Elsevier

Journal of Clinical Neuroscience

Volume 56, October 2018, Pages 114-120
Journal of Clinical Neuroscience

Clinical study
Factors influencing extended hospital stay in patients undergoing metastatic spine tumour surgery and its impact on survival

https://doi.org/10.1016/j.jocn.2018.06.041Get rights and content

Highlights

  • Retrospective review, 220 patients undergoing MSTS.

  • Median LOS = 7 days; eLOS is defined as >75th percentile of LOS, which was ≥11 days.

  • Metastases from breast, prostate and lung have higher risk of eLOS.

  • eLOS associated with: post-operative complications and/or Instrumentation >9 levels.

  • Patients with eLOS showed reduced survival.

Abstract

Metastatic spine tumour surgeries (MSTS) are indicated for preservation or restoration of neurological function, to provide mechanical stability and pain alleviation. The goal of MSTS is to improve the quality of life of the patients with spinal metastases and rarely for oncological control which is usually achieved by adjuvant therapies. Hence outcome measures such as length of stay (LOS) and rate of complications after MSTS are important indicators of quality but there is limited literature evidence for the same. We carried out a retrospective study to determine the incidence and the factors influencing normal (nLOS) and extended length of stay (eLOS) after MSTS. Data of 220 consecutive patients who underwent MSTS between 2005 and 2015 were retrieved from hospital electronic records. The preoperative, intraoperative and postoperative variables, discharge destinations as well as socioeconomic factors were analyzed. eLOS defined as positive when the LOS exceeded the 75th percentile for this cohort, was the key outcome indicator. Univariate and multivariate logistic regression analyses were performed to determine the predictive factors of eLOS. The overall median LOS was 7 days (1–30 days) and 55 patients had eLOS (LOS ≥ 11 days). Multivariate analysis revealed that significant variables independently associated with eLOS were instrumentation >9 spinal segmental levels (OR 2.89, 95% CI 1.1–7.5, p = 0.032) and presence of postoperative complications (OR 3.68, 95% CI 1.85–7.30, p < 0.001). Metastatic tumours other than breast, prostate and lung have lesser risk of eLOS (OR 0.31, 95% CI 0.14–0.70, p = 0.004). Survival estimates show that patients with eLOS have shorter survival than patients with nLOS (Crude HR 1.81, 95% CI 1.13–2.89, p = 0.003).

Introduction

Surgery forms one leg of a tripod in comprehensive management of metastatic spine disease (MSD); the others being; radiotherapy (RT), chemotherapy (CT)/hormonal therapy (HT) [1]. The goals of metastatic spine tumour surgery (MSTS) include preservation or restoration of neurologic function, providing mechanical stability, pain alleviation and rarely oncologic control. The decision for surgery is influenced by multiple factors-patient’s responsiveness to non-operative measures, estimated post-operative life expectancy, potentially achievable post-operative quality of life and surgery related costs [2]. In addition to considering physical suitability for operative treatment, it is also important to ensure that health care cost and postoperative recovery does not outweigh its potential benefits. Length of stay (LOS) is one such key factor to measure cost-effectiveness, quantify operative success and give a meaningful outcome measure that can be a potential target for quality improvement activities [3], [4].

LOS can be influenced by clinical or non-clinical causes, however increased length of hospital stay results increased financial burden, resource strain and affect delivery of efficient and quality health care [5]. Thus, understanding the factors affecting extended LOS (eLOS) will aid in addressing factors causing prolonged hospital stays much earlier in course of hospital admission. This will result in optimizing health care service delivery and provide an opportunity for patients to make an informed decision regarding surgery. Patients with spinal metastases are elderly and high-risk patients with a shorter predicted survival. Hence, deeper understanding of the factors influencing eLOS will allow both physicians and patients alike to better weigh the cost-effectiveness and risk-benefit of MSTS. Literature supports studies evaluating the factors determining eLOS in patients undergoing elective surgeries for spinal [6], [7], [8], [9] and other surgical disciplines [5]. However, there is a paucity of literature estimating LOS in patients undergoing MSTS.

With this background, we aimed to examine the factors influencing eLOS in patients undergoing MSTS by generating a multivariate model accounting for potential confounding factors which can be either preoperative, intraoperative and/or postoperative variables, as well as socioeconomic factors. We also looked at the impact of eLOS on the survival of the patients after MSTS.

Section snippets

Materials and methods

All patients who underwent MSTS at a single tertiary institution between 2005 and 2015 were identified. Ethics approval was obtained from institutional review board. Indications for surgery were neurological deficit, spinal instability, intractable pain or combination of the above. We excluded patients who underwent only vertebro/kyphoplasty, revision surgery, or those who died during hospital stay. Data were retrieved by hospital electronic records [Computerized Patient Support System (CPSS) &

Results

A total of 220 patients who underwent MSTS were included in the final analysis. Table 1 summarizes median LOS and distribution of patients with eLOS for each demographic, oncological, operative characteristics and socioeconomic status. Categorical variables are presented as numbers and percentages and continuous variables as means ± standard deviation or median and range, depending on the distribution of data. The overall median LOS was 7 days (1–30 days) (Fig. 1). The 75th percentile LOS was

Discussion

A positive improvement in the quality of life of selective patients with MSD is the definitive aim of MSTS [15]. LOS is an outcome measure that can guide quality improvement activities [4]. The LOS in patients with MSD is much higher (12–18 days) than other cancer patients [16]. As metastatic spinal cord compression (MSCC) related hospitalizations increase 3.4% annually [17], it is important to understand the risk factors and determinants of eLOS. It not only helps control the 5.3% annually

Conclusions

To summarise, our study demonstrates that instrumentation levels >9, metastases from lung, breast and prostate, and presence of major postoperative complications were factors influencing eLOS; hence should be carefully addressed whenever possible. Reduction of LOS will assist the health care providers in better resource allocation as well as enabling metastatic spine patients to spend a larger proportion of their limited life span in their home or preferred environment.

Conflict of interest

None.

Financial source

None.

Acknowledgements

We are thankful to Dr. Aye Sandar Zaw for her contribution in preparing the manuscript.

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