Caroline Thirukumaran

National Trends in the Surgical Management of Adult Lumbar Isthmic Spondylolisthesis: 1998 to 2011.

Study Design. A retrospective review. Objective. Isthmic spondylolisthesis (ISY) is a common orthopedic condition. Our objective was to identify trends in the surgical management of adult ISY in the United States and to evaluate trends in the surgical techniques utilized. Summary of Background Data. Various surgical approaches have been described for ISY but preferred trends are not known. Methods. Using the Nationwide Inpatient Sample (NIS), 47,132 adult patients (≥18 years) with ISY undergoing lumbar spine fusion from 1998 to 2011 were identified. Our primary outcome of interest was the national trend in use of anterior (ASF), posterior (PSF), posterior with interbody (P/TLIF), and combined anterior-posterior fusion (A/PSF) surgeries for ISY patients. Poisson regression, modified Walds test, and linear and logistic regression analysis with P < 0.05 were used for statistical analysis. Results. The annual rate of fusion surgeries for ISY increased 4.33 times—from 28.31 surgeries in 1998 to 122.69 surgeries per million US adults per year in 2011. Over the study period, annual rates of ASFs increased 2.65 times (P < 0.001), PSFs increased 1.03 times (P = 0.24), P/TLIFs increased 4.33 times (P < 0.001), and A/PSF increased 2.93 times (P < 0.001). In 2010 to 2011, the complication rate was significantly higher for A/PSF (18.86%, P < 0.001). PSFs had a higher complication rate of 3.61% and P/TLIFs (2.58%). The risk of complications was lower for females, elective admissions, and in hospitals in the South. Mean hospitalization charges adjusted to 2011 dollars were significantly higher for A/PSF (

Complications and readmission after lumbar spine surgery in elderly patients: an analysis of 2,320 patients

157,560; 95% CI [95% confidence interval]: 14,480–170,360; P < 0.001), followed by P/TLIFs (

Impact of Medicare’s Nonpayment Program on Hospital-acquired Conditions

103,700; 95% CI: 9840–109,030) and PSFs had lower mean hospitalization charges (

A Review of a Workers’ Compensation Database 2003 to 2013: Patient Factors Influencing Return to Work and Cumulative Financial Claims After Rotator Cuff Repair in Geriatric Workers’ Compensation Cases:

87,420; 95% CI: 8210–92,770). Conclusion. Use of fusion for ISY has significantly increased and interbody fusion has become the most preferred approach over the study period. Hospital charges and complications were highest for combined anterior-posterior fusions. Level of Evidence: 3

Impact of a Comparative Study on the Management of Scoliosis in Duchenne Muscular Dystrophy: Are Corticosteroids Decreasing the Rate of Scoliosis Surgery in the United States?

BACKGROUND CONTEXT There is a paucity of literature describing risk factors for adverse outcomes after geriatric lumbar spinal surgery. As the geriatric population increases, so does the number of lumbar spinal surgeries in this cohort. PURPOSE The purpose of the study was to determine how safe lumbar surgery is in elderly patients. Does patient selection, type of surgery, length of surgery, and other comorbidities in the elderly patient affect complication and readmission rates after surgery? STUDY DESIGN/SETTING This is a retrospective cohort study. PATIENT SAMPLE The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Database was used in the study. OUTCOME MEASURES The outcome data that were analyzed were minor and major complications, mortality, and readmissions in geriatric patients who underwent lumbar spinal surgery from 2005 to 2015. MATERIALS AND METHODS A retrospective cohort study was performed using data from the ACS NSQIP database. Patients over the age of 80 years who underwent lumbar spinal surgery from 2005 to 2013 were identified using International Statistical Classification of Diseases and Related Health Problems diagnosis codes and Current Procedural Terminology codes. Outcome data were classified as either a major complication, minor complication, readmission, or mortality. Multivariate logistic regression models were used to determine risks for developing adverse outcomes in the initial 30 postoperative days. RESULTS A total of 2,320 patients over the age of 80 years who underwent lumbar spine surgery were identified. Overall, 379 (16.34%) patients experienced at least one complication or death. Seventy-five patients (3.23%) experienced a major complication. Three hundred thirty-eight patients (14.57%) experienced a minor complication. Eighty-six patients (6.39%) were readmitted to the hospital within 30 days. Ten deaths (0.43%) were recorded in the initial 30 postoperative days. Increased operative times were strongly associated with perioperative complications (operative time >180 minutes, odds ratio [OR]: 3.07 [95% confidence interval {CI} 2.23-4.22]; operative time 120-180 minutes, OR: 1.77 [95% CI 1.27-2.47]). Instrumentation and fusion procedures were also associated with an increased risk of developing a complication (OR: 2.56 [95% CI 1.66-3.94]). Readmission was strongly associated with patients who were considered underweight (body mass index [BMI] <18.5) and who were functionally debilitated at the time of admission (OR: 4.10 [1.08-15.48] and OR: 2.79 [1.40-5.56], respectively). CONCLUSIONS Elderly patients undergoing lumbar spinal surgery have high complications and readmission rates. Risk factors for complications include longer operative time and more extensive procedures involving instrumentation and fusion. Higher readmission rates are associated with low baseline patient functional status and low patient BMI.

National Trends in Spinal Fusion Surgery for Neurofibromatosis

Background: Medicare’s Nonpayment Program of 2008 (hereafter called Program) withholds hospital reimbursement for costs related to hospital-acquired conditions (HACs). Little is known whether a hospital’s Medicare patient load [quantified by the hospital’s Medicare utilization ratio (MUR), which is the proportion of inpatient days financed by Medicare] influences its response to the Program. Objective: To determine whether the Program was associated with changes in HAC incidence, and whether this association varies across hospitals with differential Medicare patient load. Research Design: Quasi-experimental study using difference-in-differences estimation. Incidence of HACs before and after Program implementation was compared across hospital MUR quartiles. Subjects: A total of 867,584 elderly Medicare stays for acute myocardial infarction, congestive heart failure, pneumonia, and stroke that were discharged from 159 New York State hospitals from 2005 to 2012. Measures: For descriptive analysis, hospital-level mean HAC rates by month, MUR quartile, and Program phase are reported. For multivariate analysis, primary outcome is incidence of the any-or-none indicator for occurrence of at least 1 of 6 HACs. Secondary outcomes are the incidence of each HAC. Results: The Program was associated with decline in incidence of (i) any-or-none indicator among MUR quartile 2 hospitals (conditional odds ratio=0.57; 95% confidence interval, 0.38–0.87), and (ii) catheter-associated urinary tract infections among MUR quartile 3 hospitals (conditional odds ratio=0.30; 95% confidence interval, 0.12–0.75) as compared with MUR quartile 1 hospitals. Significant declines in certain HACs were noted in the stratified analysis. Conclusions: The Program was associated with decline in incidence of selected HACs, and this decline was variably greater among hospitals with higher MUR.

Does Medicare Advantage Reduce Racial Disparity in 30-Day Rehospitalization for Medicare Beneficiaries?

Background: Workers’ compensation status is associated with poor outcomes after rotator cuff repair surgery. The purpose of this study was to analyze a database of geriatric workers’ compensation patients after surgical repair of the rotator cuff and identify both medical and nonmedical patient factors that influence the time it takes for them to return to work at full duty, including a comparison of arthroscopic and open techniques. Methods: An all workers’ compensation database was queried for rotator cuff claims that were surgically managed using arthroscopic, open, or both approaches from 2003 to 2013 in patients aged ≥60. Primary outcomes were the number of days for return to full work (RTW) following surgery and the total reimbursement for health care. Multivariate analysis was performed, and data are presented as average ± standard deviation. Results: The database yielded 1903 claims for surgically treated rotator cuff conditions (arthroscopic n = 935; open n = 926; both n = 42). In multivariate RTW analyses, we did not find a significant difference between groups (RTW in days was 153 ± 134 for arthroscopy [P = .81], 160 ± 160 for open [Ref], and 140 ± 82 days for both [P = .75]). However, multivariate analysis of reimbursement claims found arthroscopic surgery claims to be 13% higher compared to claims for open surgery only (US

Impact of Medicare's Nonpayment Program on Venous Thromboembolism Following Hip and Knee Replacements

29 986 ± 16 259 for arthroscopy vs US

An Analysis of Adult Patient Risk Factors and Complications Within 30 Days After Arthroscopic Shoulder Surgery

26 495 ± 13 186 for open, P < .001). Patients aged ≥65 had more medical expenses than patients aged 60 to 64 (P = .03). Potentially modifiable variables that significantly prolonged RTW timing and higher health-care claims included need for vocational rehabilitation services and filing of a legal suit. Conclusions: Return to full-duty work in geriatric workers’ compensation patients after rotator cuff repair takes about 5 months regardless of surgical approach and costs significantly more in patients aged ≥65. Arthroscopic repairs generated 13% more cumulative health-care costs than open surgery alone. More efficient vocational rehabilitation services and minimizing legal suits may help get patients back to work sooner and reduce overall costs.

Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers compensation cases

Study Design. A cross-sectional analysis. Objective. The aim of this study was to determine whether the surgical treatment for scoliosis due to Duchenne muscular dystrophy (DMD) has decreased over a recent 11-year period, specifically, after the wide acceptance of glucocorticoid treatment for DMD. Summary of Background Data. DMD can result in a flaccid neuromuscular scoliosis that has been traditionally treated surgically. In 2004, a comparative study demonstrated that glucocorticoid treatment decreased the progression of scoliosis in DMD. Methods. We used the Nationwide Inpatient Sample from 2001 to 2012 to identify patients with DMD undergoing spinal fusion. Demographic information (age, hospital size, location, geographic status) was collected. We examined the distribution of patient and hospital characteristics among cohorts undergoing spinal fusion from 2001 to 2004 (period 1; before publication of the comparative study), 2005 to 2008 (period 2; immediately following publication of the comparative study), and 2009 to 2012 (period 3; moderate duration following publication of the comparative study). Results. We identified 1874 males undergoing spinal fusion. During this period, the overall rate of DMD surgeries declined by 48%—from 1.87 surgeries in 2001 to 0.97 surgeries in 2012 per million US males per year. This decline was significantly pronounced following the publication of the comparative study [periods 2 and 3; For period 2 vs. period 1: incidence rate ratio (IRR) = 0.71, 95% confidence interval (95% CI) = 0.56–0.91, P = 0.01; For period 3 vs. period 1: IRR = 0.77, 95% CI = 0.61–0.97, P = 0.03]. Conclusion. Our study demonstrates a significant decrease in the rate of scoliosis surgery for DMD from 2001 to 2012. It appears that the decline in surgical treatment could be related to the publication and landmark study demonstrating decreased progression of scoliosis with glucocorticoid treatment. Level of Evidence: 3