Seokchun Lim

Predictors of unplanned readmission in patients undergoing lumbar decompression: multi-institutional analysis of 7016 patients.

OBJECT Unplanned hospital readmission represents a large financial burden on the Centers for Medicare and Medicaid Services, commercial insurance payers, hospitals, and individual patients, and is a principal target for cost reduction. A large-scale, multi-institutional study that evaluates risk factors for readmission has not been previously performed in patients undergoing lumbar decompression procedures. The goal of this multicenter retrospective study was to find preoperative, intraoperative, and postoperative predictive factors that result in unplanned readmission (UR) after lumbar decompression surgery. METHODS The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who received lumbar decompression procedures in 2011. Risk-adjusted multivariate logistic regression analysis was performed to estimate independent predictors of UR. RESULTS The overall rate of UR among patients undergoing lumbar decompression was 4.4%. After multivariate logistic regression analysis, anemia (odds ratio [OR] 1.48), dependent functional status (OR 3.03), total operative duration (OR 1.003), and American Society of Anesthesiologists Physical Status Class 4 (OR 3.61) remained as independent predictors of UR. Postoperative complications that were significantly associated with UR included overall complications (OR 5.18), pulmonary embolism (OR 3.72), and unplanned reoperation (OR 56.91). CONCLUSIONS There were several risk factors for UR after lumbar spine decompression surgery. Identification of high-risk patients and appropriate allocation of resources to reduce postoperative incidence may reduce the readmission rate.

Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database

OBJECT This study evaluates the impact of resident presence in the operating room on postoperative outcomes in neurosurgery. METHODS The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all cases treated in a neurosurgery service in 2011. Propensity scoring analysis and multiple logistic regression models were used to reduce patient bias and to assess independent effect of resident involvement. RESULTS Of the 8748 neurosurgery cases identified, residents were present in 4529 cases. Residents were more likely to be involved in complex procedures with longer operative duration. The multivariate analysis found that resident involvement was not a statistically significant factor for overall complications (OR 1.116, 95% CI 0.961-1.297), surgical complications (OR 1.132, 95% CI 0.825-1.554), medical complications (OR 1.146, 95% CI 0.979-1.343), reoperation (OR 1.250, 95% CI 0.984-1.589), mortality (OR 1.164, 95% CI 0.780-1.737), or unplanned readmission (OR 1.148, 95% CI 0.946-1.393). CONCLUSIONS In this multicenter study, the authors demonstrated that resident involvement in the operating room was not a significant factor for postoperative complications in neurosurgery service. This analysis also showed that much of the observed difference in postoperative complication rates was attributable to other confounding factors. This is a quality indicator for resident trainees and current medical education. Maintaining high standards in postgraduate training is imperative in enhancing patient care and reducing postoperative complications.

Risk Factors for Postoperative Infections Following Single Level Lumbar Fusion Surgery

Study Design. Retrospective multivariate analysis of a prospectively collected, multicenter database. Objective. To identify patient characteristics and perioperative risk factors associated with postoperative infectious complications after single-level lumbar fusion (SLLF) surgery. Summary of Background Data. Postoperative infection is a known complication after lumbar fusion. Risk factors for infectious complications after lumbar fusion have not been investigated using select set of SLLF procedures. Methods. Patients who underwent SLLF between 2006 and 2011 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression analyses were performed to identify pre- and intraoperative risk factors associated with postoperative infection. Results. A total of 3353 patients were analyzed in this study. Overall, 173 (5.2%) patients experienced a postoperative infection, including 86 (2.6%) surgical site infections (SSIs) and 111 (3.3%) non-SSI infectious complications (pneumonia, urinary tract infection, sepsis/septic shock). Twenty-four (0.7%) patients experienced both SSI and non-SSI infectious complications. Postoperative SSI were associated with obesity (odds ratio [OR], 1.628; 95% confidence interval [CI], 1.042–2.544), American Society of Anesthesiologists class more than 2 (OR, 2.078; 95% CI, 1.309–3.299), and operative time more than 6 hours (OR, 2.573; 95% CI, 1.310–5.056). Risk factors for non-SSI infectious complications included age (60–69 yr; OR, 3.279; 95% CI, 1.541–6.980; and ≥70 yr; OR, 3.348; 95% CI, 1.519–7.378), female sex (OR, 1.791; 95% CI, 1.183–2.711), creatinine more than 1.5 mg/dL (OR, 2.400; 95% CI, 1.138–5.062), American Society of Anesthesiologists class more than 2 (OR, 1.835; 95% CI, 1.177–2.860), and operative time more than 6 hours (OR, 3.563; 95% CI, 2.082–6.097). Conclusion. Across a wide study population, we identified that obesity, advanced American Society of Anesthesiologists classification, and longer operative time were predictive of postoperative SSI. We also demonstrated that increased age, female sex, serum creatinine more than 1.5 mg/dL, and prolonged operative duration are associated with non-SSI infectious complications after SLLF. Continued efforts to elucidate and optimize perioperative risk factors are warranted to improve outcomes in patients requiring spinal fusion. Level of Evidence: 3

Predictors and causes of unplanned re-operations in outpatient plastic surgery: a multi-institutional analysis of 6749 patients using the 2011 NSQIP database

Abstract Unplanned re-operations carry significant implications for healthcare services, surgical outcomes, and patient safety. However, there has been a paucity of large scale, multi-centre studies that evaluate the predictors and causes of unplanned re-operation in outpatient plastic surgery. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all plastic surgery outpatient cases performed in 2011. Multiple logistic regression analysis was utilised to identify independent risk factors and causes of unplanned reoperations. Of the 6749 outpatient plastic surgery cases identified, there were 125 (1.9%) unplanned re-operations (UR). Regression analysis demonstrated that body mass index (BMI, OR = 1.041, 95% CI = 1.019–1.065), preoperative open wound/wound infection (OR = 3.498, 95% CI = 1.593–7.678), American Society of Anesthesiologists (ASA) class 3 (OR = 2.235, 95% CI = 1.048–4.765), and total work relative value units (RVU, OR = 1.014, 95% CI = 1.005–1.024) were significantly predictive of UR. Additionally, the presence of any complication was significantly associated with UR (OR = 15.065, 95% CI = 5.705–39.781). In an era of outcomes-driven medicine, unplanned re-operation is a critical quality indicator for ambulatory plastic surgery facilities. The identified risk factors will aid in surgical planning and risk adjustment.

Risk factors for complications differ between stages of tissue-expander breast reconstruction

BackgroundTissue-expander (TE) placement followed by implant exchange is currently the most popular method of breast reconstruction. There is a relative paucity of data demonstrating patient factors that predict complications specifically by stage of surgery. The present study attempts to determine what complications are most likely to occur at each stage and how the risk factors for complications vary by stage of reconstruction. MethodsA retrospective chart review was performed on all 1275 patients who had TEs placed by the 2 senior authors between 2004 and 2013. Complication rates were determined at each stage of reconstruction, and these rates were further compared between patients who had pre-stage I radiation, post-stage I radiation, and no radiation exposure. Multivariate logistic regression was used to identify independent predictors of complications at each stage of reconstruction. ResultsA total of 1639 consecutive TEs were placed by the senior authors during the study period. The overall rate for experiencing a complication at any stage of surgery was 17%. Complications occurred at uniformly higher rates during stage I for all complications (92% stage I vs 7% stage II vs 1% stage III, P < 0.001). Predictors of stage I complications included increased body mass index [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01–1.07], current smoking status (OR, 3.0; 95% CI, 1.7–4.8), and higher intraoperative percent fill (OR, 3.3; 95% CI, 1.7–6.3). Post-stage I radiation was the only independent risk factor for a stage II complication (OR, 4.5; 95% CI, 1.4–15.2). ConclusionsComplications occur at higher rates after stage I than after stage II, and as expected, stage III complications are exceedingly rare. Risk factors for stage I complications are different from risk factors for stage II complications. Body mass index and smoking are associated with complications at stage I, but do not predict complications at stage II surgery. The stratification of risk factors by stage of surgery will help surgeons and patients better manage both risk and expectations.

Spine surgeon specialty is not a risk factor for 30-day complication rates in single-level lumbar fusion: A Propensity score-matched study of 2528 patients

Study Design. Multicenter retrospective cohort study. Objective. To investigate the impact of spine surgeon specialty on 30-day complication rates in patients undergoing single-level lumbar fusion. Summary of Background Data. Operative care of the spine is delivered by surgeons who undergo either orthopedic or neurosurgical training. It is currently unknown whether surgeon specialty has an impact on 30-day complication rates in patients undergoing single-level lumbar fusion. Methods. The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify all patients who underwent single-level lumbar fusion procedures during 2006–2011. Propensity score matching analysis was employed to reduce baseline differences in patient characteristics. Univariate and multivariate analyses were performed to assess the impact of spine surgeon specialty on 30-day complication rates. Results. A total of 2970 patients were included for analysis. After propensity matching, 1264 pairs of well-matched patients remained in the cohort. Overall complication rates in the unadjusted data set were 7.3% and 7.1% for the neurosurgery and orthopedic surgery cohort, respectively. Our multivariate analysis revealed that compared with the neurosurgery cohort, the orthopedic surgery cohort did not have statistically significant differences in odds ratios (OR) for development of any complication (OR, 0.95; 95% confidence interval [CI], 0.69–1.30; P = 0.740). Similarly, spine surgeon specialty was not a risk factor in any of the specific complications studied, including medical complications (OR, 1.11; 95% CI, 0.77–1.60; P = 0.583), surgical complications (OR, 0.76; 95% CI, 0.46–1.26; P = 0.287), or reoperation (OR, 1.10; 95% CI, 0.76–1.60; P = 0.618). Conclusion. Our analysis demonstrates that spine surgeon specialty is not a risk factor for any of the reported 30-day complications in patients undergoing single-level lumbar fusion. These data support the currently dichotomous paradigm of training for spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes. Level of Evidence: 4

Predictors of adverse events after parotidectomy: a review of 2919 cases.

Objective: There is a current paucity of large-scale, multi-institutional studies that explore the risk factors for major complications following parotidectomy. Methods: The American College of Surgeons National Surgical Quality Improvement Program participant use file was reviewed to identify all patients who had undergone parotidectomy between 2006 and 2011. Risk factors that predicted adverse events were estimated by using multivariate logistic regression. Results: Of 2919 included patients, 202 patients experienced adverse outcomes within the first 30 days of surgery. These included surgical complications in 76 (2.6%) patients; medical complications in 90 (3.1%) patients; death in 7 (0.2%) patients; and reoperation in 77 (2.6%) patients. Predictors of any complication included disseminated cancer (odds ratio [OR] = 2.28; 95% confidence interval [CI], 1.05-4.95; P = .036) and increasing total relative value units (OR = 1.01; 95% CI, 1.00-1.02; P = .027). Active smoking was a major risk factor for surgical complications (OR = 1.81; 95% CI, 1.08-3.05; P = .025). Dyspnea (OR = 2.93; 95% CI, 1.37-6.27; P = .006) significantly predicted medical complications. Conclusion: Although complication rates after parotidectomy are generally low, avoidance of specific and nonspecific postoperative complications still remains an area for improvement. Future outcomes databases should include procedure-specific complications, including facial nerve injury.

Preoperative Albumin Alone is Not a Predictor of 30-Day Outcomes in Pressure Ulcer Patients: A Matched Propensity-Score Analysis of the 2006-2011 NSQIP Datasets.

BackgroundWhile there has been a great deal of literature describing the relationship between nutritional status and development of pressure ulcers, statistically rigorous studies analyzing the relationship between hypoalbuminemia and outcomes are lacking. MethodsThe American College of Surgeons’ multicenter, prospective, National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for treatment of pressure ulcers between 2006 and 2011. Matched propensity-score analysis was performed to match experimental groups with regard to preoperative comorbidities. Outcomes of interest included overall/surgical/medical complications and 30-day mortality. Multivariable logistic regression models were used to assess the independent association between hypoalbuminemia and outcomes. ResultsOver the 6-year study period, 551 patients met criteria for study inclusion. Median albumin level was 2.8 g/dL. Before propensity matching, multiple adverse outcomes were significantly elevated in patients with albumin levels below the median value (very-low albumin, or VLA), compared to control patients. However, after matching preoperative comorbidities, the differences in 30-day outcomes were eliminated. In both analyses, there was no significant difference in 30-day surgical complications. ConclusionsIt is generally understood that hypoalbuminemic patients have elevated risks for surgical procedures. In pressure ulcer patients, it appears that these risks are not due to hypoalbuminemia alone, but rather a long list of attendant comorbidities. Consequently, hypoalbuminemia alone should not be used to determine the timing of a procedure for pressure ulcer surgery. Knowledge of these risks is necessary for patient counseling and surgical planning in this population.

Predictors for Airway Complications Following Single- and Multi-level Anterior Cervical Discectomy and Fusion.

Study Design. A retrospective, multivariate analyses of a prospectively collected multicenter database. Objective. The aim of this study was to evaluate the risk factors for postoperative airway complications following single- and multilevel anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Airway compromise following ACDF may result in catastrophic outcome. However, its predictors have not been identified by a multi-institutional study. Methods. Patients who underwent ACDF between 2011 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Multiple logistic regression analysis was performed to identify the risk factors for airway compromise following ACDF. Results. Twelve thousand one hundred eighty-five patients were analyzed in this study. Our multivariate analysis identified older age, male gender, dependent functional status, chronic obstructive pulmonary disease, bleeding disorder, American Society of Anesthesiology class >2, Wound Class >2, and prolonged operative durations as significant predictors of postoperative airway compromise following ACDF. Surprisingly, multilevel and corpectomy procedures were not significant risk factors for airway complication following ACDF. Conclusion. We identified significant risk factors for airway compromise following ACDF procedures. While ACDF is considered a safe procedure, postoperative airway complication can lead to disastrous outcome. Continued efforts to elucidate preoperative risk factors and subsequent optimization are warranted to improve outcomes in ACDF. Level of Evidence: 3