Michigan Spine Surgery Improvement Collaborative Research Articles

P61. Preoperative PHQ-2 scoring predicts patient satisfaction and return to work up to one-year after lumbar fusion: a two-year analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC)

BACKGROUND CONTEXT While back pain is associated with depression, there are few studies assessing whether preoperative depression can affect outcomes after lumbar spine surgery. PURPOSE We sought to identify the relationship between a positive PHQ-2, which is predictive of depression, and patient satisfaction, return to work, and achieving ODI MCID up to 2 years after lumbar fusion. STUDY DESIGN/SETTING Prospective cohort. PATIENT SAMPLE The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective multicenter quality improvement collaborative. Currently there are more than 26 different hospitals involved, and more than 20,000 patients receiving surgery from both neurosurgeons and orthopedic spine surgeons. OUTCOME MEASURES Patient satisfaction, return to work, and achieving ODI MCID up to 2 years after lumbar fusion. METHODS Multivariate logistic regression models were constructed; variables tested include age, gender, race, PMH, preoperative diagnosis (disc herniation, spondylolisthesis, etc), preoperative symptoms (axial pain, radicular pain, etc), severity of surgery, and preoperative opioid usage. Patient satisfaction was measured by the NASS patient satisfaction index. A positive PHQ-2 score is ≥3, which has a 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. RESULTS A total of 8,585 lumbar fusion patients were analyzed. Multivariate analysis was performed. Patients with a positive PHQ-2 score were less likely to be satisfied after lumbar fusion at 90-days (OR 0.93, p CONCLUSIONS A multivariate analysis from a large, multicenter, prospective database on lumbar fusion patients was performed. We find that PHQ-2, which is a simple and accurate screening tool for depression, predicts and inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, then perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

97. The effect of physical therapy on time to discharge after lumbar interbody fusion

BACKGROUND CONTEXT With a lesser degree of tissue destruction and lower postoperative opiate burden, patients undergoing minimally-invasive spine surgery are primed to benefit from early mobilization, which can further enhance recovery and hasten rehabilitation after surgery. PURPOSE To determine the role of physical therapy on earlier postoperative discharge after minimally-invasive transforaminal lumbar interbody fusion (TLIF). STUDY DESIGN/SETTING Cohort study. PATIENT SAMPLE All patients undergoing one- and two-level minimally-invasive TLIF for degenerative lumbar diseases were operated on by the senior author from January 1, 2016 until August 31, 2018. Demographic data, comorbidities, preoperative patient-reported outcomes (PROs), intraoperative parameters, and postoperative measures were abstracted from a prospectively maintained database, ie, Michigan Spine Surgery Improvement Collaborative (MSSIC). Data on ambulation were collected from the physical therapy notes. OUTCOME MEASURES The primary outcome measure is postoperative length of acute care stay. Length of stay was divided into (1) discharge on postoperative day 1 (POD 1 cohort), (2) discharge on postoperative day 2 (POD 2 cohort), and (3) discharge on ≥3 postoperative days (POD ≥3 cohorts) to maintain three equal-time cohorts. METHODS An ordinal logistic regression model was fitted to the data to estimate the effect of discharge on postoperative day 1 vs postoperative day 2 vs postoperative ≥ day 3. Anesthesiology (ASA) classification was used as a surrogate marker of comorbidity burden. RESULTS Of the 90 patients, the day of first ambulation with physical therapy increased from a mean of 14.4 ± 9.6 hours after surgery in the POD 1 cohort, 19.2 ± 7.2 hours in the POD 2 cohort, to 24.0 ± 12.0 hours in the POD ≥3 cohort (p=0.009). Furthermore, mean distance ambulated upon first interaction with physical therapy decreased from 162.8 ± 127.5 feet in the POD 1 group, 111.2 ± 83.6 feet in the POD 2 group, to 58.7 ± 59.3 feet in the POD ≥3 group (p CONCLUSIONS Time to first ambulation with a therapist independently increases the odds of earlier discharge. Regardless of preoperative patient-reported outcomes, ambulation remains a stronger predictor of discharge. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Association Between Chronicity of Preoperative Opioid Usage Between Patient Satisfaction, Return to Work, and Achieving ODI MCID up to 2 Years After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

Abstract INTRODUCTION The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a multicenter quality improvement collaborative. Using the MSSIC database, we sought to identify the relationship between preoperative opioid usage and patient satisfaction, return to work, and achieving ODI MCID up to 2-yr after lumbar fusion. METHODS A total of 8693 lumbar fusion patients were analyzed. Patient satisfaction was measured by the NASS patient satisfaction index. Generalized estimating equations (GEE) models were constructed; variables tested include age, gender, race, PMH, and number of surgical levels. Preoperative opioid chronicity was defined as opioid naïve (no opioid usage), new opioid users (<6 wk), recent opioid users (6 wk-3 mo), frequent opioid users (3 mo-6 mo), and chronic opioid users (>6 mo). Comparisons were made to opioid naïve patients. RESULTS Chronic opioid users were less likely to be satisfied with their procedure at 90-d (OR 0.95, P < .001), 1-yr (OR 0.90, P < .001), and 2-yr (OR 0.87, P < .001) after surgery. New opioid users were more likely to achieve ODI MCID at 90-d (OR 1.25, P < .001), 1-yr (OR 1.15, P < .001), and 2-yr (OR 1.22, P < .002) postoperatively. Recent opioid users were more likely to achieve ODI MCID at 2 yr (OR 1.26, P < .001). Chronic opioid users were less likely to achieve ODI MCID at 90-d (OR 0.89, P < .001), 1-yr (OR 0.87, P = .002), and 2-yr (OR 0.82, P = .004). Chronic opioid users were also less likely to return to work at 90-d (OR 0.83, P < .001). CONCLUSION A multivariate analysis on preoperative opioid usage from a large, multicenter, prospective database on lumbar fusion patients was performed. We found that, as compared to opioid naïve patients, 2-yr postoperatively new opioid users (<6 wk) were more likely to have a favorable outcome, while chronic opioid users (>6 mo) were less likely to have a favorable outcome. Thus, preoperative opioid counseling is imperative to improve outcomes in spine surgery.

The Association Between PHQ-2 Screening and Patient Satisfaction and Return to Work Up To 2-Years After Lumbar Fusion: Analysis From the Michigan Spine Surgery Improvement Collaborative (MSSIC)

Abstract INTRODUCTION The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality improvement collaborative. Using MSSIC, we sought to identify the relationship between a positive PHQ-2, which is predictive of depression, and patient satisfaction, return to work, and achieving ODI MCID up to 2-yr after lumbar fusion. METHODS A total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the NASS patient satisfaction index. A positive PHQ-2 score is =3, which has a 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equations (GEE) models were constructed; variables tested include age, gender, race, PMH, preoperative diagnosis (disc herniation, spondylolisthesis, etc), preoperative symptoms (axial pain, radicular pain, etc), severity of surgery, and preoperative opioid usage. RESULTS Patients with a positive PHQ-2 score were less likely to be satisfied after lumbar fusion at 90-d (OR 0.93, P < .001), 1-yr (OR 0.92, P = .001), and 2-yr (OR 0.92, P = .028). A positive PHQ-2 was also associated with decreased likelihood of returning to work at 90-d (OR 0.76, P < .001), 1-yr (OR 0.85, P = .001), and at 2-yr (OR 0.82, P = .031). A positive PHQ-2 was predictive of failure to achieve ODI MCID at 90-d (OR 1.07, P = .005) but not at 1-yr or 2-yr after lumbar fusion. CONCLUSION A multivariate analysis from a large, multicenter, prospective database on lumbar fusion patients was performed. We find that PHQ-2, which is a simple and accurate screening tool for depression, is associated with an inability to return to work and worse satisfaction up to 2-yr after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, then perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

Ambulation on POD#0 Is Associated With Decreased Adverse Events After Elective Lumbar Spine Surgery: Analysis of the Michigan Spine Surgery Improvement Collaborative (MSSIC)

Abstract INTRODUCTION The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a multicenter quality-improvement collaborative. Using MSSIC, we sought to identify the relationship between ambulation on the day of surgery (POD#0) and 90-d adverse events after lumbar surgery, specifically length of stay (LOS), urinary retention (UR), urinary tract infection (UTI), ileus, readmission, surgical site infection (SSI), PE/DVT, and disposition to a rehab facility. METHODS In 23295 lumbar surgery patients, matching was performed to ensure overlap on patient variables. Generalized estimating equations (GEE) models were run on the matched dataset to further account for patient demographics, medical history, and surgical intensity. RESULTS POD#0 ambulation was associated with decreased LOS (OR 0.83, P < .001), UR (OR 0.73, P = .008), UTI (OR 0.52, P = .001), ileus (OR 0.52, P < .001), 30-d (OR 0.84, P = .035) and 90-d (OR 0.86, P = .009) readmission, and rehab discharge (OR 0.52, P < .001) for all patients. POD#0 ambulation after single-level decompression (6244 patients) decreased LOS (OR 0.72, P < .001), UR (OR 0.73, P = .004), UTI (OR 0.43, P = .003), and rehab discharge (OR 0.18, P < .001). Ambulation after multilevel decompression (5526 patients) was associated with decreased LOS (OR 0.73, P < .001), UR (OR 0.75, P = .04), ileus (OR 0.60, P = .027), and rehab discharge (OR 0.44, P < .001). Ambulation after single-level fusion (5790 patients) decreased LOS (OR 0.85, P < .001), 30-d readmission (OR 0.77, P = .032), and rehab discharge (OR 0.65, P = .004). Ambulation after multilevel fusion (5735 patients) decreased LOS (OR 0.88, P < .001), UTI (OR 0.60, P = .003), ileus (OR 0.51, P = .02), 30-d readmission (OR 0.77, P = .032), and rehab discharge (OR 0.59, P < .001). No change in rate of or DVT/PE was observed for patients who ambulated POD#0. CONCLUSION POD#0 ambulation is associated with a significantly decreased risk for several key adverse events after lumbar spine surgery. Decreasing the incidence of these outcomes would be associated with significant cost savings. As ambulation POD#0 is a modifiable factor in any patient's postoperative care following most spine surgery, it should be encouraged and incorporated into spine-related enhanced recovery after surgery (ERAS) programs.

The Association of Intraoperative Antibiotic and Surgical Site Infection After Lumbar Spine Surgery: Analysis of the Michigan Spine Surgery Improvement Collaborative

Abstract INTRODUCTION Surgical site infections (SSI) after lumbar spine surgery is costly and potentially preventable. A number of studies have shown the efficacy of vancomycin powder in preventing SSI, but there are few studies that have examined all the available perioperative antibiotics. We sought to examine associations between intraoperative antibiotic usage and SSI rates after lumbar spine surgery, as well as other risk factors for SSI, using a large prospective database. METHODS The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a large multi-institute collaborative. MSSIC was queried to test the association between intraoperative antibiotic irrigation (bacitracin, cefazolin, vancomycin, etc), intraoperative vancomycin powder only, a combination of the two, and postoperative antibiotics with SSI using generalized estimating equations (GEE) models; variables included: age, gender, BMI, diabetes, heart disease, scoliosis, previous spine surgery, preoperative ambulatory status, insurance type (public vs private), surgery type (fusion vs decompression alone), and number of surgical levels. RESULTS A total of 24 229 patients undergoing lumbar spine surgery were included in the multivariate analysis. Postoperative antibiotic prophylaxis did not affect SSI (OR 1.00, P = .987). Preoperative antibiotics were universally given, and further analysis of intraoperative antibiotic usage was done. All comparisons were done to no additional antibiotics used; using only intraoperative vancomycin powder was associated with lower SSI (OR 0.77, P = .286). Using antibiotic irrigation only was associated with a significantly higher rate of SSI (OR1 .42, P = .009). Using a combination intraoperative vancomycin and irrigation was again associated with higher SSI (OR 1.28, P = .127), but not as high as irrigation alone. Protective factors for SSI include independently ambulation (OR 0.80, P = .015) and private insurance (OR 0.74, P = .001). Risk factors for SSI include BMI (OR 1.33, P < .001), diabetes (OR 1.36, P < .001), fusion (OR 1.41, P = .001), and increasing surgical levels (OR 1.59, P = .006). CONCLUSION The use of postoperative antibiotic prophylaxis was not associated with SSI. Intraoperative antibiotic irrigation may be less effective than realized, and the use of intraoperative vancomycin powder alone may be effective in preventing SSI. The efficacy of intraoperative antibiotic irrigation in preventing infection requires further investigation. Other risk factors for SSI are confirmed.

The Potential Effect of Racial Disparities on Outcomes After Spine Surgery: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

Abstract INTRODUCTION Racial disparities have been demonstrated to affect healthcare outcomes over a wide range of disease processes. This goal of this study is to evaluate how race may influence outcomes after elective lumbar spine surgery. METHODS MSSIC was queried for all lumbar operations. Race is a patient reported measure and was stratified into three groups (Caucasian, African-American, others). Demographic information, pre-existing comorbidities, baseline PROs including ODI, NRS, EQ5D, and procedure type (number of levels, fusion) were compared across the three groups. Primary outcome measures were the NASS Patient Satisfaction Index, meeting the MCID for PROs, and return to work at 1 and 2 yr after surgery. Poisson GEE models were done to assess racial differences while adjusting for other patient characteristics. RESULTS A total of 19 191 patients were included in this analysis, 16 788 Caucasian, 1436 African-American, 967 other. Compared to Caucasians, African-Americans had higher proportions of smokers (23% vs 17%), diabetes (32% vs 20%), depression (40% vs 34%), and fusions (56% vs 49%), and greater baseline ODI (55.6 ± 16.0 vs 47.7 ± 16.2). African-American patients had significant associations with dissatisfaction after surgery (RR 1.74 at 1 yr, RR 1.86 at 2 yr), less likely to achieve MCID for ODI (RR 0.87 at 1 yr, RR 0.85 at 2 yr), and less likely to return to work (RR 0.78 at 1 yr, RR 0.82 at 2 yr). After adjusting for baseline factors and postoperative factors (ongoing depression, improvement in PRO, complications) the only significant associations were for patient dissatisfaction (RR 1.36 at 1 yr, RR 1.41 at 2 yr). CONCLUSION Despite significant baseline differences, when adjusting for potential confounding factors, there appears to be an association with race and satisfaction after surgery. Further study into factors to mitigate this disparity are necessary to enhance delivery of care and patient perceptions, regardless of race.

Patient Demographic and Surgical Factors that Affect Completion of Patient-Reported Outcomes 90 Days and 1 Year After Spine Surgery: Analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC)

The Michigan Spine Surgery Improvement Collaborative is a statewide multicenter quality improvement registry. Because missing data can affect registry results, we used MSSIC to find demographic and surgical characteristics that affect the completion of patient-reported outcomes (PROs) at 90 days and 1 year. A total of 24,404 patients who had lumbar surgery (17,813 patients) or cervical surgery (6591 patients) were included. Multivariate logistic regression models of patient disease were constructed to identify risk factors for failure to complete scheduled PRO surveys. Patients ≥65 years old and female patients were both more likely to respond at 90 days and 1 year. Increasing education was associated with greater response rate at 90 days and 1 year. Whites and African Americans had no differences in response rates. Calling provided the highest response rate at 90 days and 1 year. For cervical spine patients, only discharge to rehabilitation increased completion rates, at 90 days but not 1 year. For lumbar spine patients, spondylolisthesis or stenosis (vs. herniated disc) had a greater response rate at 1 year. Patients with leg (vs. back) pain had a greater response only at 1 year. Patients with multilevel surgery had an increased response at 1 year. Patients who underwent fusion were more likely to respond at 90 days, but not 1 year. Discharge to rehabilitation increased response at 90 days and 1 year. A multivariate analysis from a multicenter prospective database identified surgical factors that affect PRO follow-up, up to 1 year. This information can be helpful for imputing missing PRO data and could be used to strengthen data derived from large prospective databases.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative.

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery. A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition. Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings. A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry. CONCLUSIONS In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years.