Multicenter Surgical Database Research Articles

Simple severity scale for perforated peptic ulcer with generalized peritonitis: A derivation and internal validation study.

Perforated peptic ulcer (PPU) causes peritonitis and requires surgery based on disease severity. This study aimed to develop and validate a severity scale for PPU with generalized peritonitis. This retrospective cohort study used a nationwide multi-center surgical database (2013-2020). Patients aged >15 years who underwent surgery for PPU with generalized peritonitis were included and categorized into the derivation (2013-2018) and two validation (2019 and 2020) cohorts. Possible severity predictors were selected via a literature review, and Lasso models were developed to predict severe postoperative adverse events with 2000 bootstrapping. Final variables for the scoring system were determined based on inclusion frequency (≥90%) in the Lasso models. Discrimination and accuracy were evaluated using c-statistics and calibration plots. Cutoff values for minimal postoperative adverse events were examined using negative predictive values. Among 12,513 patients included (1,202 underwent laparoscopic surgery), 533 (5.9%), 138 (7.6%), and 117 (6.9%) in the derivation and two validation cohorts experienced postoperative adverse events. Age, dyspnea at rest, preoperative sepsis, III/IV/V of American Society of Anesthesiologists physical status, and albumin and creatinine were selected for the final model. A 0-11 scoring system was developed with c-statistics of 0.812-0.819. Cutoff value was determined as 5, which predicted <3% probability of postoperative adverse events regardless of type of surgery. A score of <5 predicts minimal risks for postoperative adverse events and therefore would be clinically useful to determine type of surgery. Further studies are needed to validate the score.

The incidence of reoperation for pseudarthrosis after cervical spine surgery.

Pseudarthrosis after cervical spine surgery represents an underreported and challenging complication. Using a large multi-center surgical database, we sought to: (1) report the incidence of cervical pseudarthrosis, (2) evaluate changes in rates of cervical pseudarthrosis, and (3) describe risk factors for suboptimal outcomes after cervical pseudarthrosis surgery. The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019 was used. The primary outcome was occurrence of a cervical fusion procedure with a prior diagnosis of pseudarthrosis. Fusion for pseudarthrosis was divided into anterior and posterior approaches. Post-operative complications were classified as major or minor. Prolonged LOS was defined as exceeding the 75th percentile for total hospital stay. A total of 780 patients underwent cervical fusion for pseudarthrosis, and a significant increase in rates of surgery for pseudarthrosis was seen (0.25-1.2%, p < 0.001). The majority of cervical pseudarthrosis was treated with a posterior approach (66.5%). Postoperatively, 38 (4.9%) patients suffered a complication and 247 (31.7%) had a prolonged LOS. The three strongest risk factors for complications and extended LOS were > 10% weight loss preoperatively, congestive heart failure, and pre-operative bleeding disorder. Results from a large multi-center national database revealed that surgery to treat cervical pseudarthrosis has increased from 2012 to 2019. Most pseudarthrosis was treated with a posterior approach. Reoperation to treat cervical pseudarthrosis carried risk, with 5% having complications and 32% having an extended LOS. These results lay the groundwork for a future prospective study to discern the true incidence of cervical pseudarthrosis and how to best avoid its occurrence.

Acute non-traumatic spinal subarachnoid hematomas: A report of five cases and a systematic review of literature

BackgroundThere is a lack of evidence on spinal subarachnoid hematomas because of the rarity of their spontaneous development and difficulty in diagnosis. The aim of this study was to identify the characteristics and outcomes of surgically confirmed acute non-traumatic spinal subarachnoid hematomas from a multicenter surgical database and conduct a systematic review of existing literature. MethodsFive surgically confirmed cases of acute non-traumatic spinal subarachnoid hematomas were identified from our multicenter database with 22 cases from a systematic review of existing literature. ResultsThe mean age of the 27 patients was 59 years. The length of the hematoma was longer than five vertebrae in 70% of the patients, most commonly distributed in the thoracic spine; 63% of all cases were idiopathic, 30% were under anticoagulant therapy, and the remaining 7% presented with coagulation abnormalities. As many as 70% of the patients showed some improvement in neurological symptoms after surgery during a mean follow-up period of 14 months. ConclusionsThis study elucidated the characteristics of acute non-traumatic spinal subarachnoid hematomas in patients who were surgically confirmed. Most patients were middle-aged, complained of back pain, and had the hematoma located in the thoracic spine. Seventy percent of the patients in this study had some improvement in their neurological status, most likely due to surgical decompression and hematoma evacuation.

Rates, Risk Factors, and Complications of Red Blood Cell Transfusion in Metastatic Spinal Tumor Surgery: An Analysis of a Prospective Multicenter Surgical Database

To identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery. The multicenter prospective American College of Surgeons National Quality Improvement Program database was queried for the years 2012-2016. Adult patients with disseminated cancer who underwent metastatic spinal tumor surgery were identified. Transfusion was defined as having received at least 1 intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used. Of 1601 patients identified, 623 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher American Society of Anesthesiologists class (odds ratio [OR]= 1.54), preoperative anemia (OR= 3.10), instrumentation (OR=1.63), andlonger operative time (OR= 1.52). The overall complication rate was significantly higher in patients who received a transfusion compared with patients who did not receive a transfusion (22.3% vs. 15.0%, P < 0.001). Individualcomplications that were more common in patients whoreceived a transfusion were sepsis (3.5% vs. 1.9%, P=0.050), deep vein thrombosis (6.1% vs. 3.3%, P=0.007), and prolonged ventilation (3.9% vs. 1.3%, P=0.001). RBC transfusion (OR= 1.65), hypoalbuminemia (OR= 1.53), and anterior/anterolateral approaches for corpectomy (OR= 2.11) were independent risk factors for developing a postoperative complication. RBC transfusion after metastatic spinal tumor surgery may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.

Cost-effectiveness of surgical treatment of adult spinal deformity: comparison of posterior-only versus anteroposterior approach

BACKGROUND CONTEXTConsiderable debate exists regarding the optimal surgical approach for adult spinal deformity (ASD). It remains unclear which approach, posterior-only or combined anterior-posterior (AP), is more cost-effective. Our goal is to determine the 2-year cost per quality-adjusted life year (QALY) for each approach. PURPOSETo compare the 2-year cost-effectiveness of surgical treatment for ASD between the posterior-only approach and combined AP approach. STUDY DESIGNRetrospective economic analysis of a prospective, multicenter database PATIENT SAMPLEFrom a prospective, multicenter surgical database of ASD, patients undergoing five or more level fusions through a posterior-only or AP approach were identified and compared. METHODSQALYs gained were determined using baseline, 1-year, and 2-year postoperative Short Form 6D. Cost was calculated from actual, direct hospital costs including any subsequent readmission or revision. Cost-effectiveness was determined using cost/QALY gained. RESULTSThe AP approach showed significantly higher index cost than the posterior-only approach ($84,329 vs. $64,281). This margin decreased at 2-year follow-up with total costs of $89,824 and $73,904, respectively. QALYs gained at 2 years were similar with 0.21 and 0.17 in the posterior-only and the AP approaches, respectively. The cost/QALY at 2 years after surgery was significantly higher in the AP approach ($525,080) than in the posterior-only approach ($351,086). CONCLUSIONSWe assessed 2-year cost-effectiveness for the surgical treatment through posterior-only and AP approaches. The posterior-only approach is less expensive both for the index surgery and at 2-year follow-up. The QALY gained at 2-years was similar between the two approaches. Thus, posterior-only approach was more cost-effective than the AP approach under our study parameters. However, both approaches were not cost-effective at 2-year follow-up.

P84. Predicting ASD surgeries that exceed Medicare allowable payment thresholds: a comparison of hospital costs to what the government will actually pay

BACKGROUND CONTEXT Adult Spinal Deformity (ASD) surgery is associated with a high cost. Previous studies have suggested that the actual direct hospital cost of ASD surgery is higher than the Medicare Allowable (MA) rate. MA rates are becoming the benchmark reimbursement target for hospital accounting systems. It is important to determine what factors can predict which ASD patients have actual costs below Medicare reimbursement. PURPOSE Our goal is to (1) determine if we can develop a model to predict when index episode of care (iEOC) surgical costs of ASD surgeries are below the MA threshold and (2) to identify potentially modifiable variables. STUDY DESIGN/SETTING Retrospective analysis of a prospective multi-center ASD database. PATIENT SAMPLE Adult spinal deformity patients undergoing surgical correction enrolled into a prospective, multicenter surgical database from 2008-2014. OUTCOME MEASURES Primary outcome measure is iEOC costs and patient and hospital-specific MA reimbursements, but other baseline HRQOL outcome measures were collected such as Oswestry Disability Index (ODI), SF-36 PCS, and SF-36 MCS. METHODS From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (>4 level) with cost data were identified. Index episode of care (iEOC) cost was calculated by utilizing actual direct hospital cost. MA rates were calculated using the year-appropriate CMS Inpatient Pricer Payment System Tool and were hospital specific. Demographic, baseline HRQOL, radiographic and surgical variables were analyzed. A predictive model was developed to identify variables that can predict iEOC RESULTS Administrative direct cost data was obtained from 4 of 11 centers with a total of 195 patients included in the model. A total of 109 (55%) patients had iEOC below the MA threshold. There was significant variation across the 4 centers in both the mean iEOC cost ($56,788 to $78,878,p CONCLUSIONS There is significant institutional variation in ASD cost and reimbursement with an increased likelihood of 56.8% getting reimbursed more than the cost of surgery (iEOC FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

212. Giving patients the info they want: practical answers to FAQs for shared decision-making in ASD surgery

BACKGROUND CONTEXT The shared decision-making (SDM) process is an opportunity to deliver answers to frequently asked questions (FAQs) in adult spinal deformity (ASD) surgery. PURPOSE Our goal was to present a concise list of answers to these FAQs to aid in SDM counseling. STUDY DESIGN/SETTING Retrospective analysis of a prospective multi-center ASD database. PATIENT SAMPLE Adult spinal deformity patients undergoing surgical correction enrolled into a prospective, multicenter surgical database from 2008-2016. OUTCOME MEASURES Health related quality of life (HRQOL) outcome measures were collected such as Oswestry Disability Index (ODI), SF-36 PCS, and SF-36 MCS. METHODS Adult patients undergoing ≥ 5 level fusion with minimum 2-year follow up were included. We purposely included all deformity types (heterogeneity) to provide general applicability. We compiled a list of FAQs by patients undergoing ASD surgery and utilized a retrospective analysis to provide answers. All responses are reported as either means or reaching minimal clinically important difference (MCID) at the 2-year follow-up interval. RESULTS Out of 689 ASD patients eligible for 2-year follow-up, 521 (76%) had complete follow-up. The majority were female (77%) with mean age of 58.5 years and BMI of 27.5. Mean levels fused were 11.3 with 52% being primary vs 48% revision surgeries. Will my pain improve? Back (7.2 to 3.6) and leg (4.7 to 2.6) pain were both reduced by ∼50%. Will my activity level improve? A total of 63.9% reached MCID for SRS-22r activity. Will I feel better about myself? A total of 71.2% reached MCID for SRS-22r appearance. Is there a chance I'm worse? A total of 4.1% of patients were worse (ODI). What is the likelihood I have a complication? A total of 52.9% of patients have at least 1 complication and 29.6% have a major complication. Will I need another surgery? A total of 29.6% of patients have a reoperation within 2 years. Will I regret having surgery? A total of 32% would not choose the same treatment. Will I get a blood transfusion? A total of 79.1% of patients receive a blood transfusion. How long will I stay in the hospital? Study showed 9.9 days. Will I have to go to the ICU? A total of 79.1% of patients require an ICU stay. Will I be able to return to work? A total of 71% returned to full-time work at 2 years. Will I be taller after surgery? Yes, 1.4cm was the average CONCLUSIONS The above list provides concise, practical answers to FAQs encountered in the SDM process while counseling patients for ASD surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

300. Continued inpatient care following elective anterior cervical discectomy and fusion increases the risk of 30-day readmissions and post-discharge complications

BACKGROUND CONTEXT With a shift toward value-based and bundled-payment models, identification of areas of cost and quality improvement will be required. Though abundant literature is present on the predictors of discharge destinations, few studies have studied the impact of discharge to an inpatient care facility (skilled-care or rehabilitation) on post-discharge outcomes following elective spine surgery. PURPOSE We sought to collate evidence using a large national multi-center surgical database to assess the clinical impact of continued post-discharged inpatient care (skilled care facility or inpatient rehabilitation unit) on 30-day complications, readmissions and mortality after elective anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING This was a retrospective study done using the 2015-2016 American College of Surgeons (ACS) – National Surgical Quality Improvement Program (NSQIP) database. PATIENT SAMPLE Current Procedural Terminology (CPT) codes for ACDF (CPT- 22551, 22552) were used to identify patients from the database. Only elective ACDFs being done for ≤3 levels were included in the study. Patients undergoing additional posterior cervical spine procedures (instrumentation, laminectomy, laminotomy, etc.) were excluded from the analysis. In addition, patients undergoing surgery for cervical fracture, malignancy and spinal deformity were also excluded. Finally data was filtered to remove for missing variables to prevent any confounding in analysis. Discharge disposition was defined as discharge to an inpatient care facility (skilled care or rehabilitation) vs home. Those patients being discharged to other destinations such as acute care hospitals, unskilled facilities and assisted living facilities were excluded from the analysis to ensure that the results are relevant to the objective of the study. OUTCOME MEASURES Thirty day postdischarge complications, reoperations, redmissions and mortality. METHODS Multivariate logistic regression analyses were used to assess for the independent impact of discharge to an inpatient care facility vs home on the odds of experiencing 30-day post-discharge complications, readmissions, reoperations and mortality, while controlling for preoperative, intraoperative and predischarge clinical factors and patient characteristics. RESULTS A total of 15,624 patients were finally included for analysis. A total of 459 (2.9%) patients were discharged to an inpatient care (skilled care or rehabilitation) facility. Age of ≥65 years, Black or African-American race, partially dependent or totally dependent functional health status, a LOS ≥3 days, a total operative time>150 mins, ASA grade>II and inpatient surgery were significant predictors for a discharge to skilled care/rehabilitation facility. Following adjustment for predischarge clinical characteristics, discharge to an inpatient care facility was an independent significant risk factor for renal complications (OR 8.22 [95% CI 1.84-36.7]; p=0.006) and 30-day readmissions (OR 1.63 [95% CI 1.09-2.42]; p=0.016). CONCLUSIONS Discharge to inpatient care facilities following elective ACDF is associated with higher odds of renal complications and 30-day readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimize the risk of complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Cell Saver for Adult Spinal Deformity Surgery Reduces Cost

Study DesignRetrospective cohort. ObjectivesTo determine if the use of cell saver reduces overall blood costs in adult spinal deformity (ASD) surgery. Summary of Background DataRecent studies have questioned the clinical value of cell saver during spine procedures. MethodsASD patients enrolled in a prospective, multicenter surgical database who had complete preoperative and surgical data were identified. Patients were stratified into (1) cell saver available during surgery, but no intraoperative autologous infusion (No Infusion group), or (2) cell saver available and received autologous infusion (Infusion group). ResultsThere were 427 patients in the Infusion group and 153 in the No infusion group. Patients in both groups had similar demographics. Mean autologous infusion volume was 698 mL. The Infusion group had a higher percentage of EBL relative to the estimated blood volume (42.2%) than the No Infusion group (19.6%, p < .000). Allogeneic transfusion was more common in the Infusion group (255/427, 60%) than the No Infusion group (67/153, 44%, p = .001). The number of allogeneic blood units transfused was also higher in the Infusion group (2.4) than the No Infusion group (1.7, p = .009).Total blood costs ranged from $396 to $2,146 in the No Infusion group and from $1,262 to $5,088 in the Infusion group. If the cost of cell saver blood was transformed into costs of allogeneic blood, total blood costs for the Infusion group would range from $840 to $5,418. Thus, cell saver use yielded a mean cost savings ranging from $330 to $422 (allogeneic blood averted). Linear regression showed that after an EBL of 614 mL, cell saver becomes cost-efficient. ConclusionCompared to transfusing allogeneic blood, cell saver autologous infusion did not reduce the proportion or the volume of allogeneic transfusion for patients undergoing surgery for adult spinal deformity. The use of cell saver becomes cost-efficient above an EBL of 614 mL, producing a cost savings of $330 to $422. Level of EvidenceLevel III.

P114 - Comparative Analysis of Perioperative Outcomes Using Nationally Derived Hospital Discharge Data Relative to a Prospective Multi-Center Surgical Database of Adult Spinal Deformity Surgery

P114 - Comparative Analysis of Perioperative Outcomes Using Nationally Derived Hospital Discharge Data Relative to a Prospective Multi-Center Surgical Database of Adult Spinal Deformity Surgery

Postoperative Complications for Elderly Patients After Single-Level Lumbar Fusions for Spondylolisthesis

A large-scale study on postoperative complications of lumbar fusion surgery for spondylolisthesis comparing patients >80 years old with younger patients has not been performed. The purpose of this study is to assess the effects of extreme age (>80 years old) on early postoperative outcomes after single-level lumbar fusions for spondylolisthesis. From a validated multicenter surgical database, 2475 patients who underwent a single-level lumbar fusion procedure for spondylolisthesis were selected retrospectively. An extreme age cohort with 227 patients >80 years old was compared with a typical age cohort with 2248 patients 45-65 years old. The preoperative characteristics and comorbidities were different between the typical age cohort and the extreme age cohort, with older patients having more preoperative comorbidities, including a lack of independent functional health status before surgery (P < 0.001), severe chronic obstructive pulmonary disease (P <0.020), and hypertension requiring medication (P < 0.001). There was significantly greater morbidity among the >80 cohort regarding urinary tract infection (P= 0.008; odds ratio= 3.30; 95% confidence interval, 1.47-7.40) and intraoperative and postoperative transfusions (P < 0.001; odds ratio= 2.186; 95% confidence interval, 1.54-3.11). There was significantly greater morbidity among the younger cohort regarding cardiac arrest requiring cardiopulmonary resuscitation (P= 0.043; odds ratio= 0.099; 95% confidence interval, 0.014-0.704). This is the first large study comparing the rates of postoperative complications of lumbar fusion surgery for spondylolisthesis in patients >80 years old versus younger patients. The data support that age alone should not exclude a patient for this procedure. However, extra caution is warranted given the slightly increased morbidity.

Analysis of Sagittal Alignment in Thoracic and Thoracolumbar Curves in Adolescent Idiopathic Scoliosis

Retrospective chart review and radiographic analysis. To determine if differences exist in the sagittal alignment of adolescent idiopathic scoliosis (AIS) patients with thoracic versus thoracolumbar curve patterns. Relative anterior overgrowth has been suggested as the possible pathomechanism behind thoracic scoliosis. Given the proposed importance of the sagittal alignment on the development of AIS and the known association between pelvic parameters and sagittal alignment, the authors postulate that pelvic incidence may influence the location of vertebral column collapse associated with different AIS curve types. A multicenter surgical database was used to compare preoperative radiographic measurements between patients with primary thoracic curves (Lenke 1A, B), primary thoracolumbar curves (Lenke 5), and normal adolescents. Pelvic incidence was significantly greater in both groups of AIS patients compared with normal adolescents. Patients in the primary thoracic curve group were found to have a significantly increased sacral slope and a decreased thoracic kyphosis relative to the control group. Patients in the primary thoracolumbar curve group had a significantly increased pelvic tilt; however, a relatively normal thoracic kyphosis, lumbar lordosis, and sacral slope compared with the respective control values. An increased pelvic incidence, associated with both thoracic and thoracolumbar curves when compared with the normal adolescent population, does not appear to be the potential determinant of the development of thoracic versus thoracolumbar scoliosis, but may be a risk factor for the development of adolescent idiopathic scoliosis. The theory of anterior overgrowth may be supported by the identification of thoracic hypokyphosis, despite an increased pelvic incidence and lumbar lordosis, in patients with thoracic scoliosis. The association between sagittal measurements and the etiology of thoracolumbar curve formation is less clear; however, regional anterior overgrowth in the lumbar spine may also be responsible for the deformity.