Hospital competitive intensity and perioperative outcomes following lumbar spinal fusion

Publication date: Available online 4 September 2017
Source:The Spine Journal
Author(s): Wesley M. Durand, Joseph R. Johnson, Neill Y. Li, JaeWon Yang, Adam E.M. Eltorai, J. Mason DePasse, Alan H. Daniels
Background ContextInter-hospital competition has been shown to influence adoption of surgical techniques and approaches, clinical patient outcomes, and healthcare resource utilization for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.PurposeThis investigation sought to examine the relationship between inter-hospital competitive intensity and perioperative outcomes following lumbar spinal fusion.Study Design/SettingThis study utilized the Nationwide Inpatient Sample (NIS) dataset, years 2003, 2006, and 2009.Patient SamplePatients were included based on the presence of International Classification of Disease, 9^th Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI).Outcome MeasuresPerioperative complications, defined using an ICD-9-CM coding algorithm.MethodsThe HHI, a validated measure of competition within a market, was utilized to assess hospital market competitiveness. HHI was calculated based on hospital cachement area. Multiple regression was performed to adjust for confounding variables including: patient age, sex, primary payer, severity of illness score, primary vs. revision fusion, anterior vs. posterior approach, national region, hospital bed size, location/teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications.ResultsIn total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099 – 0.724). The average patient age was 55.4 years (SE = 0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998), and fusions with posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or Midwest (27.0%, n=112,758) regions. In multiple regression analysis, increased hospital competitive intensity was associated with increased total complication rate (OR 1.52, p<0.0001), device-related complications (OR 1.46, p=0.0294), genitourinary complications (OR 2.15, p=0.0091), infection (OR 3.48, p<0.0001), neurologic complications (OR 1.69, p=0.0422), total charges (+29%, p=0.0034), and inpatient hospital length of stay (LOS) (+16%, p=0.0012). Likelihood of complications at State-owned hospitals (OR 2.81, p=0.0001) was more highly associated with HHI than at private-non-profit hospitals (OR 1.39, p=0.0050). Occurrence of complications at urban teaching hospitals (OR 2.14, p<0.0001) was generally more associated with HHI than at urban non-teaching hospitals (OR 1.19, p=0.2457).ConclusionsIncreased inter-hospital competitive intensity is associated with increased odds of complications, increased total charges, and prolonged LOS following lumbar spine fusion. These differences are generally highest among State-owned and urban teaching hospitals. Differences in outcome related to hospital competition may be due to sub-optimal resource allocation. Identifying differences in perioperative outcomes associated with hospital market competition is important in the contemporary environment of healthcare reimbursement reform and hospital consolidation. Perioperative outcome disparities between highly competitive and minimally competitive areas should be monitored and further studied.



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