Publications by authors named "Dengzhi Wang"

28 Publications

  • Page 1 of 1

Burden of Pre-operative Opioid Use and Its Impact on Healthcare Utilization After Primary Single Level Lumbar Discectomy.

Spine J 2021 Apr 16. Epub 2021 Apr 16.

Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, U.S.A. 40202. Electronic address:

Background Context: The complication profile and higher cost of care associated with pre-operative opioid use and spinal fusion is well described. However, the burden of opioid use and its impact in patients undergoing lumbar discectomy is not known. Knowledge of this, especially for a relatively benign and predictable procedure will be important in bundled and value-based payment models.

Purpose: To study the burden of pre-operative opioid use and its effect on post-operative healthcare utilization, cost, and opioid use in patients undergoing primary single level lumbar discectomy.

Study Design: Retrospective cohort study PATIENT SAMPLE: 29,745 patients undergoing primary single level lumbar discectomy from the IBM® MarketScan® (2000-2018) database.

Outcome Measures: 90-day and 1-year utilization of lumbar epidural steroid injections (ESIs), emergency department (ED) services, lumbar magnetic resonance imaging (MRI), hospital readmission, and revision lumbar surgery. Continued opioid use beyond 3-months post-operatively until 1-year was also studied. We have reported costs associated with healthcare utilization among opioid groups.

Methods: Patients were categorized in opioid use groups based on the duration and number of oral prescriptions prior to discectomy (opioid naïve, < 3-months opioid use, chronic pre-operative use, chronic pre-operative opioid use with 3-month gap before surgery, and other). The risk of association of pre-operative opioid use with outcome measures was studied using multivariable logistic regression analysis with adjustment for various demographic and clinical variables.

Results: A total of 29,745 patients with mean age of 45.3± 9.6 years were studied. Pre-operatively, 29.0% were opioid naïve, 35.0% had < 3-months use and 12.0% were chronic opioid users. There was a significantly higher rate of post-operative lumbar ESIs, MRI, ED visits, readmission and revision surgery within 90-days and 1-year after surgery in chronic pre-operative opioid users as compared to patients with < 3-months use and opioid naïve patients (p<0.001). Chronic post-operative opioid use was present in 62.6% of the pre-operative chronic opioid users as compared to 5.6% of patients with < 3-months opioid use. A 3-month prescription free period before surgery in chronic pre-operative opioid users cut the incidence of chronic post-operative opioid use by more than half, at 25.7%. Cost of care and adjusted analysis of risk have been described.

Conclusion: Chronic pre-operative opioid use was present in 12% of a national cohort of lumbar discectomy patients. Such opioid use was associated with significantly higher post-operative healthcare utilization, risk of revision surgery, and costs at 90-days and 1-year post-operatively. Two-third of chronic pre-operative opioid users had continued long-term post-operative opioid use. However, a 3-month prescription free period before surgery in chronic opioid users reduces the risk of long-term post-operative use. This data will be useful for patient education, pre-operative opioid use optimization, and risk-adjustment in value-based payment models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.spinee.2021.04.013DOI Listing
April 2021

Patterns and Impact of Electronic Health Records-Defined Depression Phenotypes in Spine Surgery.

Neurosurgery 2021 Apr 16. Epub 2021 Apr 16.

Pacific Northwest University of Health Sciences, Yakima, Washington, USA.

Background: Preoperative depression is a risk factor for poor outcomes after spine surgery.

Objective: To understand effects of depression on spine surgery outcomes and healthcare resource utilization.

Methods: Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use.

Results: Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery.

Conclusion: EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyab096DOI Listing
April 2021

Health Care Utilization and Associated Economic Burden of Postoperative Surgical Site Infection after Spinal Surgery with Follow-Up of 24 Months.

J Neurol Surg A Cent Eur Neurosurg 2021 Apr 12. Epub 2021 Apr 12.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Surgical site infection (SSI) may lead to vertebral osteomyelitis, diskitis, paraspinal musculoskeletal infection, and abscess, and remains a significant concern in postoperative management of spinal surgery. SSI is associated with greater postoperative morbidity and increased health care payments.

Methods:  We conducted a retrospective analysis using MarketScan to identify health care utilization payments and risk factors associated with SSI that occurs postoperatively. Known patient- or procedure-related risk factors were searched across those receiving spine surgery who developed postoperative infection.

Results:  A total of 33,061 patients who developed infection after spinal surgery were identified in Marketscan. Overall payments at 6 months, including index hospitalization for those with infection, were $53,573 and $46,985 for the cohort with no infection. At 24 months, the infection group had overall payments of $83,280 and $66,221 for no infection. Risk factors with largest effect size most likely to contribute to infection versus no infection were depression (4.6%), diabetes (3.7), anemia (3.3%), two or more levels (2.8%), tobacco use (2.2%), trauma (2.1%), neoplasm (1.8%), congestive heart failure (1.3%), instrumentation (1.1%), renal failure (0.9%), intravenous drug use (0.8%), and malnutrition (0.5%).

Conclusions:  SSIs were associated with significant health care utilization payments at 24 months of follow-up. The following clinical and procedural risk factors appear to be predictive of postoperative SSI: depression, diabetes, anemia, two or more levels, tobacco use, trauma, neoplasm, congestive heart failure, instrumentation, renal failure, intravenous drug use, and malnutrition. Interpretation of modifiable and nonmodifiable risk factors for infection informs surgeons of expected postoperative course and preoperative risk for this most common and deleterious postoperative complication to spinal surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1720984DOI Listing
April 2021

Preoperative and Postoperative Opioid Dependence in Patients Undergoing Anterior Cervical Diskectomy and Fusion for Degenerative Spinal Disorders.

J Neurol Surg A Cent Eur Neurosurg 2021 May 4;82(3):232-240. Epub 2021 Feb 4.

Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Anterior cervical diskectomy and fusion (ACDF) is a procedure for effectively relieving radiculopathy. Opioids are commonly overprescribed in postsurgical settings and prescriptions vary widely among providers. We identify trends in opioid dependence before and after ACDF.

Methods:  We used the Truven Health MarketScan data to identify adult patients undergoing ACDF for degenerative cervical spine conditions between 2009 and 2015. Patients were segregated in four cohorts of preoperative and postoperative opioid nondependence (ND) or dependence (D) with 15 months of postoperative follow-up.

Results:  A total of 25,403 patients with median age of 52 years (18-92) who underwent ACDF met the inclusion criteria. Breakdown of the four cohorts was as follows: prior nondependent who remain nondependent (NDND): 62.76% ( = 15,944); prior nondependent who become dependent (NDD): 4.6% ( = 1,168); prior dependent who become nondependent (DND): 14.03% ( = 3,564); and prior dependent who remain dependent (DD): 18.61% ( = 4,727). Opioid dependence decreased 9.43% postoperatively. Overall payments and 30-day readmissions increased 1.96 and 1.79 times for opioid dependent versus nondependent cohorts, respectively. Adjusted payments at 3 to 15 months were significantly increased for dependent cohorts with 3.56-fold increase for the DD cohort when compared with the NDND cohort. Length of stay, complications, medication refills, outpatient measures, and hospital admissions were also higher in those groups with postoperative opioid dependence when compared with those who were not opioid dependent.

Conclusions:  Opioid dependence after ACDF is associated with increased hospital readmissions, complication rates at 30 days, and payments within 3 months and 3 to 15 months postdischarge. Overall opioid dependence was decreased after ACDF procedure, however, a smaller number of opioid-dependent and opioid-naive patients became dependent postoperatively and should be followed carefully.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1718759DOI Listing
May 2021

Tumors in the cauda equina: A SEER analysis of tumor types and predictors of outcome.

J Clin Neurosci 2020 Nov 14;81:227-233. Epub 2020 Oct 14.

Neurological Surgery, Kentucky Spinal Cord Research Center; University of Louisville School of Medicine, Louisville, KY, USA.

Caudaequinatumors are histologically diverse. International Classification of Diseases for Oncology (ICD-O3) confers dedicated site code (C72. 1) for cauda equina. This code is excluded during analyses of other primary spinal cord tumors. In this retrospective study, the Surveillance, Epidemiology and End Results (SEER) data for primary cauda equina tumors (PCET, C72. 1) excluding the tumors of spinal meninges (C70. 1) from 1992 to 2015 were reviewed. Demographic characteristics, tumor types, and clinical outcomes were analyzed using univariable analysis. Overall survival was estimated using Kaplan-Meier methods and compared for age, histology and treatment type. 293 patients with PCET met inclusion criteria. The most common tumors comprised schwannoma (32%), myxopapillary ependymoma (21%), malignant ependymoma (22%). The median age at diagnosis was 50 years (range < 1 year to 98 years), 57% of patients were males. 77% of the patients underwent surgery. Median follow up time for these patients was 70 months. Of the 293 patients, 250 (85%) were living at the end of 2015. The cause of death was tumor or CNS related in 15 patients. 136 patients were followed for <5 years, of which 102 were censored and 34 died (11.6%) before 5 years. Using univariable analysis, age at diagnosis (Hazard Ratio, HR 1.05; confidence interval, CI 1.03-1.07; p < 0.001), malignant tumor type (HR 2.88, CI 1.15-7.19, p = 0.0239) and absence of surgical intervention (HR 2.54, CI1.26-5.11, p = 0.0092) were predictors of increased mortality. Although most patients did well, older age and lack of surgical intervention were associated with worse survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.09.068DOI Listing
November 2020

Impact of Surgical Approaches on Complications, Emergency Room Admissions, and Health Care Utilization in Patients Undergoing Lumbar Fusions for Degenerative Disc Diseases: A MarketScan Database Analysis.

World Neurosurg 2021 Jan 15;145:e305-e319. Epub 2020 Oct 15.

Department of Neurosurgery, Pacific Northwest University of Health Sciences, Yakima, Washington, USA. Electronic address:

Objective: To identify the impact of different surgical approaches for lumbar degenerative disc disease (DDD) on complications, reoperations/readmissions, and health care utilization.

Methods: We used International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Terminology codes to extract data from MarketScan. Patients were divided into 6 groups: single-level anterior only (sA), single-level anterior + posterior (sAP), single-level posterior (sP), multilevel anterior (mA), multilevel anterior + posterior (mAP), and multilevel posterior only (mP). Outcomes of interest were cumulative complication rates, reoperation rates, readmission, and health care utilization at 6, 12, and 24 months.

Results: Of 148,499 patients, 3% had sA fusion and 54% had mP procedures. Patients in the mAP cohort incurred higher cumulative complication rates (21%) compared with sA (13%), sAP (15%), sP (14%), mA (18%), and mP (18%). Emergency room admissions within 30 days were highest in the mA cohort (14%) followed by mAP (11%) and mP (8%). At 12 and 24 months, patients with mA procedures were most likely to have either new fusion or refusion (8% and 12%) followed by sA (7% and 10%), sAP (4% and 7%), mAP (4% and 8%) mP (4% and 7%), and sP (3% and 7%). Compared with the mP cohort, patients in the mA cohort incurred 1.2 times the overall median payments, whereas mAP and sA incurred 1.1 times the payments at 12 months. This difference was further reduced at 24 months.

Conclusions: mAP procedures are associated with higher cumulative complications and health care utilization compared with other procedures and the difference in health care utilization tends to decrease over 12 and 24 months.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.10.048DOI Listing
January 2021

Recombinant Human Bone Morphogenetic Protein-2 Use in Adult Spinal Deformity Surgery: Comparative Analysis and Healthcare Utilization at 24 Months' Follow-up.

Global Spine J 2020 Aug 26:2192568220947377. Epub 2020 Aug 26.

5170University of Louisville, Louisville, KY, USA.

Study Design: Retrospective cohort study.

Objective: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used to achieve fusion in adult spinal deformity (ASD) surgery. Our aim was to investigate the long-term impact of rhBMP-2 use for clinical outcomes and health care utilization in this patient population.

Methods: We conducted an analysis using MarketScan to identify health resource utilization of rhBMP-2 use for ASD after surgical intervention compared to fusion without rhBMP-2 at 24 months' follow-up. Outcomes assessed included length of stay, complications, pseudoarthrosis, reoperation, outpatient services, and health care payments.

Results: Of 7115 patients who underwent surgery for ASD, 854 received rhBMP-2 and 6261 were operated upon without use of rhBMP-2. One month after discharge, the rhBMP-2 cohort had a nonsignificant trend in fewer complications (15.38%) than those who did not receive rhBMP-2 (18.07%), = .0558. At 12 months, pseudoarthrosis was reported in 2.8% of cases with no BMP and 01.14% of cases with BMP, = .0048. Average payments at 12 months were $120 138 for the rhBMP-2 group and $118 373 for the no rhBMP-2 group, = .8228. At 24 months, payments were $141 664 for the rhBMP-2 group and $144 179 for the group that did not receive rhBMP-2, = .5946.

Conclusions: In ASD surgery, use of rhBMP-2 was not associated with increased complications or reoperations at index hospitalization and 1-month follow-up. Overall payments, including index hospitalization, readmissions, reoperations, and outpatient services were not different compared to those without the use of rhBMP-2 at 12 months and 24 months after discharge.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568220947377DOI Listing
August 2020

Economics of the Management of Craniospinal Chordoma and Chondrosarcoma and the feasibility of the bundled payment model.

BMC Neurol 2020 Aug 21;20(1):312. Epub 2020 Aug 21.

Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner way, Ste.1500, Louisville, KY, 40202, USA.

Background: The Centers for Medicare and Medicaid Services (CMS) created a new reimbursement model "Bundled Payment for Care Improvement (BPCI)" which reimburses providers a predetermined payment in advance to cover all possible services rendered within a certain time window. Chordoma and Chondrosarcoma are locally aggressive malignant primary bony tumors. Treatment includes surgical resection and radiotherapy with substantial risk for recurrence which necessitates monitoring and further treatment. We assessed the feasibility of the BPCI model in these neurosurgical diseases.

Methods: We selected patients with chordoma/chondrosarcoma from inpatient admission table using the International Classification of Disease, 9th (ICD-9), and 10th (ICD-10) revision codes. We collected the patients' demographics and insurance type at the index hospitalization. We recorded the following outcomes length of stay, total payment, discharge disposition, and complications for the index hospitalization. For post-discharge, we collected the 30 days and 3/6/12 months inpatient admission, outpatient service, and medication refills. Continuous variables were summarized by means with standard deviations, median with interquartile and full ranges (minimum-maximum); Continuous outcomes were compared by nonparametric Wilcoxson rank-sum test. All tests were 2-sided with a significance level of 0.05. Statistical data analysis was performed in SAS 9.4 (SAS Institute, Inc, Cary, NC).

Results: The population size was 2041 patients which included 1412 patients with cranial (group1), 343 patients with a mobile spine (group 2), and 286 patients with sacrococcygeal (group 3) chordoma and chondrosarcoma. For index hospitalization, the median length of stay (days) was 4, 6, and 7 for groups 1, 2, and 3 respectively (P<.001). The mean payments were ($58,130), ($84,854), and ($82,440), for groups 1, 2, and 3 respectively (P=.02). The complication rates were 30%, 35%, and 43% for groups 1, 2, and 3 respectively (P<.001). Twelve months post-discharge, the hospital readmission rates were 44%, 53%, and 65% for groups 1, 2, and 3, respectively (P<.001). The median payments for this period were ($72,294), ($76,827), and ($101,474), for groups 1, 2, and 3, respectively (P <.001).

Conclusion: The management of craniospinal chordoma and chondrosarcoma is costly and may extend over a prolonged period. The success of BPCI requires a joint effort between insurers and hospitals. Also, it should consider patients' comorbidities, the complexity of the disease. Finally, the adoptionof quality improvement programs by hospitals can help with cost reduction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12883-020-01850-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7441625PMC
August 2020

Evaluation of Predictive Models for Complications following Spinal Surgery.

J Neurol Surg A Cent Eur Neurosurg 2020 Nov 14;81(6):535-545. Epub 2020 Aug 14.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.

Background:  Complications rates vary across spinal surgery procedures and are difficult to predict due to heterogeneity in patient characteristics, surgical methods, and hospital volume. Incorporation of predictive models for complications may guide surgeon decision making and improve outcomes.

Methods:  We evaluate current independently validated predictive models for complications in spinal surgery with respect to study design and model generation, accuracy, reliability, and utility. We conducted our search using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and the Participants, Intervention, Comparison, Outcomes, Study Design model through the PubMed and Ovid Medline databases.

Results:  A total of 18 articles met inclusion criteria including 30 validated predictive models of complications after adult spinal surgery. National registry databases were used in 12 studies. Validation cohorts were used in seven studies for verification; three studies used other methods including random sample bootstrapping techniques or cross-validation. Reported area under the curve (AUC) values ranged from 0.37 to 1.0. Studies described treatment for deformity, degenerative conditions, inclusive spinal surgery (neoplasm, trauma, infection, deformity, degenerative), and miscellaneous (disk herniation, spinal epidural abscess). The most commonly cited risk factors for complications included in predictive models included age, body mass index, diabetes, sex, and smoking. Those models in the deformity subset that included radiographic and anatomical grading features reported higher AUC values than those that included patient demographics or medical comorbidities alone.

Conclusions:  We identified a cohort of 30 validated predictive models of complications following spinal surgery for degenerative conditions, deformity, infection, and trauma. Accurate evidence-based predictive models may enhance shared decision making, improve rehabilitation, reduce adverse events, and inform best practices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1709709DOI Listing
November 2020

Factors Impacting Outcomes and Health Care Utilization in Osteoporotic Patients Undergoing Lumbar Spine Fusions: A MarketScan Database Analysis.

World Neurosurg 2020 09 22;141:e976-e988. Epub 2020 Jun 22.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Objective: To identify factors impacting long-term complications, reoperations, readmission rates, and health care utilization in patients with osteoporosis (OP) following lumbar fusions.

Methods: We used International Classification of Disease, Ninth Revision, International Classification of Disease, Tenth Revision , and Current Procedural Terminology codes to extract data from MarketScan (2000-2016). Patients undergoing lumbar spine fusion were divided into 2 groups based on preoperative diagnosis: OP or non-OP. We used multivariable generalized linear regression models to analyze outcomes of interest (reoperation rates, readmissions, complications, health care utilization) at 1, 6, 12, and 24 months after discharge.

Results: MarketScan identified 116,749 patients who underwent lumbar fusion with ≥24 months of follow-up; 6% had OP. OP patients had a higher incidence of complications (14% vs. 9%); were less likely to be discharged home (77% vs. 86%, P < 0.05); had more new fusions or refusions at 6 months (2.9% vs. 2.1%), 12 months (5% vs. 3.8%), and 24 months (8.5% vs. 7.4%); incurred more outpatient services at 12 months (80 vs. 61) and 24 months (148 vs. 115); and incurred higher overall costs at 12 months ($22,932 vs. $17,017) and 24 months ($48,379 vs. $35,888). Elderly OP patients (>65 years old) who underwent multilevel lumbar fusions had longer hospitalization, had higher complication rates, and incurred lower costs at 6, 12, and 24 months compared with young non-OP patients who underwent single-level lumbar fusion.

Conclusions: Patients of all ages with OP had higher complication rates and required revision surgeries at 6, 12, and 24 months compared with non-OP patients. Elderly OP patients having multilevel lumbar fusions were twice as likely to have complications and lower health care utilization compared with younger non-OP patients who underwent single-level fusion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.06.107DOI Listing
September 2020

An image features assisted line selection method in laser-induced breakdown spectroscopy.

Anal Chim Acta 2020 May 17;1111:139-146. Epub 2020 Mar 17.

Wuhan National Laboratory for Optoelectronics (WNLO), Huazhong University of Science and Technology (HUST), Wuhan, Hubei, 430074, PR China.

Analytical lines play a crucial role in laser-induced breakdown spectroscopy (LIBS) technology. To improve the classification performance of LIBS, an image features assisted line selection (IFALS) method which based on spectral morphology and the characteristics of Harris corners was proposed. With this method, a classification experiment for 24 metamorphic rock samples was conducted with linear discriminant analysis (LDA) algorithm. The result showed that the classification accuracy was increased from 94.38% of the conventional classification model MLS-LDA (Manual line selection-linear discriminant analysis) to 98.54% of IFALS-LDA. Furthermore, the time required for the whole classification process was decreased from 2768.38 s of MLS-LDA to 4.36 s of the proposed method, thus the classification efficiency was greatly improved. In addition, compared with the existing automatic line selection method, the convergence rate of IFALS-LDA is significantly faster than that of ASPI (Automatic spectral peaks identification)-LDA. This study demonstrates that LIBS assisted with the image features in machine vision can promote the analytical performance of LIBS technology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.aca.2020.03.030DOI Listing
May 2020

National Trends and Factors Predicting Outcomes Following Laser Interstitial Thermal Therapy for Brain Lesions: Nationwide Inpatient Sample Analysis.

World Neurosurg 2020 07 3;139:e88-e97. Epub 2020 Apr 3.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Laser interstitial thermal therapy (LITT) is a stereotactic-guided technique, which is increasingly being performed for brain lesions. The aim of our study was to report the national trends and factors predicting the clinical outcomes following LITT using the Nationwide Inpatient Sample.

Methods: We extracted data from 2011-2016 using ICD-9/10 codes. Patients with a primary procedure of LITT were included. Patient demographics, complications, length of hospital stay, discharge disposition, and index-hospitalization charges were analyzed.

Results: A cohort of 1768 patients was identified from the database. Mean length of hospital stay was 3.2 days, 82% of patients were discharged to home, and in-hospitalization cost was $124,225. Complications and mortality were noted in 12.9% and 2.5% of patients following LITT, respectively. Non-Caucasian patients (estimate ratio [ER] 4.26), those with other insurance (compared with commercial, ER: 5.35), 3 and 4+ comorbidity indexes, patients with higher quartile median household income (second, third, and fourth quartile compared with first quartile), and those who underwent nonelective procedures were likely to have higher complications and less likely to be discharged home. Patients with 4+ comorbidity indexes were likely to have longer length of hospital stay (ER 1.39) and higher complications (ER: 7.95) and were less likely to be discharged home (ER: 0.17) and have higher in-hospitalization cost (ER: 1.21).

Conclusions: LITT is increasingly being performed with low complication rates. Non-Caucasian race, higher comorbidity index, noncommercial insurance, and nonelective procedures were predictors of higher complications and being less likely to be discharged home. In-hospitalization charges were higher in patients with higher comorbidity index and those with noncommercial insurance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.03.124DOI Listing
July 2020

Inverse national trends of laser interstitial thermal therapy and open surgical procedures for refractory epilepsy: a Nationwide Inpatient Sample-based propensity score matching analysis.

Neurosurg Focus 2020 04;48(4):E11

Objective: Surgery for medically refractory epilepsy (RE) is an underutilized treatment modality, despite its efficacy. Laser interstitial thermal therapy (LITT), which is minimally invasive, is increasingly being utilized for a variety of brain lesions and offers comparable seizure outcomes. The aim of this study was to report the national trends of open surgical procedures for RE with the advent of LITT.

Methods: Data were extracted using the ICD-9/10 codes from the Nationwide Inpatient Sample (NIS, 2012-2016) in this retrospective study. Patients with a primary diagnosis of RE who underwent either open surgeries (lobectomy, partial lobectomy, and amygdalohippocampectomy) or LITT were included. Patient demographics, complications, hospital length of stay (LOS), discharge disposition, and index hospitalization costs were analyzed. Propensity score matching (PSM) was used to analyze outcomes.

Results: A cohort of 128,525 in-hospital patients with RE was included and 5.5% (n = 7045) of these patients underwent either open surgical procedures (94.3%) or LITT (5.7%). LITT is increasingly being performed at a rate of 1.09 per 1000 epilepsy admissions/year, while open surgical procedures are decreasing at a rate of 10.4/1000 cases/year. The majority of procedures were elective (92%) and were performed at large-bed-size hospitals (86%). All LITT procedures were performed at teaching facilities and the majority were performed in the South (37%) and West (30%) regions. The median LOS was 1 day for the LITT cohort and 4 days for the open cohort. Index hospitalization charges were significantly lower following LITT compared to open procedures ($108,332 for LITT vs $124,012 for open surgery, p < 0.0001). LITT was associated with shorter median LOS, high likelihood of discharge home, and lower median index hospitalization charges compared to open procedures for RE on PSM analysis.

Conclusions: LITT is increasingly being performed in favor of open surgical procedures. LITT is associated with a shorter LOS, a higher likelihood of being discharged home, and lower index hospitalization charges compared to open procedures. LITT is a safe treatment modality in carefully selected patients with RE and offers an opportunity to increase the utilization of surgical treatment in patients who may be opposed to open surgery or have contraindications that preclude open surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.1.FOCUS19935DOI Listing
April 2020

Inverse National Trends in Decompressive Craniectomy versus Endovascular Thrombectomy for Stroke.

World Neurosurg 2020 06 13;138:e642-e651. Epub 2020 Mar 13.

Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA. Electronic address:

Objective: Endovascular thrombectomy (ET) for acute large vessel occlusion reduces infarct size, and it should hypothetically decrease the incidence of major ischemic strokes requiring decompressive craniectomy (DC). The aim of this retrospective cohort study is to determine trends in the utilization of ET versus DC for stroke in the United States over a 10-year span.

Methods: We extracted data from the Nationwide Inpatient Sample using International Classification of Diseases-9/10 codes from 2006-2016. Patients with a primary diagnosis of stroke were included. Baseline demographics, outcomes, and hospital charges were analyzed.

Results: The study cohort comprised 14,578,654 patients diagnosed with stroke. During the study period, DC and ET were performed in 124,718 and 62,637 patients, respectively. The number of stroke patients who underwent either ET or DC increased by 266% from 2006 to 2016. During that time period, the ET utilization rate increased (0.19% in 2006 to 14.07% in 2016, P < 0.0004), whereas the DC utilization rate decreased (7.07% in 2006 to 6.43% in 2016, P < 0.0001). In 2015, the utilization rate of ET (9.73%) exceeded that of DC (9.67%). ET-treated patients had shorter hospitalization durations (mean 8.8 vs. 16.8 days, P < 0.0001), lower mortality (16.2% vs. 19.3%), higher likelihood of discharge home (27.1% vs. 24.1%, P < 0.0001), and reduced hospital charges (mean $189,724 vs. $261,314, P < 0.0001).

Conclusions: We identified an inverse relationship between national trends in rising ET and diminishing DC utilization for stroke treatment over a recent decade. Although direct causation cannot be inferred, our findings suggest that ET curtails the necessity for DC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.03.022DOI Listing
June 2020

Impact of Surgical Timing and Approaches to Health Care Utilization in Patients Undergoing Surgery for Acute Traumatic Cervical Spinal Cord Injury.

Cureus 2019 Nov 15;11(11):e6166. Epub 2019 Nov 15.

Neurosurgery, University of Louisville School of Medicine, Louisville, USA.

Objective Acute traumatic cervical spinal cord injury (AcSCI) causes significant morbidity and has an impact on health care utilization. The aim of our study was to analyze health care utilization in patients undergoing surgical decompression and fusion for AcSCI based on timing and type of surgical approaches.  Patient and methods Data were extracted using ICD9/10 and CPT codes from MarketScan (IBM Corp. Armonk, New York [v. 2000-2015]). We defined the comparative groups based on the timing of surgery (early <24 hours and late >24 hours) and surgical approaches: anterior, posterior and circumferential. Outcomes of interest were: length of hospital stay, discharge disposition and health care utilization in the index hospitalization, within 30 days after discharge and 12 months following injury. Results Of 1604 patients, 80.9% had early procedures and 55.7% of these had anterior-only procedures. Overall, the median age was 46 years in the early surgery group and 47 years in the late surgery group. Patients in the early surgical group incurred higher outpatient services and there was no difference in cumulative median payments (index + 12 months) across the cohorts (early: $127,379, late: $121,049). The incidence of repeat surgery at the index level did not differ based on the timing of surgery (early 5% vs. late 7%). Complications were higher in the circumferential surgery cohort irrespective of the timing of surgery. Overall, combined median payment (index hospitalization + 12 months) was significantly higher for early circumferential cohorts compared to the anterior or posterior-only cohort ($195,990 and $109,977 vs. $121,236 respectively). Conclusion Late (>24 hours) surgeries were associated with a higher likelihood to be discharged home, lower utilization of outpatient services, higher hospital readmissions and no differences in payments (index and cumulative) compared to early surgeries. Circumferential approaches were associated with higher complication rates, lesser likelihood to be discharged home, higher utilization of outpatient services compared to anterior-only approaches.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.6166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913951PMC
November 2019

A Two-decade Assessment of Changing Practice for Surgical Decompression and Fixation after Traumatic Spinal Cord Injury - Impact on Healthcare Utilization and Cost.

Cureus 2019 Nov 14;11(11):e6156. Epub 2019 Nov 14.

Neurosurgery, University of Louisville School of Medicine, Louisville, USA.

Early surgery after traumatic spinal cord injury (TSCI) has been associated with a greater neurological recovery and reduced secondary complications. In this study, we aimed to evaluate the trend of early TSCI surgery (within 24 hours) over two decades and the effect on length of hospitalization, complications, and hospital charges. We extracted emergency admissions of adults diagnosed with TSCI from the National Inpatient Sample database (1998-2016). We analyzed the trend of early surgery and concurrent trends of complication rate, length of stay (LOS) and hospital charges. These outcomes were then compared between early and late surgery cohorts. There were 3942 (53%) TSCI patients who underwent early surgery, and 3446 (47%) were operated after 24 hours. The combined patient group characteristics consisted of median age 43 years (IQR: 29-59), 73% males, 72% white, 44% private payer, 18% Medicare, 17% Medicaid, 51% cervical, 30% thoracic, 75% from large hospitals, and 79% from teaching hospitals. The trend of early surgery, adjusted for annual case-mix, increased from 45% in 1998 to 64% in 2016. Each year was associated with 1.60% more patients undergoing early surgery than the previous year (-value <0.05). During these years, the total LOS decreased, while hospital charges increased. Patients who underwent early surgery spent four fewer days in the hospital, accrued $28,705 lower in hospital charges and had 2.8% fewer complications than those with delay surgery. We found that the rate of early surgery has significantly increased from 1998 to 2016. However, as of 2016, one-third of patients still did not undergo spinal surgery within 24 hours. Late surgery is associated with higher complications, longer stays, and higher charges. The causes of delayed surgery are undoubtedly justified in some situations but require further delineation. Surgeons should consider performing surgery within 24 hours on patients with TSCI whenever feasible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.6156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913978PMC
November 2019

Long-Term Comparison of Health Care Utilization and Reoperation Rates in Patients Undergoing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disc Disease.

World Neurosurg 2020 Feb 13;134:e855-e865. Epub 2019 Nov 13.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.

Background: Thus study was a retrospective cohort analysis. Anterior cervical discectomy and fusion (ACDF) has been the gold-standard procedure for single-level degenerative disc disease (DDD). Recently, cervical disc arthroplasty (CDA) has become increasingly prevalent as an alternative intervention.

Objective: To examine the long-term costs and reoperation rates associated with CDA and ACDF for the treatment of single-level DDD.

Methods: In the present study, we performed a retrospective cohort analysis using the MarketScan database of patients who underwent either ACDF or CDA between 2007 and 2011 and had 5 years postsurgery follow-up. Outcomes related to the health care utilization, cost, and reoperation were analyzed after propensity score matching (PSM).

Results: Of 12,434 patients, 12,099 underwent ACDF and 335 CDA. Length of hospital stay and initial hospitalization cost was higher after ACDF compared with CDA. More patients undergoing CDA had early physical therapy compared with patients undergoing ACDF (CDA 30.15% vs. ACDF 22.39%; P = 0.0176). Five years after surgery, there was no significant difference in overall payments between patients undergoing ACDF and patients undergoing CDA. Reoperation rates were comparable at 5 years after the index procedure (CDA 8.06% vs. ACDF 9.25%; P = 0.5862). Patients who underwent ACDF showed decreased use of tramadol after surgery (15.09% before surgery vs. 9.55% after surgery; P < 0.0001).

Conclusions: We found no difference in health care utilization between ACDF and CDA procedures for DDD 5 years after surgery. Also, there was no difference in reoperation rates during the study period. ACDF resulted in significant reduction in overall opioid use after versus before procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.11.012DOI Listing
February 2020

Simulating Episode-Based Bundled Payments for Cranial Neurosurgical Procedures.

Neurosurgery 2020 07;87(1):86-95

Department of Neurosurgery, Stanford University, Stanford, California.

Background: Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Payments for Care Improvement (BPCI) in order to improve care coordination and cost efficiency. BPCI has not yet been applied to cranial neurosurgical procedures.

Objective: To determine projected values of episode-based bundled payments when applied to common cranial neurosurgical procedures using retrospective data from a large database.

Methods: We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment payments for 4 groups of common cranial neurosurgical procedures.

Results: We identified 15 276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-d bundle projected payments ranging from $ 58,200 for craniotomy for meningioma to $ 102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected payments for a 30-d bundle and 70.5% of projected payments for a 90-d bundle. Multivariable analysis showed that hospital readmission, discharge to postacute care facilities, venous-thrombo-embolism, medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle payments.

Conclusion: For the first time, to our knowledge, we project the values of episode-based bundled payments for common vascular and tumor cranial operations. As previously identified in orthopedic procedures, there is significant variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, postdischarge care significantly impacts total bundle payments in cranial neurosurgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz353DOI Listing
July 2020

Ninety-Day Bundled Payment Reimbursement for Patients Undergoing Anterior and Posterior Procedures for Degenerative Cervical Radiculopathy.

Neurosurgery 2019 11;85(5):E851-E859

Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Background: Anterior cervical discectomy with fusion (ACDF) or posterior cervical foraminotomy (PCF) are the mainstay surgical treatment options for patients with degenerative cervical radiculopathy (DCR).

Objective: To compare 90-d bundled payments between ACDF and PCF for DCR in a cohort study.

Methods: Data were extracted from MarketScan database (2000-2016) using ICD-9, ICD-10, and CPT-4 codes. The bundle payments were calculated as the payments accumulated from the index hospitalization admission to 90 d postsurgery. We also analyzed the index hospitalization (physician, hospital, and total) and the postdischarge payments (hospital readmission, outpatient services, medications, and total). Surgical groups were matched based on baseline characteristics (age, sex, insurance type, and Elixhauser score).

Results: A total of 100 041 patients met the inclusion criteria. 94.9% of patients (n = 95 031). Patients underwent ACDF with 5.1% (n = 5 010) treated via PCF. Overall, median 90-d costs were significantly higher for ACDF than for PCF ($31567 vs $18412; P < .0001). The median total index hospitalization ($27841 vs $15043), physician ($4572 vs $1920), and hospital payments ($14540 vs $7404) were higher for ACDF compared to PCF for both single- and multiple-level cohorts (P < .0001). There was no difference in overall 90-d postdischarge payments. Factors associated with higher 90-d payments for both cohorts included age and comorbidity scores.

Conclusion: ACDF is associated with greater bundle payments in patients diagnosed with DCR. No difference was noted for the total postdischarge payments. PCF may be a cost-effective surgical option in appropriately selected patients with unilateral, paracentral, and foraminal soft herniated discs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz123DOI Listing
November 2019

Enhanced Recovery After Surgery (ERAS) for Spine Surgery: A Systematic Review.

World Neurosurg 2019 Oct 2;130:415-426. Epub 2019 Jul 2.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Enhanced recovery after surgery (ERAS) represents an evidence-based multidisciplinary approach to perioperative management after major surgery that decreases complications and readmissions and improves functional recovery. Spine surgery is a traditionally invasive intervention with an extended recovery phase and may benefit from ERAS protocol integration.

Methods: We analyzed the use of ERAS in spine surgery by completing a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model through PubMed and Ovid databases to identify studies that fit our search criteria. We assess the outcomes and ERAS elements selected across protocols as well as the study design and internal validation methods.

Results: A total of 19 studies met the inclusion criteria and were used in our analysis. Patient populations differed significantly across all 4 studies. Reduction in length of stay was reported in 7 studies using the ERAS protocol. Comparative studies between ERAS and non-ERAS show improved pain scores and reduced opioid consumption postoperatively, but no differences in complications or readmissions between groups. Complication rates under ERAS protocols ranged from 2.0% to 31.7%. Significant pain reduction in visual analog scale scores was observed with 3 ERAS protocols. Direct, indirect, and total cost decreases were also observed with implementation of ERAS protocols.

Conclusions: A limited cohort of studies with significant variability in patient population and ERAS protocol implementation have evaluated the integration of ERAS within spine surgery. ERAS in spine surgery may provide reductions in complications, readmissions, length of stay, and opioid use, in combination with improvements in patient-reported outcomes and functional recovery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.06.181DOI Listing
October 2019

Health Care Utilization and Payments of Postoperative and Drug Abuse-Related Spinal Infections.

Spine (Phila Pa 1976) 2019 Oct;44(20):1449-1455

Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Study Design: Retrospective analysis of data extracted from the MarketScan database (2000-2016) using International Classification of Diseases (ICD)-9, ICD-10, and Current Procedural Terminology-4 codes.

Objective: Evaluate the economic costs and health care utilization associated with spine infections.

Summary Of Background Data: Spinal infections (SI) are associated with significant morbidity and mortality. A recent spike in SI is attributed to the drug abuse epidemic. Management of SI represents a large burden on the health care system.

Methods: We assessed payments and outcomes at the index hospitalization, 1-, 3-, 6-, and 12-month follow up. Outcomes assessed included length of stay, complications, operation rates, and health care utilization. Outcomes were compared between cohorts with spinal infections: (1) with prior surgery, (2) drug abuse, and (3) without previous exposure to surgery or drug abuse, denoted as control.

Results: We identified 43,972 patients; 15.6% (N = 6847) of patients underwent prior surgery, 3.8% (N = 1,668) were previously expose to drug abuse while 80.6% fell into the control group. Both the postsurgical and drug abuse groups longer hospital stay compared with the control cohort (5 d vs. 4 d, P < 0.0001). Exposure to IV drug abuse was associated with increased risk of complications compared with the control group (43% vs. 38%, P < 0.0001). Payments at 1-month follow-up were significantly (P < 0.0001) higher among the postsurgical group compared with both groups. However, at 12-months follow-up, payments were significantly (P < 0.0001) higher in the drug abuse group compared with both groups. Only postsurgical infections were associated with higher number of surgical interventions both at presentation and 1 year follow up.

Conclusion: SI following surgery or IV drug abuse are associated with higher payments, complication rates, and longer hospital stays. Drug abuse related SI are associated with the highest complication rates, readmissions, and overall payments at 1 year of follow up despite the lower rate of surgical interventions.

Level Of Evidence: 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000003102DOI Listing
October 2019

Differences in clinical outcomes and health care utilization between octogenarians and nonagenarians following decompression for lumbar spinal stenosis. A market scan analysis.

Clin Neurol Neurosurg 2019 07 1;182:63-69. Epub 2019 May 1.

Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA. Electronic address:

Objective: Lumbar spinal stenosis (LSS) in octogenarians and beyond has a significant impact on quality of life requiring surgical decompression and hence impact on health care utilization. Risk of surgical failure and impact on health care resources is always a concern in this patient population (more so in nonagenarians). The aim of our study was to compare clinical outcomes and healthcare utilization in patients (80-89 vs.90+) undergoing decompression for LSS.

Patients And Methods: Data was extracted using ICD9/10 and CPT codes from MarketScan (2001-2015) in this retrospective study. We defined the comparative groups based on the age groups (80-89 and 90+), in patients with LSS. Outcomes of interest were: length of hospital stay, discharge disposition and utilization in the index hospitalization, 6- months, 12 months following index procedure as well as the associated health care utilization. Patient characteristics and outcomes among cohorts were compared using univariate tests. Outcomes were further compared using adjusted multivariable regression models. Statistical analysis was performed with SAS 9.4.

Results: A cohort of 5387 was identified from the database, 96.38% were in the 80-89 age group and 3.62%were in the 90+ age group. The proportion of patients undergoing surgery for LSS among 80-89 (95.7-98.5%) and 90+ age group (1.5-4.3%) remained constant through the years. Interestingly, 13.83% and 16.92% of patients had Elixhauser comorbidity index of 3+ in 80-89 age group and 90+ age groups respectively. Decompression with fusion was performed in 19.4% of patients in 80-89 age group, compared to 9.74% of patients in 90+ age group. There was no difference in median length of hospital stay (3 days, p = 0.19) and complications across the cohorts (80-89: 16.7%; 90+: 18.46% p = 0.51). 70.6% of patients in 80-89 age groups were discharged to home compared to 60.5% in 90+ age group (p = 0.0023). At 6 months follow-up, overall rate of new decompression, new fusion, re-fusion at index level were 2.38%, 0.59% and 0.33% only, with no differences across the cohorts. Interestingly, patients in 80-89 age group incurred higher outpatient services, number of medication refills and related payments at 6-months and 12-months follow-up, compared to patients in 90+ age group. Overall, combined median post-discharge payments at 12 months were similar across the groups [80-89 (median $ 40,257) and 90+ (median$ 36,161), p = 0.14].

Conclusion: Using MarketScan database, there has been a gradual decline in the number of decompressions being performed for LSS in elderly patients (>80 years of age), however there is no change in the proportion of octogenarians and nonagenarians undergoing decompression for LSS. There was no difference in rate of reoperations and overall health care utilization among the groups. Surgery for LSS can be offered to nonagenarians (in appropriately selected patients) with no difference in clinical outcomes and health care utilization, compared to octogenarians.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clineuro.2019.04.031DOI Listing
July 2019

Outcomes of decompression and fusion for treatment of spinal infection

Neurosurg Focus 2019 02 15;46(1):E7. Epub 2019 Feb 15.

1Department of Neurosurgery, University of Louisville, Louisville, Kentucky.

Objective: Spine infection including vertebral osteomyelitis, discitis, paraspinal musculoskeletal infection, and spinal abscess refractory to medical management poses significant challenges to the treating physician. Surgical management is often required in patients suffering neurological deficits or spinal deformity with significant pain. To date, best practices have not been elucidated for the optimization of health outcomes and resource utilization in the setting of surgical intervention for spinal infection. The authors conducted the present study to assess the magnitude of reoperation rates in both fusion and nonfusion groups as well as overall health resource utilization following surgical decompression for spine infection.

Methods: The authors performed an analysis using MarketScan (2001–2015) to identify health outcomes and healthcare utilization metrics of spine infection following surgical intervention with decompression alone or combined with fusion. Adult patients underwent surgical management for primary or secondary spinal infection and were followed up for at least 12 months postoperatively. Assessed outcomes included reoperation, healthcare utilization and payment at the index hospitalization and within 12 months after discharge, postoperative complications, and infection recurrence.

Results: A total of 2662 patients in the database were eligible for inclusion in this study. Rehospitalization for infection was observed in 3.99% of patients who had undergone fusion and in 11.25% of those treated with decompression alone. Reoperation was needed in 12.7% of the patients without fusion and 8.16% of those with fusion. Complications within 30 days were more common in the nonfusion group (24.64%) than in the fusion group (16.49%). Overall postoperative payments after 12 months totaled $33,137 for the nonfusion group and $23,426 for the fusion group.

Conclusions: In this large cohort study with a 12-month follow-up, the recurrence of infection, reoperation rates, and complications were higher in patients treated with decompression alone than in those treated with decompression plus fusion. These findings along with imaging characteristics, disease severity, extent of bony resection, and the presence of instability may help surgeons decide whether to include fusion at the time of initial surgery. Further studies that control for selection bias in appropriately matched cohorts are necessary to determine the additive benefits of fusion in spinal infection management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.10.FOCUS18460DOI Listing
February 2019

Insights into complication rates, reoperation rates, and healthcare utilization associated with use of recombinant human bone morphogenetic protein-2 in patients with spine infections.

Neurosurg Focus 2019 01;46(1):E8

1Department of Neurosurgery, University of Louisville, Louisville, Kentucky; and.

OBJECTIVEUse of recombinant human bone morphogenetic protein-2 (rhBMP-2) in patients with spine infections is controversial. The purpose of this study was to identify long-term complications, reoperations, and healthcare utilization associated with rhBMP-2 use in patients with spine infections.METHODSThis retrospective study extracted data using ICD-9/10 and CPT codes from MarketScan (2000-2016). Patients were dichotomized into 2 groups (rhBMP-2, no rhBMP-2) based on whether rhBMP-2 was used during fusion surgery for spinal infections. Outcomes of interest were reoperation rates (index level, other levels), readmission rates, discharge disposition, length of stay, complications, and healthcare resource utilization at the index hospitalization and 1, 3, 6, 12, and 24 months following discharge. Outcomes were compared using nonparametric 2-group tests and generalized linear regression models.RESULTSThe database search identified 2762 patients with > 24 months' follow-up; rhBMP-2 was used in 8.4% of their cases. The patients' median age was 53 years, 52.43% were female, and 15.11% had an Elixhauser Comorbidity Index ≥ 3. Patients in the rhBMP-2 group had higher comorbidity indices, incurred higher costs at index hospitalization, were discharged home in most cases, and had lower complication rates than those in the no-rhBMP-2 group. There was no statistically significant between-groups difference in complication rates 1 month following discharge or in reoperation rates at 3, 6, 12, and 24 months following the procedure. Patients in the no-rhBMP-2 group incurred higher utilization of outpatient services and medication refill costs at 1, 3, 6, 12, and 24 months following surgery.CONCLUSIONSIn patients undergoing surgery for spine infection, rhBMP-2 use was associated with lower complication rates and higher median payments during index hospitalization compared to cases in which rhBMP-2 was not used. There was no significant between-groups difference in reoperation rates (index and other levels) at 3, 6, 12, and 24 months after the index operation. Patients treated with rhBMP-2 incurred lower utilization of outpatient services and overall payments. These results indicate that rhBMP-2 can be used safely in patients with spine infections with cost-effective utilization of healthcare resources and without an increase in complications or reoperation rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.10.FOCUS18448DOI Listing
January 2019

Bundled Payment Models in Spine Surgery: Current Challenges and Opportunities, a Systematic Review.

World Neurosurg 2019 Mar 12;123:177-183. Epub 2018 Dec 12.

Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA. Electronic address:

Background: Bundled payments offer a lump sum for management of particular conditions over a specified period that has the potential to reduce health care payments. In addition, bundled payments represent a shift toward patient-centered reimbursement, which has the upside of improved care coordination among providers and may lead to improved outcomes.

Objective: To review the challenges and sources of payment variation and opportunities for restructuring bundled payments plans in the context of spine surgery.

Methods: We reviewed episodes of care over the past 10 years. We completed a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model in PubMed and Ovid databases to identify studies that met our search criteria.

Results: Ten studies met the search criteria, which were retrospective in design. The primary recipient of reimbursement was the hospital associated with the index procedure (59.7%-77% of the bundled payment), followed by surgeon reimbursement (12.8%-14%) and post-acute care rehabilitation (3.6%-7.3%). On average, the index hospitalization was $32,467, ranging from $11,880 to $107,642, depending on number of levels fused, complications, and malignancy. Readmission was shown to increase the 90-day payment by 50%-200% for uncomplicated fusion.

Conclusions: The implementation of spine surgery in bundled payment models offers opportunity for health care cost reduction. Patient heterogeneity, complications, and index hospitalization pricing are among factors that contribute to the challenge of payment variation. Development of standard care pathways, multidisciplinary coordination between inpatient and outpatient postoperative care, and empowerment of patients are also key elements of progress in the evolution of bundled payments in spine surgery. We anticipate more individualized risk-adjusted prediction models of payment for spine surgery, contributing to more manageable variation in payment and favorable models of bundled payments for payers and providers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2018.12.001DOI Listing
March 2019

Variability in the utility of predictive models in predicting patient-reported outcomes following spine surgery for degenerative conditions: a systematic review.

Neurosurg Focus 2018 11;45(5):E10

1Department of Neurosurgery, University of Louisville, Kentucky.

OBJECTIVEThere is increasing emphasis on patient-reported outcomes (PROs) to quantitatively evaluate quality outcomes from degenerative spine surgery. However, accurate prediction of PROs is challenging due to heterogeneity in outcome measures, patient characteristics, treatment characteristics, and methodological characteristics. The purpose of this study was to evaluate the current landscape of independently validated predictive models for PROs in elective degenerative spinal surgery with respect to study design and model generation, training, accuracy, reliability, variance, and utility.METHODSThe authors analyzed the current predictive models in PROs by performing a search of the PubMed and Ovid databases using PRISMA guidelines and a PICOS (participants, intervention, comparison, outcomes, study design) model. They assessed the common outcomes and variables used across models as well as the study design and internal validation methods.RESULTSA total of 7 articles met the inclusion criteria, including a total of 17 validated predictive models of PROs after adult degenerative spine surgery. National registry databases were used in 4 of the studies. Validation cohorts were used in 2 studies for model verification and 5 studies used other methods, including random sample bootstrapping techniques. Reported c-index values ranged from 0.47 to 0.79. Two studies report the area under the curve (0.71-0.83) and one reports a misclassification rate (9.9%). Several positive predictors, including high baseline pain intensity and disability, demonstrated high likelihood of favorable PROs.CONCLUSIONSA limited but effective cohort of validated predictive models of spine surgical outcomes had proven good predictability for PROs. Instruments with predictive accuracy can enhance shared decision-making, improve rehabilitation, and inform best practices in the setting of heterogeneous patient characteristics and surgical factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.8.FOCUS18331DOI Listing
November 2018

Opioid Dependence and Health Care Utilization After Decompression and Fusion in Patients With Adult Degenerative Scoliosis.

Spine (Phila Pa 1976) 2019 02;44(4):280-290

Department of Neurosurgery, University of Louisville, Louisville, KY.

Study Design: Retrospective study.

Objective: To identify factors associated with opioid dependence after surgery for adult degenerative scoliosis (ADSc).

Summary Of Background Data: Opioid epidemic is of prodigious concern throughout the United States.

Methods: Data was extracted using national MarketScan database (2000-2016). Opioid dependence was defined as continued opioid use or >10 opioid prescriptions for 1 year either before or 3 to 15 months after the procedure. Patients were segregated into four groups based on opioid dependence before and postsurgery: NDND (before nondependent who remain non-dependent), NDD (before nondependent who become dependent), DND (before dependent who become non-dependent) and DD (before dependent who remain dependent). Outcomes were discharge disposition, length of stay, complications, and healthcare resource utilization.

Results: Approximately, 35.82% (n = 268) of patients were identified to have opioid dependence before surgery and 28.34% (n = 212) were identified to have opioid dependence after surgery for ADSc. After surgical fusion for ADSc, patients were twice likely to become opioid independent than they were to become dependent (13.77% vs. 6.28%, OR: 2.191, 95% CI: 21.552-3.094; P < 0.0001). Before opioid dependence (RR: 14.841; 95% CI: 9.867, 22.323; P < 0.0001) was identified as a significant predictor of opioid dependence after surgery for ADSc. In our study, 57.9%, 6.28%, 13.77%, and 22.06% of patients were in groups NDND, NDD, DND, and DD respectively. DD and NDD were likely to incur 3.03 and 2.28 times respectively the overall costs compared with patients' ingroup NDND (P < 0.0001), at 3 to 15 months postsurgery (median $21648 for NDD; $40,975 for DD; and $ 13571 for NDND groups).

Conclusion: Surgery for ADSc was not associated with increased likelihood of opioid dependence, especially in opioid naïve patients. Patients on regular opiate treatment before surgery were likely to remain on opiates after surgery. Patients who continued to be opioid dependent or become dependent after surgery incur significantly higher healthcare utilization at 3 and 3 to 15 months.

Level Of Evidence: 4.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BRS.0000000000002794DOI Listing
February 2019

Nanocrystalline LaO/NiO composite as high performance electrodes for supercapacitors.

Dalton Trans 2017 Dec 20;46(47):16532-16540. Epub 2017 Nov 20.

College of Materials Science and Engineering, Sichuan University, Chengdu 610064, China.

Nanocrystalline LaO/NiO composite electrodes were synthesized via two types of facile cathodic electrodeposition methods onto nickel foam followed by thermal annealing without any binders. Scanning electron microscopy and transmission electron microscopy investigation revealed that LaO nanocrystalline particles with an average diameter of 50 nm are uniformly distributed in the NiO layer or alternately deposited with the NiO layer onto the substrate. It is speculated that LaO particles can participate in the faradaic reaction directly and offer more redox sites. Besides this, the unique Ni/La layered structure facilitates the diffusion of ions and retards the electrode polarization, thus leading to a better rate capability and cycling stability of NiO. As a result, the obtained electrodes display very competitive electrochemical performance (a specific capacitance of 1238 F g at a current density of 0.5 A g, excellent rate capability of 86% of the original capacitance at 10 A g and excellent cycling stability of 93% capacitance after 10 000 cycles). In addition, asymmetric coin devices were assembled using LaO/NiO as the positive electrode and active carbon as the negative electrode. The assembled asymmetric devices demonstrate a high energy density of 13.12 W h kg at a power density of 90.72 W kg.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1039/c7dt03815aDOI Listing
December 2017