William Kreuter

Trends, Major Medical Complications, and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults

CONTEXT In recent decades, the fastest growth in lumbar surgery occurred in older patients with spinal stenosis. Trials indicate that for selected patients, decompressive surgery offers an advantage over nonoperative treatment, but surgeons often recommend more invasive fusion procedures. Comorbidity is common in older patients, so benefits and risks must be carefully weighed in the choice of surgical procedure. OBJECTIVE To examine trends in use of different types of stenosis operations and the association of complications and resource use with surgical complexity. DESIGN, SETTING, AND PATIENTS Retrospective cohort analysis of Medicare claims for 2002-2007, focusing on 2007 to assess complications and resource use in US hospitals. Operations for Medicare recipients undergoing surgery for lumbar stenosis (n = 32,152 in the first 11 months of 2007) were grouped into 3 gradations of invasiveness: decompression alone, simple fusion (1 or 2 disk levels, single surgical approach), or complex fusion (more than 2 disk levels or combined anterior and posterior approach). MAIN OUTCOME MEASURES Rates of the 3 types of surgery, major complications, postoperative mortality, and resource use. RESULTS Overall, surgical rates declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 beneficiaries. Life-threatening complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50-3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US

United States trends in lumbar fusion surgery for degenerative conditions.

80,888 compared with US

Low back pain hospitalization: Recent united states trends and regional variations

23,724 for decompression alone. CONCLUSIONS Among Medicare recipients, between 2002 and 2007, the frequency of complex fusion procedures for spinal stenosis increased while the frequency of decompression surgery and simple fusions decreased. In 2007, compared with decompression, simple fusion and complex fusion were associated with increased risk of major complications, 30-day mortality, and resource use.

Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly

Study Design. Retrospective cohort study using national sample administrative data. Objectives. To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures. Summary of Background Data. Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery. Methods. We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection. Results. In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses. Conclusions. Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.

Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures.

Study Design. This study describes recent United States trends and regional variations in the management of low back pain. Objectives. The authors investigated recent temporal trends and compared practices in different geographic regions. Summary of Background Data. Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. Methods. National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. Results. Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. Conclusions. Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems. [Key words: low back pain management, trends, regional variations, practice patterns] Spine 1994;19:1207–1213

Complications and mortality associated with cervical spine surgery for degenerative disease in the United States.

BACKGROUND It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival. METHODS We examined fee-for-service Medicare data from 1992 through 2005 to identify beneficiaries 65 years of age or older who underwent CPR in U.S. hospitals. We examined temporal trends in the incidence of CPR and the rate of survival after CPR, as well as patient- and hospital-level predictors of survival to discharge. RESULTS We identified 433,985 patients who underwent in-hospital CPR; 18.3% of these patients (95% confidence interval [CI], 18.2 to 18.5) survived to discharge. The rate of survival did not change substantially during the period from 1992 through 2005. The overall incidence of CPR was 2.73 events per 1000 admissions; the incidence was higher among black and other nonwhite patients. The proportion of patients undergoing in-hospital CPR before death increased over time and was higher for nonwhite patients. The survival rate was lower among patients who were men, were older, had more coexisting illnesses, or were admitted from a skilled-nursing facility. The adjusted odds of survival for black patients were 23.6% lower than those for similar white patients (95% CI, 21.2 to 25.9). The association between race and survival was partially explained by hospital effects: black patients were more likely to undergo CPR in hospitals that have lower rates of post-CPR survival. Among patients surviving in-hospital CPR, the proportion of patients discharged home rather than to a health care facility decreased over time. CONCLUSIONS Survival after in-hospital CPR did not improve from 1992 through 2005. The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased. Black race was associated with higher rates of CPR but lower rates of survival after CPR.

Relationship between the Volume of Total Hip Replacements Performed by Providers and the Rates of Postoperative Complications in the State of Washington

Study Design. Retrospective cohort study using a hospital discharge registry of all nonfederal acute care hospitals in Washington state. Objectives. To determine the cumulative incidence of reoperation following lumbar surgery for degenerative disease and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone. Summary of Background Data. Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear. Methods. Adults who underwent inpatient lumbar surgery for degenerative spine disorders in 1990–1993 (n = 24,882) were identified from International Classification of Diseases ninth Revision, Clinical Modification codes and then categorized as having either a lumbar decompression surgery or lumbar fusion surgery. We then compared the subsequent incidence of lumbar spine surgery between these groups. Results. Patients who had surgery in 1990–93 had a 19% cumulative incidence of reoperation during the subsequent 11 years. Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% vs. 28.0%, P = 0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, P = 0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis. Conclusion. Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.

Population-based trends in volumes and rates of ambulatory lumbar spine surgery.

Study Design. Retrospective cohort. Objectives. To describe the incidence of complications and mortality associated with surgery for degenerative disease of the cervical spine using population-based data. To evaluate the associations between complications and mortality and age, primary diagnosis and type of surgical procedure. Summary of Background Data. Recent studies have shown an increase in the number of cervical spine surgeries performed for degenerative disease in the United States. However, the associations between complications and mortality and age, primary diagnosis and type of surgical procedure are not well described using population-based data. Methods. We created an algorithm defining degenerative cervical spine disease and associated complications using the International Classification of Diseases-ninth revision Clinical Modification codes. Using the Nationwide Inpatient Sample, we determined the primary diagnoses, surgical procedures, and associated in-hospital complications and mortality from 1992 to 2001. Results. From 1992 to 2001, the Nationwide Inpatient Sample included an estimated 932,009 (0.3%) hospital discharges associated with cervical spine surgery for degenerative disease. The majority of admissions were for herniated disc (56%) and cervical spondylosis with myelopathy (19%). Complications and mortality were more common in the elderly, and after posterior fusions or surgical procedures associated with a primary diagnosis of cervical spondylosis with myelopathy. Conclusions. There are significant differences in outcome associated with age, primary diagnosis, and type of surgical procedure. Administrative databases may underestimate the incidence of complications, but these population-based studies may provide information for comparison with surgical case series and help evaluate rare or severe complications.

Treatment Intensity at the End of Life in Older Adults Receiving Long-term Dialysis

Since the late 1970s, an empirical relationship between the volume of procedures performed by a provider (a hospital or surgeon) and the outcome has been documented for various operations. The present study examines the relationship between the volume of hip replacements performed by surgeons and hospitals and the postoperative rate of complications. A statewide hospital discharge registry was used to identify patients who had had an elective hip replacement between 1988 and 1991. Patients who had had a revision procedure, who had been referred on an emergency basis, or who had had a diagnosis of a fracture or a malignant tumor on admission were excluded. There were 7936 eligible patients who had had 8774 hip replacements. The average annual number of all hip replacements performed from 1987 through 1991 was subsequently determined for each hospital and surgeon who had cared for at least one patient in the study cohort. The rate of operative complications was modeled as a function of the volume of procedures performed by the surgeon or hospital (the surgeon or hospital volume), with adjustment for the age of the patient, gender, co-morbidity, and operative diagnosis. We noted significant differences in the case mix of low-volume providers compared with that of high-volume providers (p < 0.01). In general, surgeons and hospitals with a volume below the fortieth percentile managed patients who had a more adverse risk profile in terms of age, co-morbidity, and diagnosis. Even after adjustment for the case mix, there was a significant relationship between surgeons who averaged fewer than two hip replacements annually (low-volume surgeons) and a worse outcome (p < 0.05). Patients managed by these low-volume surgeons tended to have higher mortality rates, more infections, higher rates of revision operations, and more serious complications during the index hospitalization. The duration of hospitalization was inversely related to surgeon volume and directly associated with hospital volume. Hospital charges were inversely related to hospital volume, even after adjustment for patient-related factors as well as the duration of hospitalization, the year of the operation, and the destination after discharge (p < 0.05). More detailed information is required to investigate the reason for these observed variations in the rates of complications. If future studies confirm an association between low-volume providers and an adverse outcome, performance of some types of elective total hip replacements at regional centers should be considered.

Trends and Variations in Cervical Spine Surgery in the United States: Medicare Beneficiaries, 1992 to 2005

Study Design. Sequential cross-sectional study. Objectives. To quantify patterns of outpatient lumbar spine surgery. Summary of Background Data. Outpatient lumbar spine surgery patterns are undocumented. Methods. We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUPs State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates. Results. Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000. Conclusions. While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.