Dialysis is an independent risk factor for perioperative adverse events, readmission, reoperation and mortality for patients undergoing elective spine surgery

Publication date: Available online 2 August 2018

Source: The Spine Journal

Author(s): Taylor D. Ottesen, Ryan P. McLynn, Cheryl K. Zogg, Blake N. Shultz, Nathaniel T. Ondeck, Patawut Bovonratwet, Kirthi S. Bellamkonda, Lee E. Rubin, Jonathan N. Grauer

Abstract

Background Context

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.

Purpose

The current study utilizes a large, national sample with 30-day follow-up to investigate dialysis as risk factor for perioperative complications independent of patient demographics or comorbidities.

Study Design/Setting

Retrospective cohort study.

Patient Sample

Patients undergoing elective spine surgery with or without dialysis from the 2005-2015 NSQIP database.

Outcome Measures

Post-operative complications within 30 days and binomial reoperation, readmission, and mortality within 30 days.

Methods

National Surgical Quality Improvement Program (NSQIP) 2005-2015 databases were queried for adult dialysis-dependent and dialysis-independent patients undergoing elective spinal surgery. Differences in 30-day outcomes were compared using risk-adjusted multivariate regression and coarsened exact matching analysis for adverse events, unplanned readmission, reoperation, and mortality. The percentage of complications occurring before versus after hospital discharge was also assessed. The authors have no financial disclosures related to this study.

Results

A total of 467 dialysis and 173,311 non-dialysis patients met inclusion criteria. Controlling for age, sex, BMI, functional status, and American Society of Anesthesiologists (ASA) class, dialysis patients were found to be at significantly greater odds of any adverse event (Odds ratio [OR]=2.52 before, 2.17 after matching, p=<0.001), major adverse event (OR=2.90 before, 2.52 after matching, p=<0.001), and minor adverse event (OR=1.50 before matching, p=<0.025, but not significantly different after matching). Further, dialysis patients were significantly more likely to return to the operating room (OR= 2.77 before, 2.50 after matching, p=<0.001), have unplanned readmissions (OR=2.73 before, 2.37 after matching, p=<0.001), and die within 30 days (OR=3.77 before, 2.71 after matching, p=<0.001). Adverse events occurred post discharge for 51.78% of non-dialysis patients and for 43.80% of dialysis patients.

Conclusions

Dialysis patients undergoing elective spine surgery are at significantly higher risk for aggregated adverse outcomes, return to the operating room, readmission, and death than non-dialysis patients, even after controlling for patient demographics and overall health (as indicted by ASA class). These differences need to be considered when determining treatment options. Additionally, with bundled payments expected in spine surgery, physicians and hospitals need to account for increased costs and liabilities when working with dialysis patients.

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