journal》2018,18(12):2232-2238
Background Context
The role of arthrodesis in the surgical management of lumbar spondylolisthesis remains controversial. We hypothesized that practice patterns and outcomes for this patient population may vary widely.Purpose
This study aimed to characterize geographic variation in surgical practices and outcomes for patients with lumbar spondylolisthesis.Study Design/Setting
A retrospective analysis on a national longitudinal database between 2007 and 2014 was carried out.Methods
We calculated arthrodesis rates, inpatient and long-term costs, and key quality indicators (eg, reoperation rates). Using linear and logistic regression models, we then calculated expected quality indicator values, adjusting for patient-level demographic factors, and compared these values with the observed values, to assess quality variation apart from differences in patient populations.Results
We identified a cohort of 67,077 patients (60.7% female, mean age of 59.8 years (standard deviation, 12.0) with lumbar spondylolisthesis who received either laminectomy or laminectomy with arthrodesis. The majority of patients received arthrodesis (91.8%). Actual rates of arthrodesis varied from 97.5% in South Dakota to 81.5% in Oregon. Geography remained a significant predictor of arthrodesis even after adjusting for demographic factors (p<.001). Marked geographic variation was also observed in initial costs ($32,485 in Alabama to $78,433 in Colorado), 2-year postoperative costs ($15,612 in Arkansas to $34,096 in New Jersey), length of hospital stay (2.6 days in Arkansas to 4.5 in Washington, D.C.), 30-day complication rates (9.5% in South Dakota to 22.4% in Maryland), 30-day readmission rates (2.5% in South Dakota to 13.6% in Connecticut), and reoperation rates (1.8% in Maine to 12.7% in Alabama).Conclusions
There is marked geographic variation in the rates of arthrodesis in treatment of spondylolisthesis within the United States. This variation remains pronounced after accounting for patient-level demographic differences. Costs of surgery and quality outcomes also vary widely. Further study is necessary to understand the drivers of this variation. 相似文献6.
Paul T. Ogink Teun Teunis Olivier van Wulfften Palthe Karen Sepucha Christopher M. Bono Joseph H. Schwab Thomas D. Cha 《The spine journal》2018,18(9):1584-1591
Background Context
Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation.Purpose
(1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability.Study Design
Retrospective cohort study.Patient Sample
A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution.Outcome Measures
Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis.Methods
We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients.Results
Male gender (β 0.10, 95% confidence interval [CI] 0.05–0.15, p<.001), seeing an additional provider (β 0.77, 95% CI 0.69–0.86, p<.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74–0.84, p<.001) were associated with higher costs. Providers in the high cost tier had more office visits (p<.001), more imaging procedures (p<.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975).Conclusions
Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost. 相似文献7.
Background
We performed 163 laparoscopic cholecystectomies at our institution during the third quarter of 2016. Direct supply cost per case varied from $524 to $1,022 among 14 surgeons. The purpose of this study was to determine the reasons for cost variation between high- and low-cost surgeons and identify opportunities for cost reduction.Methods
Average cost of supplies per case was examined for laparoscopic cholecystectomy during a 6-month period. Two groups were created, with the 4 highest-cost surgeons comprising group A and the 2 lowest-cost surgeons comprising group B. The cost for each item was identified, and utilization was compared between groups.Results
The average supply cost per case in group A was significantly greater than group B ($930 vs. $518). The difference persisted in subgroup analyses of both inpatients and patients with high American Society of Anesthesiologists scores. Compared with group A, surgeons in group B used reusable instruments more often and tended to choose lower-cost disposables.Conclusions
Significant variation in direct cost exists between surgeons performing laparoscopic cholecystectomy. Much of the cost difference can be accounted for by a relatively small number of high-cost instruments. We identified areas for cost savings by substituting lesser cost alternatives without compromising the quality of patient care. 相似文献8.
Ehsan Jazini Jeffrey L. Gum Steven D. Glassman Charles H. Crawford Mladen Djurasovic Roge Kirk Owens John R. Dimar Katlyn E. McGraw Leah Y. Carreon 《The spine journal》2018,18(11):1969-1973
Background Context
Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective.Purpose
Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach.Study Design/Setting
This study is a propensity-matched cost-effectiveness comparison.Patient Sample
Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study.Outcome Measures
The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D).Methods
From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery).Results
Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328?minutes, p=.039) but no difference in estimated blood loss (526 vs. 548?cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327.Conclusions
Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated. 相似文献9.
Christopher R. Shubert Michael L. Kendrick Elizabeth B. Habermann Amy E. Glasgow Bijan J. Borah James P. Moriarty Sean P. Cleary Rory L. Smoot Michael B. Farnell David M. Nagorney Mark J. Truty Florencia G. Que 《Surgery》2018,163(3):495-502
Background
Morbidity and costs after pancreatoduodenectomy remain increased, driven by postoperative pancreatic fistula (POPF). A risk-based pathway for pancreatoduodenectomy (RBP-PD) was implemented and the clinical and cost outcomes compared with that of our historic practice.Methods
Prospective clinical and cost outcomes for our RBP-PD cohort treated from September 2014 to September 2015 were compared with a previously published cohort of pancreatoduodenectomies from January 2007 to February 2014.Results
A total of 128 RBP-PD cases were compared with 808 historic controls. Apart from less blood loss, there were no significant clinical differences between the 2 groups. Overall POPF rate did not change. Average duration of stay decreased to 10 days from 12 (P?<?.001) despite similar readmission rates. Postsurgical interventional radiology procedures decreased to 18.0% from 26.4% (P?=?.048). Utilization of and duration of stay in monitored care decreased to 23.4% from 35.6% (P?<?.01) and to 1 day from 3 (P?<?.01). On multivariable analysis RBP-PD was independently associated with decreased odds of higher postoperative pancreatic fistula grade, monitored care, and prolonged duration of stay. Inpatient cost of care decreased $6,387 per patient (–11.1%, P?=?.016), and total 30-day costs decreased $8,565 per patient (–13.7%, P?=?.01), representing a total 30-day cost savings of $1.1 million.Conclusion
RBP-PD significantly improved patient outcomes, decreased costs of care, and likely has applicability for surgical care beyond pancreatoduodenectomy. 相似文献10.
Samuel C. Overley Steven J. McAnany Robert L. Brochin Jun S. Kim Robert K. Merrill Sheeraz A. Qureshi 《The spine journal》2018,18(1):63-71
Background Context
Anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) are both acceptable surgical options for the treatment of cervical myelopathy and radiculopathy. To date, there are limited economic analyses assessing the relative cost-effectiveness of two-level ACDF versus CDR.Purpose
The purpose of this study was to determine the 5-year cost-effectiveness of two-level ACDF versus CDR.Study Design
The study design is a secondary analysis of prospectively collected data.Patient Sample
Patients in the Prestige cervical disc investigational device exemption (IDE) study who underwent either a two-level CDR or a two-level ACDF were included in the study.Outcome Measures
The outcome measures were cost and quality-adjusted life years (QALYs).Materials and Methods
A Markov state-transition model was used to evaluate data from the two-level Prestige cervical disc IDE study. Data from the 36-item Short Form Health Survey were converted into utilities using the short form (SF)-6D algorithm. Costs were calculated from the payer perspective. QALYs were used to represent effectiveness. A probabilistic sensitivity analysis (PSA) was performed using a Monte Carlo simulation.Results
The base-case analysis, assuming a 40-year-old person who failed appropriate conservative care, generated a 5-year cost of $130,417 for CDR and $116,717 for ACDF. Cervical disc replacement and ACDF generated 3.45 and 3.23 QALYs, respectively. The incremental cost-effectiveness ratio (ICER) was calculated to be $62,337/QALY for CDR. The Monte Carlo simulation validated the base-case scenario. Cervical disc replacement had an average cost of $130,445 (confidence interval [CI]: $108,395–$152,761) with an average effectiveness of 3.46 (CI: 3.05–3.83). Anterior cervical discectomy and fusion had an average cost of $116,595 (CI: $95,439–$137,937) and an average effectiveness of 3.23 (CI: 2.84–3.59). The ICER was calculated at $62,133/QALY with respect to CDR. Using a $100,000/QALY willingness to pay (WTP), CDR is the more cost-effective strategy and would be selected 61.5% of the time by the simulation.Conclusions
Two-level CDR and ACDF are both cost-effective strategies at 5 years. Neither strategy was found to be more cost-effective with an ICER greater than the $50,000/QALY WTP threshold. The assumptions used in the analysis were strongly validated with the results of the PSA. 相似文献11.
Background Context
The influence of rheumatoid arthritis (RA) on the lumbar spine has received relatively little attention compared with cervical spine, and few studies have been conducted for adjacent segment disease (ASD) after lumbar fusion in patients with RA.Purpose
The present study aims to determine the incidence of ASD requiring surgery (ASDrS) after short lumbar fusion and to evaluate risk factors for ASDrS, including RA.Study Design
This is a retrospective cohort study.Patient Sample
The present study included 479 patients who underwent lumbar spinal fusion of three or fewer levels, with the mean follow-up period of 51.2 (12–132) months.Outcome Measures
The development of ASD and consequent revision surgery were reviewed using follow-up data.Methods
The ASDrS-free survival rate of adjacent segments was calculated through Kaplan-Meier method. The log-rank test and Cox regression analysis were used to evaluate risk factors comprising RA, age, gender, obesity, osteoporosis, diabetes, smoking, surgical method, and the number of fusion segments.Results
After short lumbar fusion, revision surgery for ASD was performed in 37 patients (7.7%). Kaplan-Meier analysis predicted that the ASDrS-free survival rate of adjacent segments was 97.8% at 3 years, 92.7% at 5 years, and 86.8% at 7 years. In risk factor analysis, patients with RA showed a 4.5 times higher risk of ASDrS than patients without RA (p<.001), and patients with three-segment fusion showed a 2.7 times higher risk than patients with one- or two-segment fusion (p=.005).Conclusions
Adjacent segment disease requiring surgery was predicted in 13.2% of patients at 7 years after short lumbar fusion. Rheumatoid arthritis and the number of fusion segments were confirmed as risk factors. 相似文献12.
Background
We evaluated whether diagnostic thyroidectomy for indeterminate thyroid nodules would be more cost-effective than genetic testing after including the costs of long-term surveillance.Methods
We used a Markov decision model to estimate the cost-effectiveness of thyroid lobectomy versus genetic testing (Afirma®) for evaluation of indeterminate (Bethesda 3–4) thyroid nodules. The base case was a 40-year-old woman with a 1-cm indeterminate nodule. Probabilities and estimates of utilities were obtained from the literature. Cost estimates were based on Medicare reimbursements with a 3% discount rate for costs and quality-adjusted life-years.Results
During a 5-year period after the diagnosis of indeterminate thyroid nodules, lobectomy was less costly and more effective than Afirma® (lobectomy: $6,100; 4.50 quality-adjusted life- years vs Afirma®: $9,400; 4.47 quality-adjusted life-years). Only in 253 of 10,000 simulations (2.5%) did Afirma® show a net benefit at a cost-effectiveness threshold of $100,000 per quality- adjusted life-years. There was only a 0.3% probability of Afirma® being cost saving and a 14.9% probability of improving quality-adjusted life-years.Conclusions
Our base case estimate suggests that diagnostic lobectomy dominates genetic testing as a strategy for ruling out malignancy of indeterminate thyroid nodules. These results, however, were highly sensitive to estimates of utilities after lobectomy and living under surveillance after Afirma®. 相似文献13.
Michael G. Fehlings So Kato Lawrence G. Lenke Hiroaki Nakashima Narihito Nagoshi Christopher I. Shaffrey Kenneth M.C. Cheung Leah Carreon Mark B. Dekutoski Frank J. Schwab Oheneba Boachie-Adjei Khaled M. Kebaish Christopher P. Ames Yong Qiu Yukihiro Matsuyama Benny T. Dahl Hossein Mehdian Ferran Pellisé-Urquiza Sigurd H. Berven 《The spine journal》2018,18(10):1733-1740
Background Context
Significant variability in neurologic outcomes after surgical correction for adult spinal deformity (ASD) has been reported. Risk factors for decline in neurologic motor outcomes are poorly understood.Purpose
The objective of the present investigation was to identify the risk factors for postoperative neurologic motor decline in patients undergoing complex ASD surgery.Study Design/Setting
This is a prospective international multicenter cohort study.Patient Sample
From September 2011 to October 2012, 272 patients undergoing complex ASD surgery were prospectively enrolled in a multicenter, international cohort study in 15 sites.Outcome Measures
Neurologic decline was defined as any postoperative deterioration in American Spinal Injury Association lower extremity motor score (LEMS) compared with preoperative status.Methods
To identify risk factors, 10 candidate variables were selected for univariable analysis from the dataset based on clinical relevance, and a multivariable logistic regression analysis was used with backward stepwise selection.Results
Complete datasets on 265 patients were available for analysis and 61 (23%) patients showed a decline in LEMS at discharge. Univariable analysis showed that the key factors associated with postoperative neurologic deterioration included older age, lumbar-level osteotomy, three-column osteotomy, and larger blood loss. Multivariable analysis revealed that older age (odds ratio [OR]=1.5 per 10 years, 95% confidence interval [CI] 1.1–2.1, p=.005), larger coronal deformity angular ratio [DAR] (OR=1.1 per 1 unit, 95% CI 1.0–1.2, p=.037), and lumbar osteotomy (OR=3.3, 95% CI 1.2–9.2, p=.022) were the three major predictors of neurologic decline.Conclusions
Twenty-three percent of patients undergoing complex ASD surgery experienced a postoperative neurologic decline. Age, coronal DAR, and lumbar osteotomy were identified as the key contributing factors. 相似文献14.
Susana Núñez-Pereira Alba Vila-Casademunt Montse Domingo-Sàbat Juan Bagó Emre R. Acaroglu Ahmet Alanay Ibrahim Obeid Francisco Javier Sánchez Pérez-Grueso Frank Kleinstück Ferran Pellisé 《The spine journal》2018,18(6):926-934
Background Context
Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes.Purpose
The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery.Design
This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database.Patient Sample
The present study included 280 patients from a multicenter international prospective database.Outcome Measure
Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work.Methods
Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models.Results
Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups.At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group.Conclusions
Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up. 相似文献15.
Todd J. Blumberg Erik Woelber Carlo Bellabarba Richard Bransford Nicholas Spina 《The spine journal》2018,18(2):300-306
Background Context
Although many risk factors are known to contribute to the development of a postoperative surgical site infection (SSI) following spinal surgery, little is known regarding the costs associated with the management of this complication, or the predictors for which patients will require increased resources for the management of SSI.Purpose
The aim of this study was to identify specific risk factors for increased treatment costs and length of stay in the management of a postoperative SSI.Study Design/Setting
This is a retrospective cohort study of all patients undergoing spine surgery at a single institution for 3 consecutive years.Patient Sample
The study included 90 patients who were required to return to the operating room following spine surgery for postoperative SSI.Outcome Measures
The primary outcome measure was length of stay and hospital costs for patients with postoperative SSI following spine surgery at a single institution.Methods
A retrospective review of all patients undergoing spine surgery at a single institution for 3 consecutive years was performed to identify patients requiring secondary surgical intervention for SSI. Demographic and financial data from both the index admission and all subsequent readmissions within 2 years of the index procedure were reviewed. Independent variables abstracted from patient records were analyzed to determine the nature and the extent of their associations with total direct hospital costs and length of stay.Results
A total of 90 patients were identified that resulted in 110 readmissions, and these patients cumulatively underwent 138 irrigation and debridement (I&D) procedures for the management of postoperative spine SSI. The average length of stay for the index operation and secondary readmissions were 6.9 and 9.6 days, respectively. The mean direct cost of the treatment for SSI was $16,242. The length of stay, the number of levels fused, methicillin-resistant Staphylococcus aureus (MRSA), decreased serum albumin on readmission, and the number of I&D procedures required were significantly associated with increased treatment costs.Conclusions
Preoperative nutritional status assessment and MRSA colonization screening with targeted prophylaxis represent potentially modifiable risk factors in the treatment of SSI. Further study is needed to investigate the relationship between poor nutrition status and increased length of stay and total costs in the treatment of SSI following spine surgery. 相似文献16.
Mitsuru Yagi Hideaki Ohne Shinjiro Kaneko Masafumi Machida Yoshiyuki Yato Takashi Asazuma 《The spine journal》2018,18(1):36-43
Background Context
The effect of corrective spine surgery on standing stability in adult spinal deformity (ASD) has not been fully documented.Purpose
To compare pre- and postoperative standing balance and posture in patients with ASD.Study Design/Setting
This study is a prospective case series.Patient Sample
Standing balance before and after corrective spine surgery was compared in 35 consecutive female patients with ASD (65.6±6.9 years, body mass index 22.3±2.7?kg/m2, Cobb angle 50.2±19.2°, C7 plumb line 9.3±5.6?cm, and pelvic incidence-lumbar lordosis mismatch 40.8±23.3°).Outcome Measures
The Scoliosis Research Society Patient Questionnaire, the Oswestry Disability Index, and force-plate analysis were used to evaluate the patient outcomes.Materials and Methods
We reviewed patient charts and X-rays and compared standing balance before and after corrective spine surgery. All subjects were assessed by force-plate analysis using optical markers while standing naturally on a custom-built force platform. The spinal tilt, pelvic obliquity, pelvic tilt, and joint angle were calculated. The lower leg lean volume was obtained by whole-body dual X-ray absorptiometry to assess muscle strength.Results
ASD patients showed significant differences between the left and right sides in ground reaction force (dGRFs), hip (dHip), and knee angle (dKnee) while standing (dGRF 15.1±8.7%, dHip 7.1±6.6°, dKnee 5.9±5.5°). The recorded center-of-gravity (CoG) area was not improved after surgery, whereas the dGRF, dHip, and dKnee all decreased. The spinal tilt, pelvic obliquity, and pelvic tilt were all significantly improved after surgery. We found significant correlations between the radiographic trunk shift and the postoperative coronal CoG distance and recorded CoG area, and between the sagittal CoG distance and the age and the lean volume of the lower extremities (trunk shift R=0.33, 0.45; age R=0.32; lean volume R=0.31).Conclusions
Corrective spinal surgery improved the spinal alignment and joint angles in patients with ASD but did not improve the standing stability. A correlation found between the sagittal CoG distance and the lean volume of the lower extremities indicated the importance of the leg muscles for stability when standing, whereas a correlation found between the coronal CoG distance and trunk shift reflected the attenuated postural response in the ASD patients. 相似文献17.
Shoji Seki Norikazu Hirano Isao Matsushita Yoshiharu Kawaguchi Masato Nakano Taketoshi Yasuda Hiraku Motomura Kayo Suzuki Yasuhito Yahara Kenta Watanabe Hiroto Makino Tomoatsu Kimura 《The spine journal》2018,18(1):99-106
Background Context
Although the cervical spine is only occasionally involved in rheumatoid arthritis (RA), involvement of the lumbar spine is even less common. A few reports on lumbar spinal stenosis in patients with RA have appeared. Although disc space narrowing occurs in aging, postoperative adjacent segment disease (ASD) in patients with RA has not been subject to much analysis.Purpose
The objective of this study was to investigate differences in ASD and clinical outcomes between lumbar spinal decompression with and without fusion in patients with RA.Study Design/Setting
This is a retrospective comparative study.Patient Sample
A total of 52 patients with RA who underwent surgery for lumbar spinal disorders were included. Twenty-seven patients underwent decompression surgery with fusion and 25 underwent decompression surgery alone.Outcome Measures
Intervertebral disc space narrowing and spondylolisthesis of the segment immediately cranial to the surgical site were measured using a three-dimensional volume rendering software. Pre- and postoperative evaluation of RA activity and Japanese Orthopaedic Association (JOA) scores were conducted.Materials and Methods
All patients had preoperative and annual postoperative lumbar radiographs and were followed up for a mean of 5.1 years (range 3.5–10.9 years). Pre- and postoperative (2 years after surgery) JOA scores were recorded and any postoperative complications were investigated. Degrees of intervertebral disc narrowing and spondylolisthesis at the adjacent levels were evaluated on radiographs and were compared between the two groups. Analysis was performed to look for any correlation between ASD and RA disease activities.Results
Postoperative JOA scores were significantly improved in both groups. The rate of revision surgery was significantly higher in the fusion group than that in the non-fusion group. The rate of ASD was significantly greater in the fusion group than that in the non-fusion group at the final follow-up examination. Both matrix metalloproteinase 3 (MMP-3) and the 28-joint disease activity score incorporating C-reactive protein levels (DAS28-CRP) were significantly associated with the incidence and severity of ASD.Conclusions
Adjacent segment disease and the need for revision surgery were significantly higher in the fusion group than those in the non-fusion group. A preoperative high MMP-3 and DAS28-CRP are likely to be associated with postoperative ASD. 相似文献18.
Sarah B. Bateni Jennifer L. Olson Jeffrey S. Hoch Robert J. Canter Richard J. Bold 《Annals of surgical oncology》2018,25(13):3804-3811
Background
Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status.Methods
We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost–charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing?≥?19 operations annually.Results
The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [??$1175, 95% confidence interval (CI) ??$3254 to $904, p?=?0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (??$99, 95% CI ??$1612 to 1414, p?=?0.90), one or more adverse outcomes (??$1586, 95% CI ??$4771 to 1599, p?=?0.33), or one or more complications (??$2835, 95% CI ??$7588 to 1919, p?=?0.24).Conclusions
While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.19.
Philip K. Louie Steven M. Presciutti Stephanie E. Iantorno Daniel D. Bohl Kevin Shah Grant D. Shifflett Howard S. An 《The spine journal》2017,17(9):1264-1271
Background Context
Anterior cervical discectomy and fusion (ACDF) is a very common operative intervention for the treatment of cervical spine degenerative disease in those who have failed non-operative measures. However, studies examining long-term follow-up on patients who underwent ACDF reveal evidence of radiographic and clinical degenerative disc disease at the levels adjacent to the fusion construct. Consistent with other junctional regions of the spine, the cervicothoracic junction (CTJ) has significant morphologic variations. As a result, the CTJ undergoes significant static and dynamic stress. Given these findings, there has been some thought that ACDF down to C7 may experience additional risks for adjacent segment degeneration/disease (ASD) when compared with ASDFs that are cephalad to C7.Purpose
The goal of this study is to evaluate the rate of radiographic and clinical ASD in patients who have undergone single- or multilevel ACDF, down to C7.Study Design
This is a retrospective cohort study.Patient Sample
The sample included consecutive patients from a single orthopedic surgeon at one quaternary referral medical center who underwent an ACDF between January 2008 and November 2014. Indications for surgery included radiculopathy, myelopathy, or myeloradiculopathy in the setting of failed conservative treatments. Patients were excluded if they had an ACDF of which the caudal level was cephalad to C7 or if they had undergone a previous cervical fusion.Outcome Measures
Radiographic diagnosis of ASD was determined by the presence of disc space narrowing >50%, new or enlarged osteophytes, end plate sclerosis, or increased calcification of the anterior longitudinal ligament (ALL). Postoperatively, data were collected on the presence of new radicular or myelopathic symptoms indicative of pathology at C7–T1, indicating a diagnosis of clinical ASD.Methods
Demographic information was collected for all patients, which included age, sex, body mass index, smoking status, and Charleston Comorbidity Index (CCI). Several radiographic parameters were measured preoperatively, immediately postoperatively, and at the last follow-up: C2–C7 lordosis, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and T1 slope C2–C7 lordosis were measured using the Cobb angle between the inferior end plate of C2 to the inferior end plate of C7. Radiographic and clinical factors associated with ASD were analyzed postoperatively.Results
Four patients (4.8%) presented with clinical evidence of ASD, all of whom also showed signs of radiographic ASD and improved with conservative measures. No patients underwent reoperation for ASD at the C7–T1 junction. Thirty patients (36.1%) presented radiographic evidence of ASD. These were generally older (54.4 vs. 48.4 years; p=.014). There were neither significant differences in radiographic parameters nor between single- versus multilevel ACDFs and the development of ASD.Conclusions
The cervicothoracic junction may present with vulnerability to ASD given the junctional biomechanics. However, this study provides evidence that an ACDF with the caudal level of C7 does not incur additional risk of ASD, showing similar outcomes to ACDFs at other levels. 相似文献20.
Christopher D. Witiw Lindsay A. Tetreault Fabrice Smieliauskas Branko Kopjar Eric M. Massicotte Michael G. Fehlings 《The spine journal》2017,17(1):15-25