Elsevier

Journal of Clinical Neuroscience

Volume 31, September 2016, Pages 137-141
Journal of Clinical Neuroscience

Clinical study
Prolonged length of stay after posterior surgery for cervical spondylotic myelopathy in patients over 65 years of age

https://doi.org/10.1016/j.jocn.2016.02.017Get rights and content

Highlights

  • A large inpatient database was used to identify elderly patients who underwent posterior surgery for cervical myelopathy.

  • Prolonged length of stay (PLOS) was defined as stay beyond 6 days in this study.

  • Predictive factors for PLOS included alcohol abuse, deep vein thrombosis, myocardial infarction, pneumonia, and others.

  • PLOS was associated with significantly higher mortality rates and total hospital charges compared to the control group.

Abstract

Prolonged length of stay (PLOS) has been associated with increased hospital resource utilization and worsened patient outcomes in multiple studies. In this study, we defined and identified factors associated with PLOS after posterior surgery for cervical spondylotic myelopathy in patients over the age of 65. PLOS was defined as length of stay beyond the “prolongation point” (that is, the day after which discharge rates begin to decline). Using the United States Nationwide Inpatient Sample database, 2742 patients met inclusion criteria, out of whom 16.5% experienced PLOS (stay beyond 6 days). After multivariate analysis, increasing age was independently associated with PLOS (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02–1.06). Multiple comorbid conditions were associated with PLOS, including alcohol abuse (OR 3.85, 95% CI 1.87–7.94), congestive heart failure (OR 1.72, 95% CI 1.11–2.64), obesity (OR 1.70, 95% CI 1.14–2.55), and deficiency anemia (OR 1.44, 95% CI 1.01–2.05); the strongest associated operative parameter was blood transfusion (OR 2.39, 95% CI 1.75–3.28). Major complications independently associated with PLOS were deep vein thrombosis (OR 18.32, 95% CI 6.50–51.61), myocardial infarction (OR 8.98, 95% CI 2.92–27.56), pneumonia (OR 6.67, 95% CI 3.17–14.05), acute respiratory failure (OR 6.27, 95% CI 3.43–11.45), hemorrhage/hematoma (OR 5.04, 95% CI 2.69–9.44), and implant-related complications (OR 2.49, 95% CI 1.24–4.98). Average total hospital charges for patients who experienced PLOS were $122,965 US dollars, compared to $76,870 for the control group (p < 0.001). Mortality for patients who experienced PLOS was 2.7% versus 0.5% for patients who did not epxerience PLOS (p < 0.001). In conclusion, patients over the age of 65 who underwent posterior surgery for cervical myelopathy and stayed over 6 days in hospital were defined as having PLOS. Hospital charges and mortality rates were significantly higher for patients who experienced PLOS. Potentially modifiable and/or preventable risk factors were also identified.

Introduction

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the elderly population [1]. Although the prevalence of CSM is unknown [2], age-related cervical spondylosis is known to affect almost 95% of patients over the age of 65 [3]. Surgical decompression can be performed anteriorly or posteriorly, and is typically indicated for patients with progressive weakness, gait instability, urinary frequency or incontinence, loss of hand dexterity, and/or impairment in daily activities [4]. Though both approaches have shown relatively equal functional outcomes [5], the posterior approach (typically laminectomy and stabilization) is sometimes preferred in older patients, given the lower risk of swallowing difficulty and common presence of multi-level disease [6]. Nonetheless, posterior approaches have been associated with a higher rate of surgical site infection [7] and C5 palsy [8], among others, and longer lengths of stay (LOS) when compared to anterior approaches [9].

LOS of any surgical patient is mainly a function of patient characteristics (such as age and comorbid conditions), procedure complexity, development of any postoperative complication or adverse event, and others. In an era of rising healthcare costs, surgeons and providers are constantly seeking ways to improve cost-effectiveness while maintaining or improving patient outcomes [10]. Prolonged length of stay (PLOS), oftentimes the result of a postoperative complication or a severely-ill patient, has been associated with significant increases in hospital resource utilization and worsened patient outcomes [11], [12]. The definition of PLOS, however, is not universal and varies throughout the literature [12], [13], [14], [15].

The purpose of this study is to provide a definition of PLOS based on when discharge rates begin to decline for patients over 65 years of age who underwent posterior surgery for CSM, based on previous work by Silber et al. [13], [14], [15]. Secondary objectives include identification of independent risk factors for PLOS, as well as examining the association between PLOS and total hospital charges and in-hospital mortality.

Section snippets

Study design and inclusion criteria

This case-control study utilized the Nationwide Inpatient Sample (NIS) administrative databases from 2002 to 2011. The NIS is a database containing admission information for over 8 million hospital stays per year, representing a 20% sample of all discharges in the United States for any given year.

Inclusion criteria were patients over the age of 65 undergoing posterior fusion for CSM. Patients were identified via International Classification of Diseases 9th Version (ICD-9) codes 81.03 for

Results

A total of 2742 admissions were examined. After analysis, discharge rates for patients who underwent posterior surgery for CSM were increasing through day 6; each passing day would increase the discharge rate, thus bringing patients closer to release (Fig. 1). After day 6, the discharge rate decreased, meaning that with each passing day patients would be less likely to be discharged; this was defined as PLOS. After 10 days, discharge patters became unstable due to the low sample size. Average

Discussion

PLOS, defined in this study as a hospital stay beyond the “prolongation point” [15], may be regarded as a consequence of complication development or “disorganization in care delivery” [15]. In this study of patients over 65 years of age who underwent posterior surgery for CSM, PLOS was defined as stay beyond 6 days, which was the day after which discharge rates declined (Fig. 1). Additionally, several independent factors associated with PLOS were identified, as well as the relationship between

Conclusions

Patients over the age of 65 who underwent posterior surgery for CSM and stayed in the hospital for over 6 days were defined as having a PLOS in this study. After day 6, the discharge rate steadily decreased, meaning that patients would be less likely to be discharged with each passing day. Patients experienced a PLOS most likely due to a combination of older age, preoperative comorbidities, and development of a severe in-hospital complication. More importantly, it was found that hospital charges

Conflicts of Interest/Disclosures

Daniel Sciubba has consulting agreements with Medtronic, Depuy-Synthes, Orthofix and Globus.

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