General Session: Cervical-1
Presented by: C. Jalai - View Audio/Video Presentation (Members Only)
P. Passias(1), C. Jalai(2), N. Worley(2), G. Poorman(3), S. Vira(2), S. Hasan(2), A. White(4), M. Gerling(2), V. Lafage(5), T. Errico(2)
(1) NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, NYC, NY, United States
(2) NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, New York, NY, United States
(3) New York University, Hospital for Joint Diseases, New York, NY, United States
(4) Harvard Medical School, Department of Orthopaedic Surgery, Boston, MA, United States
(5) Hospital for Special Surgery, Department of Orthopaedics, New York, NY, United States
Object: Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. Both patient-related and non-patient-related factors may influence these metrics. The factors most relevant to Cervical Spondylotic Myelopathy (CSM), a disorder commonly treated with surgery, are not yet well established. The purpose of this study is to identify pre-operative and intra-operative factors that are associated with extended LOS and/or 30-day readmission following elective surgery for CSM.
Methods: This study was a retrospective review of a prospective database. Inclusion criteria for this study were surgical patients with a diagnosis of CSM (based on ICD-9 code 721.1) between 2010 and 2012 at institutions represented by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patients with fracture, ≥9 levels fused, or cancer were excluded. Extended hospital LOS was defined as the 75th percentile of the cohort. Outcome measures included hospital LOS, 30-day readmission, and return to OR. Univariate analysis and multivariate logistic regression identified significant predictors for extended hospital LOS, readmission within 30 days, and reoperation. Linear regression modeling was used to evaluate variables.
Results: The total included patient cohort included 3057 surgical CSM cases. Patient age (OR 1.496, p< 0.001), diabetes (OR 1.691, p=0.007), American Society of Anesthesiologists (ASA) class (OR 2.081, p=0.018), posterior surgical approach (OR 2.695, p< 0.001), and operative time (OR 1.008, p< 0.001) were significant positive predictors for extended LOS (≥4 days). 30-day readmission data was available for 32% of the cohort (976 patients). Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were. Diabetes (OR 1.460, p=0.009) and ASA class (OR 2.539, p=0.033) were significant positive predictors for hospital readmission. A sub-group analysis of readmitted patients who required a subsequent operation (return to OR) identified age (OR 0.918, p=0.004) as a negative predictor and pulmonary comorbidities (OR 4.584, p=0.038) as a positive predictor.
Conclusions: Patients with diabetes, higher ASA Class, and increased operative time have increased risk for extended hospital LOS. Diabetes and ASA class significantly predicted hospital readmission within 30 days. Pre-operative pulmonary comorbidities increased the reoperation risk, while increased age reduced the risk. Attention to these factors may be helpful in the treatment of these patients. It should also be recognized that some of the factors influencing quality metrics (such as LOS) might not be modifiable; this should be taken into consideration when using these metrics to assess quality of care.