Elsevier

World Neurosurgery

Volume 123, March 2019, Pages e482-e487
World Neurosurgery

Original Article
Discharge to Inpatient Care Facility Following Revision Posterior Lumbar Fusions—Risk Factors and Postdischarge Outcomes

https://doi.org/10.1016/j.wneu.2018.11.191Get rights and content

Background

Recent literature has denoted care in an inpatient facility after discharge to be linked with worse outcomes after elective primary lumbar and cervical fusions. No study has explored the risk factors and associated postdischarge outcomes after discharge to inpatient facility after revision posterior lumbar fusion.

Methods

The 2012–2016 American College of Surgeons–National Surgical Quality Improvement Program were queried using Current Procedural Terminology codes for posterior lumbar fusions (22630, 22633, 22614) combined with Current Procedural Terminology codes for revision—22830 (exploration of spinal fusion), 22849 (reinsertion of spinal fixation device), 22850 (removal of posterior nonsegmental instrumentation), and 22852 (removal of posterior segmental instrumentation).

Results

Of 1170 patients who underwent revision posterior lumbar fusion, 253 (21.6%) were discharged to an inpatient care facility and 917 (78.4%) were discharged to home. Significant risk factors associated with discharge to inpatient care facility were age 60–69 years (odds ratio [OR] 3.62), age ≥70 years (OR 7.46), female gender (OR 1.61), partially dependent functional health status before surgery (OR 2.94), history of chronic obstructive pulmonary disease (OR 1.92), a length of stay >3 days (OR 3.13), and the occurrence of any predischarge complication (OR 4.10). Discharge to inpatient care facilities versus home was associated with a higher risk of experiencing any postdischarge complication (8.3% vs. 3.2%; OR 2.2).

Conclusions

Providers should understand the need of construction of care pathways and reducing discharge to inpatient facilities to mitigate the risks of experiencing adverse outcomes and consequently reduce the financial burden on the health care system.

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)

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    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.

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.

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