Clinical study
Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures

https://doi.org/10.1016/j.jocn.2020.04.067Get rights and content

Highlights

  • Elective spine surgery patients experienced an overall HAC rate of 3.3%

  • HACs are more common in elective spine surgery as compared to other common elective procedures.

  • Common HACs in spine surgery are surgical site infection, UTI, and venous thromboembolism.

Abstract

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called “never events.” The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons’ NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.

Introduction

Within the last decade there has been a paradigm shift within the healthcare system with increasing emphasis on value based care. This holds true for patients undergoing spine surgery in an effort to optimize quality and safety. Despite advances in perioperative management and surgical technique, patients undergoing spine surgery remain at risk for complication with varying rates in the literature [1], [2], [3]. A subset of these complications are viewed as preventable conditions and have been classified as hospital-acquired conditions (HACs), or the so called “never events”. HACs encompass a broad group of comorbidities and complications with select International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes including surgical site infection (SSI), venous thromboembolism (VTE), and urinary tract infections (UTI).

In 2008, the Centers for Medicare and Medicaid Services formulated an initiative focusing on HACs and how these adverse events are managed within the healthcare system. As part of the initiative, HACs and their associated treatment are no longer reimbursed in the inpatient setting [4]. As such, in addition to having a detrimental effect on patient care, HACs have a significant financial impact on providers, hospital institutions, and patients [5], [6], [7]. Limiting these complications is therefore important to improve both the quality of patient care and to optimize resource allocation.

The objective of this study was to assess the national prevalence of HACs in patients undergoing spine surgery. We focused on the three most common HACs in this patient population: surgical site infection, venous thromboembolism, and urinary tract infections [8], [9]. These rates were then compared to those for other common surgical procedures with the goal of defining baseline data for outcome improvement and to aid in the development of prevention strategies.

Section snippets

Data sources

The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized for this study. ACS-NSQIP was developed by the Department of Veterans Affairs in order to track surgical interventions across US hospitals. NSQIP tracks 135 clinical metrics, including pre-operative risk factors and demographics, intra-operative variables, and 30-day post-operative outcomes using Current Procedural Terminology (CPT) and International Classification of Disease 9th

Study sample – Spine surgery patients

90,551 elective spine surgery patients were identified in the NSQIP database, of which 3021 (3.3%) developed at least one HAC (Table 2). SSI was the most common HAC (1.4%), followed by UTI (1.3%) and VTE (0.8%). Stratified by surgery type, fusion procedures were associated with higher rates of overall HACs compared to decompression-only procedures (3.8% vs 2.7%, p < 0.001) as well as higher rates of each individual HAC (SSI: 1.5% vs 1.3%, UTI: 1.5% vs 0.9%, and VTE: 1.0% vs 0.5%, all p < 0.05).

HACs compared between spine surgery and bariatric surgery

Discussion

With growing focus on value-based care in the current healthcare system, greater emphasis has been placed on improving system efficiency: reducing readmissions, complications, and errors. [12] As such, one solution has been to limit, as much as possible, certain defined preventable hospital-acquired complications (HACs) known as “never events” – meaning they should never occur given that the standard of care is upheld. [10] The Centers for Medicare and Medicaid Services formulated a plan in

Conclusion

HACs developed with greater frequency in elective spine surgery patients than in other common elective procedures including bariatric surgery and THA (3.4% vs 2.8%, p < 0.001); with SSI, being the most common HAC in spine surgery at 1.4%. Additionally, within elective spine surgery, fusion procedures were associated with higher rates of overall HACs compared to decompression-only procedures (3.8% vs 2.7%, p < 0.001). HACs occurred more frequently in cardiothoracic surgery, colectomy, and

Disclosure of funding related to current work

Peter G Passias MD – Reports personal consulting fees for Spinewave, Zimmer Biomet, DePuy Synthes, and Medicrea outside the submitted work.

Ethical review committee statement

Not applicable given that it is de-identified nationally-available data.

CRediT authorship contribution statement

Samantha R. Horn: Formal analysis, Investigation, Methodology, Writing - original draft. Frank A. Segreto: Resources, Software. Haddy Alas: Writing - original draft. Cole Bortz: Visualization, Software. Brendan Jackson-Fowl: Project administration, Validation. Avery E. Brown: Supervision, Writing - review & editing. Katherine E. Pierce: Visualization, Investigation. Dennis Vasquez-Montes: Data curation, Formal analysis. Max I. Egers: Writing - review & editing. Breton G. Line: Resources,

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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