Original ArticleDischarge to Inpatient Care Facility Following Revision Posterior Lumbar Fusions—Risk Factors and Postdischarge Outcomes
Introduction
Lumbar fusions are one of the top 3 areas of annual Medicare spending, and are key contributors to the ever increasing financial burden of the current health care system.1 Despite the increasing number of lumbar fusion surgeries taking place in the United States annually, the proportion of patients experiencing adverse outcomes still remains high with nearly 20%–40% of the patients undergoing a reoperation and/or revision surgery after the index procedure.2, 3 In a recent trend analysis using a nationwide inpatient database, researchers found that there was a nearly 51% increase in the incidence of revision fusions from 2002 to 2009.4
Revision lumbar fusions are complex surgeries, and are associated with a longer hospital length of stay (LOS), higher costs, and a worse complication profile as compared with primary lumbar fusions.5 Although previous studies have quantified and explored risk factors for adverse outcomes after revision lumbar fusions, no study has explored the impact of discharge destination on postdischarge outcomes alone. This is particularly important in the current health care climate, as recent studies on arthroplasty6, 7 and elective spine procedures8 have noted that discharge to inpatient care facilities may be associated with a higher risk of adverse outcomes, as compared with a home discharge, and therefore may increase costs for the entire episode of care.
With a reported 18% of revision lumbar fusion patients experiencing a nonroutine discharge to a facility other than home,5 and a relative absence of literature with regard to postdischarge outcomes for revision lumbar fusions, we used a national surgical database to address our primary research questions: 1) What are the risk factors for a discharge to inpatient care facility after a revision posterior lumbar fusion, and 2) Does continued inpatient care in a facility after revision posterior lumbar fusion increase the risk of experiencing adverse outcomes, including complications, readmissions, and reoperations?
Section snippets
Database and Patient Selection
This was a retrospective review of prospectively collected data from the 2012–2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. The ACS-NSQIP is a national surgical outcomes database, containing data from more than 500 participating hospitals across the United States. The data are recorded by trained clinical reviewers with a strict review protocol.9 Because of a regular auditing process, the database is commended for its accuracy and has
Baseline Clinical Characteristics
After application of inclusion/exclusion criteria, a total of 1170 patients were retrieved from the database. Of 1170 patients who underwent revision posterior lumbar fusion, 253 (21.6%) were discharged to an inpatient care facility (SNF = 10.9%, IRF = 10.7%) and 917 (78.4%) were discharged to home. Detailed description of baseline clinical characteristics of patients being discharged home versus patients being discharged to an inpatient care facility after revision posterior lumbar fusions is
Discussion
Revision surgery after a primary lumbar fusion is an unfortunate, yet relatively common occurrence and is an important driver contributing to the increased financial burden on the health care system. Because of the increased complexity of the surgery, a significant number of patients require long-term continued inpatient care in a facility after discharge to ensure good outcome after surgery. Despite more than 20% of patients undergoing a nonroutine discharge, no study has evaluated the impact
Conclusions
The current study identifies numerous risk factors associated with a discharge to an inpatient care facility after revision posterior lumbar fusions. Furthermore, discharge to an inpatient care facility is shown to be associated with a 2-fold increase in the risk of experiencing any postdischarge complication. Providers can use these factors to better understand and preoperatively screen patients who may be at a risk for an inpatient care facility, and aim at ensuring a home discharge in these
References (17)
- et al.
Comparative in-hospital morbidity and mortality after revision versus primary thoracic and lumbar spine fusion
Spine J
(2010) - et al.
Inpatient outcomes and postoperative complications after primary versus revision lumbar spinal fusion surgeries for degenerative lumbar disc disease: a national (nationwide) inpatient sample analysis, 2002-2011
World Neurosurg
(2016) - et al.
Continued inpatient care after primary total knee arthroplasty increases 30-day post-discharge complications: a propensity score-adjusted analysis
J Arthroplasty
(2017) - et al.
Does the Medicare 3-day rule increase length of stay?
J Arthroplasty
(2015) - et al.
Skilled nursing facility star rating, patient outcomes, and readmission risk after total joint arthroplasty
J Arthroplasty
(2018) - et al.
Patient expectation is the most important predictor of discharge destination after primary total joint arthroplasty
J Arthroplasty
(2015) - et al.
Incremental hospital cost and length-of-stay associated with treating adverse events among Medicare beneficiaries undergoing lumbar spinal fusion during fiscal year 2013
Spine (Phila Pa 1976)
(2016) - et al.
Predicting postoperative morbidity and readmission for revision posterior lumbar fusion
Clin Spine Surg
(2017)
Cited by (2)
Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery
2019, Surgery (United States)Citation Excerpt :In turn, after these complex surgical interventions, 10% to 50% of patients eventually require skilled assistance after discharge (“nonroutine” discharge), including the use of home health care (HHC), skilled nursing facilities (SNFs), or intermediate care facilities (ICFs).6–9 Among orthopedic surgical patients, discharge to SNFs and ICFs has been associated with increased postdischarge complications, readmissions, and costs.10–12 Nevertheless, the impact of nonroutine discharge on perioperative outcomes, including readmission rates among HP patients, has not been extensively studied.
Predicting 30-Day Perioperative Outcomes in Adult Spinal Deformity Patients with Baseline Paralysis or Functional Dependence
2022, International Journal of Spine Surgery
Conflict of interest statement: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.