Publications by authors named "Nicholas M Rabah"

14 Publications

  • Page 1 of 1

A Retrospective Analysis of the L3-L4 Disc and Spinopelvic Parameters on Outcomes in Thoracolumbar Fusion: Was Art Steffee Right?

World Neurosurg 2021 Dec 23. Epub 2021 Dec 23.

Center for Spine Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Objective: To determine whether the L3-L4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery and to explore the relationship between radiographic and patient-reported outcomes after thoracolumbar fusion surgery.

Methods: Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D-3L) scores and adverse events including adjacent-segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-L4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D-3L, respectively.

Results: In total, 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-L4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D-3L scores, although scores were significantly improved postfusion in all dimensions except Self-Care (P = 0.51).

Conclusions: L3-L4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. The degree of spinopelvic alignment did not correlate to improvement in EQ-5D-3L score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of postfusion alignment.
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http://dx.doi.org/10.1016/j.wneu.2021.12.065DOI Listing
December 2021

The 2021 Neurosurgery Match: An analysis of the impact of virtual interviewing and other COVID-19 related changes.

World Neurosurg 2021 Dec 2. Epub 2021 Dec 2.

Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio. Electronic address:

Given safety concerns during the COVID-19 pandemic, residency programs suspended away rotations in 2021 and the interview process transitioned to a virtual video format. In this study, we assessed the extent to which these changes affected match outcomes and if medical school ranking, international graduate status, or affiliation with a home neurosurgery program affected these outcomes. A cross-sectional analysis of neurosurgery match data from 2016-2021 was performed, and match outcomes were assessed based on matched program geography and program research ranking. Chi square tests were performed to identify significant differences between 2021 and 2016-2020 match results. A total of 1324 confirmed matched neurosurgery residents were identified from 2016-2021 (2016-2020: n=1113, 2021: n=211). There was no statistically significant difference in the rates of matching at a home program, within state, or within region between 2021 and 2016-2020 in the overall cohort. Proportions of international graduates and students without home programs among matched applicants were unchanged in 2021. In 2021, students from top 25 medical schools were less likely to match within their state or region (p<.05). Our findings may reflect an enhanced weighting given by programs to applicants from top medical schools in the absence of data from in-person rotations and interviews. These findings, coupled with the potential benefits of an increasingly virtual application process in improving equity and diversity among candidates from underrepresented communities, should be considered when determining permanent modifications to future residency application cycles.
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http://dx.doi.org/10.1016/j.wneu.2021.11.109DOI Listing
December 2021

Patient complaints in the postoperative period following spine surgery.

J Neurosurg Spine 2021 Oct 15:1-8. Epub 2021 Oct 15.

2Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio.

Objective: Patient complaints are associated with a number of surgical and medical outcomes. Despite high rates of patient complaints regarding spine surgeons and efforts to study patient complaints across medicine and surgery, few studies have analyzed the complaints of patients undergoing spinal surgery. The authors present a retrospective analysis that, to their knowledge, is the first study to directly investigate the complaints of spine surgery patients in the postoperative period.

Methods: Institutional records were reviewed over a 5-year period (2015-2019) to identify patients who underwent spine surgery and submitted a complaint to the institution's ombudsman's office within 1 year of their surgery. A control group, comprising patients who underwent spine surgery without filing a complaint, was matched to the group that filed complaints by admission diagnosis and procedure codes through propensity score matching. Patient demographic and clinical data were obtained by medical record review and compared between the two groups. Patient complaints were reviewed and categorized using a previously established taxonomy.

Results: A total of 52 patients were identified who submitted a complaint after their spine surgery. There were 56 total complaints identified (4 patients submitted 2 each) that reported on 82 specific issues. Patient complaints were most often related to the quality of care received and communication breakdown between the healthcare team and the patient. Patients who submitted complaints were more likely to be Black or African American, have worse baseline health status, and have had prior spine surgery. After their surgery, these patients were also more likely to have longer hospital stays, experience postoperative complications, and require reoperation.

Conclusions: Complaints were most often related to the quality of care received and communication breakdown. A number of patient-level demographic and clinical characteristics were associated with an increased likelihood of a complaint being filed after spine surgery, and patients who filed complaints were more likely to experience postoperative complications. Improving communication with patients could play a key role in working to address and reduce postoperative complaints. Further study is needed to better understand patient complaints after spine surgery and investigate ways to optimize the care of patients with risks for postoperative complaints.
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http://dx.doi.org/10.3171/2021.6.SPINE21637DOI Listing
October 2021

Predictors of Nonelective Surgery for Spinal Metastases: Insights from a National Database.

Spine (Phila Pa 1976) 2021 Dec;46(24):E1334-E1342

Center for Spine Health, Cleveland Clinic, Cleveland, OH.

Study Design: Secondary analysis of a national all-payer database.

Objective: Our objectives were to identify patient- and hospital-level factors independently associated with the receipt of nonelective surgery and determine whether nonelective surgery portends differences in perioperative outcomes compared to elective surgery for spinal metastases.

Summary Of Background Data: Spinal metastases may progress to symptomatic epidural spinal cord compression that warrants urgent surgical intervention. Although nonelective surgery for spinal metastases has been associated with poor postoperative outcomes, literature evaluating disparities in the receipt of nonelective versus elective surgery in this population is lacking.

Methods: The National Inpatient Sample (2012-2015) was queried for patients who underwent surgical intervention for spinal metastases. Multivariable logistic regression models were constructed to evaluate the association of patient- and hospital-level factors with the receipt of nonelective surgery, as well as to evaluate the influence of admission status on perioperative outcomes.

Results: After adjusting for disease-related factors and other baseline covariates, our multivariable logistic regression model revealed several sociodemographic differences in the receipt of nonelective surgery. Patients of black (odds ratio [OR] = 1.38, 95% confidence interval [CI]: 1.03-1.84, P = 0.032) and other race (OR = 1.50, 95% CI: 1.13-1.98, P = 0.005) had greater odds of undergoing nonelective surgery than their white counterparts. Patients of lower income (OR = 1.40, 95% CI: 1.06-1.84, P = 0.019) and public insurance status (OR = 1.56, 95% CI: 1.26-1.93, P < 0.001) were more likely to receive nonelective surgery than higher income and privately insured patients, respectively. Higher comorbidity burden was also associated with greater odds of non-elective admission (OR = 2.94, 95% CI: 2.07-4.16, P  < 0.001). With respect to perioperative outcomes, multivariable analysis revealed that patients receiving nonelective surgery were more likely to experience nonroutine discharge (OR = 2.50, 95% CI: 2.09-2.98, P  < 0.001) and extended length of stay [LOS] (OR = 2.45, 95% CI: 1.91-3.16, P < 0.001).

Conclusion: The present study demonstrates substantial disparities in the receipt of nonelective surgery across sociodemographic groups and highlights its association with nonroutine discharge and extended LOS.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004109DOI Listing
December 2021

Identifying treatment patterns in patients with Bertolotti syndrome: an elusive cause of chronic low back pain.

Spine J 2021 09 16;21(9):1497-1503. Epub 2021 May 16.

Center for Spine Health, Department of Neurosurgery, Neurologic Institute, Cleveland Clinic Foundation, 9500 Euclid Av, Suite S40, Cleveland, OH, 44195, USA; Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.

Background Context: Bertolotti Syndrome is a diagnosis given to patients with lower back pain arising from a lumbosacral transitional vertebra (LSTV). These patients can experience symptomatology similar to common degenerative diseases of the spine, making Bertolotti Syndrome difficult to diagnose with clinical presentation alone. Castellvi classified the LSTV seen in this condition and specifically in types IIa and IIb, a "pseudoarticulation" is present between the fifth lumbar transverse process and the sacral ala, resulting in a semi-mobile joint with cartilaginous surfaces.Treatment outcomes for Bertolotti Syndrome are poorly understood but can involve diagnostic and therapeutic injections and ultimately surgical resection of the pseudoarticulation (pseudoarthrectomy) or fusion of surrounding segments.

Purpose: To examine spine and regional injection patterns and clinical outcomes for patients with diagnosed and undiagnosed Bertolotti Syndrome.

Design: Retrospective observational cohort study of patients seen at a single institution's tertiary spine center over a 10-year period.

Patient Sample: Cohort consisted of 67 patients with an identified or unidentified LSTV who were provided injections or surgery for symptoms related to their chronic low back pain and radiculopathy.

Outcome Measures: Self-reported clinical improvement following injections and pseudoarthrectomy.

Methods: Patient charts were reviewed. Identification of a type II LSTV was confirmed through provider notes and imaging. Variables collected included demographics, injection history and outcomes, and surgical history for those who underwent pseudoarthrectomy.

Results: A total of 22 out of 67 patients (33%) had an LSTV that was not identified by their provider. Diagnosed patients underwent fewer injections for their symptoms than those whose LSTV was never previously identified (p = 0.031). Only those diagnosed received an injection at the LSTV pseudoarticulation, which demonstrated significant symptomatic improvement at immediate follow up compared to all other injection types (p = 0.002). Patients who responded well to pseudoarticulation injections were offered a pseudoarthrectomy, which was more likely to result in symptom relief at most recent follow up than patients who underwent further injections without surgery (p < 0.001).

Conclusions: Undiagnosed patients are subject to a higher quantity of injections at locations less likely to provide relief than pseudoarticulation injections. These patients in turn cannot be offered a pseudoarthrectomy which can result in significant relief compared to continued injections alone. Proper and timely identification of an LSTV dramatically alters the clinical course of these patients as they can only be offered treatment directed towards the LSTV once it is identified.
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http://dx.doi.org/10.1016/j.spinee.2021.05.008DOI Listing
September 2021

Predictors of Operative Duration and Complications in Single-Level Posterior Interbody Fusions for Degenerative Spondylolisthesis.

World Neurosurg 2021 07 18;151:e317-e323. Epub 2021 Apr 18.

Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Neurosurgery, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA.

Background: The goal of this study was to identify predictors of prolonged operative time (OT) in patients receiving posterior/transforaminal lumbar interbody fusion (P/TLIF) and examine the relationship between prolonged OT and perioperative outcomes in this population.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing single-level P/TLIF (Common Procedural Terminology code) between 2012 and 2018. Multivariable linear regression models were constructed to identify factors independently associated with changes in OT and examine the relationship between prolonged OT and perioperative outcomes (overall complications, surgical complications, medical complications, 30-day readmission, 30-day reoperation, and length of stay). All models were adjusted for sociodemographic variables, comorbidities, and procedure-specific variables.

Results: Our cohort included 6260 patients. After adjusting for baseline covariates, age between 19 and 39 years increased OT by 15.14 minutes, male sex increased OT by 12.91 minutes, African American race increased OT by 17.82 minutes, other race increased OT by 18.13 minutes, obesity class III increased OT by 27.80 minutes, and the use of navigation increased OT by 10.83 minutes. Our multivariate logistic regression also found that after 2 hours, each additional hour of OT was associated with an increased risk of any complication (3-3.99 hours, odds ratio [OR], 1.68; 4-4.99 hours, OR, 2.33; and >5 hours, OR, 4.65). Incremental increases in OT were also associated with an increased risk of extended length of stay, readmission, and return to the operating room.

Conclusions: The results of this study highlight several factors associated with prolonged OT and underscore its association with poorer perioperative outcomes. These data can be used to risk stratify patients before single-level P/TLIF.
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http://dx.doi.org/10.1016/j.wneu.2021.04.034DOI Listing
July 2021

Key drivers of patient satisfaction with spine surgeons in the outpatient setting.

J Neurosurg Spine 2021 Mar 19:1-8. Epub 2021 Mar 19.

1Center for Spine Health, Cleveland Clinic.

Objective: The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) was developed as a result of the value-based purchasing initiative by the Center for Medicare & Medicaid Services. It allows patients to rate their experience with their provider in the outpatient setting. These ratings are then reported in aggregate and made publicly available, allowing patients to make informed choices during physician selection. In this study, the authors sought to elucidate the primary drivers of patient satisfaction in the office-based spine surgery setting as represented by the CG-CAHPS.

Methods: All patients who underwent lumbar spine surgery between 2009 and 2017 and completed a patient experience survey were studied. The satisfied group comprised patients who selected a top-box score (9 or 10) for overall provider rating (OPR) on the CG-CAHPS, while the unsatisfied group comprised the remaining patients. Demographic and surgical characteristics were compared using the chi-square test for categorical variables and the Student t-test for continuous variables. A multivariable logistic regression model was developed to analyze the association of patient and surgeon characteristics with OPR. Survey items were then added to the baseline model individually, adjusting for covariates.

Results: The study population included 647 patients who had undergone lumbar spine surgery. Of these patients, 564 (87%) selected an OPR of 9 or 10 on the CG-CAHPS and were included in the satisfied group. Patient characteristics were similar between the two groups. The two groups did not differ significantly regarding patient-reported health status measures. After adjusting for potential confounders, the following survey items were associated with the greatest odds of selecting a top-box OPR: did this provider show respect for what you had to say? (OR 21.26, 95% CI 9.98-48.10); and did this provider seem to know the important information about your medical history? (OR 20.93, 95% CI 11.96-45.50).

Conclusions: The present study sought to identify the key drivers of patient satisfaction in the postoperative office-based spine surgery setting and found several important associations. After adjusting for potential confounders, several items relating to physician communication were found to be the strongest predictors of patient satisfaction. This highlights the importance of effective communication in the patient-provider interaction and elucidates avenues for quality improvement efforts in the spine care setting.
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http://dx.doi.org/10.3171/2020.9.SPINE201292DOI Listing
March 2021

The association of preoperative TNF-alpha inhibitor use and reoperation rates in spinal fusion surgery.

Spine J 2021 06 2;21(6):972-979. Epub 2021 Feb 2.

Center for Spine Health, Cleveland Clinic, Desk S40, 9500 Euclid Ave, Cleveland, OH 44195, USA.

Background Context: Preoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied.

Purpose: The purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery.

Study Design: This is a retrospective review.

Patient Sample: A total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018.

Outcome Measure: Reoperation within 1 year.

Methods: We retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery.

Results: Our study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4-7.0) and 2.2 (95% CI 0.96-5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group.

Conclusions: Patients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making.
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http://dx.doi.org/10.1016/j.spinee.2021.01.020DOI Listing
June 2021

The Impact of Preoperative Depression on Patient Satisfaction With Spine Surgeons in the Outpatient Setting.

Spine (Phila Pa 1976) 2021 Feb;46(3):184-190

Center for Spine Health, Cleveland Clinic, Cleveland, OH.

Study Design: Retrospective review.

Objective: The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery.

Summary Of Background Data: The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear.

Methods: Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined.

Results: Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06-0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11-0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06-0.63, P = 0.007).

Conclusion: Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003763DOI Listing
February 2021

The association between patient rating of their spine surgeon and quality of postoperative outcome.

J Neurosurg Spine 2020 Dec 18:1-7. Epub 2020 Dec 18.

1Center for Spine Health, Cleveland Clinic.

Objective: The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey was developed by the Centers for Medicare and Medicaid Services as a result of their value-based purchasing initiative. It allows patients to rate their experience with their provider in the outpatient setting. This presents a unique situation in healthcare in which the patient experience drives the marketplace, and since its creation, providers have sought to improve patient satisfaction. Within the spine surgery setting, however, the question remains whether improved patient satisfaction correlates with improved outcomes.

Methods: All patients who had undergone lumbar spine surgery between 2009 and 2017 and who completed a CG-CAHPS survey after their procedure were studied. Demographic and surgical characteristics were then obtained. The primary outcomes of this study include patient-reported health outcomes measures such as the Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) surveys for both mental health (PROMIS-GH-MH) and physical health (PROMIS-GH-PH), and the visual analog scale for back pain (VAS-BP). A multivariable linear regression analysis was used to assess whether patient satisfaction with their provider was associated with changes in each health status measure after adjusting for potential confounders.

Results: The study population included 647 patients who had undergone lumbar spine surgery. Of these, 564 (87%) indicated that they were satisfied with the care they received. Demographic and surgical characteristics were largely similar between the two groups. Multivariable linear regression demonstrated that patient satisfaction with their provider was not a significant predictor of change in two of the three patient-reported outcomes (PROMIS-GH-MH and PROMIS-GH-PH) assessed at 1 year. However, top-box patient satisfaction with their provider was a significant predictor of improvement in VAS-BP scores at 1 year.

Conclusions: The authors found that after adjusting for patient-level covariates such as age, diagnosis of disc displacement, self-reported mental health, self-reported overall health, and preoperative patient-reported outcome measure status, a significant association was observed between top-box overall provider rating and 1-year improvement in VAS-BP, but no such association was observed for PROMIS-GH-PH and PROMIS-GH-MH. This suggests that pain-related outcome measures may serve as better predictors of patients' satisfaction with their spine surgeons. Furthermore, this suggests that the current method by which patient satisfaction is being assessed and publicly reported may not necessarily correlate with validated measures that are used within the spine surgery setting to assess surgical efficacy.
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http://dx.doi.org/10.3171/2020.7.SPINE20478DOI Listing
December 2020

The Association Between Physicians' Communication and Patient-Reported Outcomes in Spine Surgery.

Spine (Phila Pa 1976) 2020 Aug;45(15):1073-1080

Center for Spine Health, Cleveland Clinic, Cleveland, OH.

Study Design: Retrospective cohort study using prospectively collected data.

Objective: Determine the association between satisfaction with physician communication and patient-reported outcomes in the inpatient spine surgery setting.

Summary Of Background Data: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys measure the patient experience of care and influence reimbursement for hospital systems and providers in the United States. It is not known whether patient satisfaction with physician communication is associated with better outcomes after spine surgery. Therefore, we evaluated the association between patient satisfaction with physician communication on the HCAHPS survey and improvements in validated patient-reported outcomes measures in a spine surgery population.

Methods: HCAHPS responses were obtained for patients undergoing elective cervical or lumbar spine surgery from 2013 to 2015. Patient-reported health status measures were the primary outcomes, including EuroQol Five Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Visual Analog Scores for Back and Neck Pain (VAS-BP/NP). The association between satisfaction with communication and preoperative to 1 year postoperative changes in each health status measure was evaluated utilizing multivariable linear regression models.

Results: Our study included 648 patients, of which, 479 (74.4%) created our satisfied cohort. Demographically, our two cohorts were similar with regards to preoperative clinical measures; however, the satisfied cohort had a higher self-rating of their mental health (P < 0.01), and overall health (P < 0.01). After adjusting for clinically relevant confounders, our results demonstrated no significant association between satisfaction with physician communication and improvement in EQ-5D (P = 0.312), PDQ (P = 0.498), or VAS pain scores (P = 0.592).

Conclusion: Patient satisfaction with physician communication was not associated with 1-year postoperative improvement in EQ-5D, PDQ, and VAS-Pain after spine surgery. These findings do not diminish the importance of effective communication between doctor and patient, but instead suggest that within the spine surgery setting, using only patient experience data may not accurately reflect the true quality of care received during their inpatient stay.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003458DOI Listing
August 2020

Are There Nationwide Socioeconomic and Demographic Disparities in the Use of Outpatient Orthopaedic Services?

Clin Orthop Relat Res 2020 05;478(5):979-989

N. M. Rabah, K. D. Knusel, H. A. Khan, R. E. Marcus, Department of Orthopaedics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Background: Although disparities in the use of healthcare services in the United States have been well-documented, information examining sociodemographic disparities in the use of healthcare services (for example, office-based and emergency department [ED] care) for nonemergent musculoskeletal conditions is limited.

Questions/purposes: This study was designed to answer two important questions: (1) Are there identifiable nationwide sociodemographic disparities in the use of either office-based orthopaedic care or ED care for common, nonemergent musculoskeletal conditions? (2) Is there a meaningful difference in expenditures associated with these same conditions when care is provided in the office rather than the ED?

Methods: This study analyzed data from the 2007 to 2015 Medical Expenditure Panel Survey (MEPS). The MEPS is a nationally representative database administered by the Agency for Healthcare Research and Quality that tracks patient interactions with the healthcare system and expenditures associated with each visit, making it an ideal data source for our study. Differences in the use of office-based and ED care were assessed across different socioeconomic and demographic groups. Healthcare expenditures associated with office-based and ED care were tabulated for each of the musculoskeletal conditions included in this study. The MEPS database defines expenditures as direct payments, including out-of-pocket payments and payments from insurances. In all, 63,514 participants were included in our study. Fifty-one percent (32,177 of 63,514) of patients were aged 35 to 64 years and 29% were older than 65 years (18,445 of 63,514). Women comprised 58% (37,031 of 63,514) of our population, while men comprised 42% (26,483 of 63,514). Our study was limited to the following eight categories of common, nonemergent musculoskeletal conditions: osteoarthritis (40%, 25,200 of 63,514), joint derangement (0.5%, 285 of 63,514), other joint conditions (43%, 27,499 of 63,514), muscle or ligament conditions (6%, 3726 of 63,514), bone or cartilage conditions (8%, 5035 of 63,514), foot conditions (1%, 585 of 63,514), fractures (7%, 4189 of 63,514), and sprains or strains (18%, 11,387 of 63,514). Multivariable logistic regression was used to ascertain which demographic, socioeconomic, and health-related factors were independently associated with differences in the use of office-based orthopaedic services and ED care for musculoskeletal conditions. Furthermore, expenditures over the course of our study period for each of our musculoskeletal categories were calculated per visit in both the outpatient and the ED settings, and adjusted for inflation.

Results: After controlling for covariates like age, gender, region, insurance status, income, education level, and self-reported health status, we found substantially lower use of outpatient musculoskeletal care among patients who were Hispanic (odds ratio 0.79 [95% confidence interval 0.72 to 0.86]; p < 0.001), non-Hispanic black (OR 0.77 [95% CI 0.70 to 0.84]; p < 0.001), lesser-educated (OR 0.72 [95% CI 0.65 to 0.81]; p < 0.001), lower-income (OR 0.80 [95% CI 0.73 to 0.88]; p < 0.001), and nonprivately-insured (OR 0.85 [95% CI 0.79 to 0.91]; p < 0.001). Public insurance status (OR 1.30 [95% CI 1.17 to 1.44]; p < 0.001), lower income (OR 1.53 [95% CI 1.28 to 1.82]; p < 0.001), and lesser education status (OR 1.35 [95% CI 1.14 to 1.60]; p = 0.001) were also associated with greater use of musculoskeletal care in the ED. Healthcare expenditures associated with care for musculoskeletal conditions was substantially greater in the ED than in the office-based orthopaedic setting.

Conclusions: There are substantial sociodemographic disparities in the use of office-based orthopaedic care and ED care for common, nonemergent musculoskeletal conditions. Because of the lower expenditures associated with office-based orthopaedic care, orthopaedic surgeons should make a concerted effort to improve access to outpatient care for these populations. This may be achieved through collaboration with policymakers, greater initiatives to provide care specific to minority populations, and targeted efforts to improve healthcare literacy.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7170672PMC
May 2020

Health Disparities in the Access and Cost of Health Care for Otolaryngologic Conditions.

Otolaryngol Head Neck Surg 2020 Apr 18;162(4):479-488. Epub 2020 Feb 18.

Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.

Objective: To demonstrate whether race, education, income, or insurance status influences where patients seek medical care and the cost of care for a broad range of otolaryngologic diseases in the United States.

Study Design: Retrospective cohort study using data from the Medical Expenditure Panel Survey, from 2007 to 2015.

Setting: Nationally representative database.

Subjects And Methods: Patients with 14 common otolaryngologic conditions were identified using self-reported data and diagnosis codes. To analyze disparities in the utilization and cost of otolaryngologic care, a multivariate logistic regression model was used to compare outpatient and emergency department visit rates and costs for African American, Hispanic, and Caucasian patients, controlling for sociodemographic characteristics.

Results: Of 78,864 respondents with self-reported otolaryngologic conditions, African American and Hispanic patients were significantly less likely to visit outpatient otolaryngologists than Caucasians (African American: adjusted odds ratio [aOR], 0.57; 95% CI, 0.5-0.65; Hispanic: aOR, 0.64; 95% CI, 0.56-0.73) and reported lower average costs per emergency department visit than Caucasians (African American: $4013.67; Hispanic: $3906.21; Caucasian: $7606.46; < .001). In addition, uninsured, low-income patients without higher education were significantly less likely to receive outpatient otolaryngologic care than privately insured, higher-income, and more educated individuals (uninsured: aOR, 0.38; 95% CI, 0.29-0.51; poor: aOR, 0.75; 95% CI, 0.64-0.87; no degree: aOR, 0.67; 95% CI, 0.54-0.82).

Conclusion: In this study, significant racial and socioeconomic discrepancies exist in the utilization and cost of health care for otolaryngologic conditions in the United States.
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http://dx.doi.org/10.1177/0194599820904369DOI Listing
April 2020

The Impact of Preoperative Depression on Hospital Consumer Assessment of Healthcare Providers and Systems Survey Results in a Cervical Spine Surgery Setting.

Spine (Phila Pa 1976) 2020 Jan;45(1):65-70

Center for Spine Health, Cleveland Clinic, Cleveland, OH.

Study Design: Retrospective cohort study using prospectively collected data.

Objective: The aim of this study was to determine the association between preoperative depression and patient experience in a cervical spine surgery population.

Summary Of Background Data: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used to measure patient experience and its scores directly influence reimbursement in the United States. Although it is well-established in the literature that untreated depression is associated with worse patient-reported outcomes in cervical spine surgery, no previous studies have analyzed the association between depression and patient satisfaction for these patients.

Methods: HCAHPS survey responses from patients undergoing cervical spine surgery between 2013 and 2015 were collected at a tertiary care center. HCHAPS survey responses were linked to demographic data as well as patient-reported quality of life (QOL) metrics including Patient Health Questionnaire, EuroQol 5 Dimensions index, and Visual Analog Scale for neck pain for each patient. Preoperative PHQ-9 scores of ≥10 (moderate to severe depression) was used to define preoperative depression. Uni- and multivariable analyses were performed to investigate the association of preoperative depression and top-box scores on several dimensions on the HCAHPS survey.

Results: In our 145-patient cohort, depressed patients were on average younger, had higher preoperative neck pain scores, and had a lower health-related QOL. Depressed patients were less likely to report satisfaction with questions related to doctor respect (P = 0.020) and doctors listening (P = 0.030). After adjusting for covariates, multivariable logistic regression analysis revealed that patients with preoperative depression had lower odds of feeling respected by their physicians (odds ratio = 0.14, 95% confidence interval: 0.02-0.87, P = 0.035).

Conclusion: In patients undergoing cervical spine surgery, preoperative depression was found to have a negative association with patient perceptions of doctor communication as measured by the HCAHPS survey. These results highlight depression as a risk factor for worse patient experience communicating with their spine surgeon.

Level Of Evidence: 3.
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Source
http://dx.doi.org/10.1097/BRS.0000000000003222DOI Listing
January 2020
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