Predictors of adverse discharge disposition in adult spinal deformity and associated costs

Publication date: Available online 9 April 2018
Source:The Spine Journal
Author(s): Peter G. Passias, Gregory W. Poorman, Cole A. Bortz, Rabia Qureshi, Bassel G. Diebo, Justin C. Paul, Samantha R. Horn, Frank A. Segreto, Alexandra Pyne, Cyrus M. Jalai, Virginie Lafage, Shay Bess, Frank J. Schwab, Hamid Hassanzadeh
Background ContextWith advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators for adverse discharge disposition in ASD surgeries is paramount.PurposeOn nationwide and surgeon-created databases, identify predictors of adverse discharge disposition after ASD surgeries and view corresponding differences in charges.Study Design/SettingRetrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and cost data from Medicare PearlDiver Database.Patient SamplePatients undergoing thoracolumbar surgery for correction of ASD.Outcome MeasuresPrimary: Discharge disposition home vs. not home. Secondary: Cost differences across discharge groups.MethodsPatients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x), and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30-day and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion.Results1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. Upon multivariate regression analysis, age over 60 years (OR: 0.28 CI: 0.22-0.34) and female sex (p=0.003) were independent predictors of adverse discharge status. Partially dependent pre-operational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR:0.57 CI:0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR:0.51 CI:0.40-0.64), interbody device placement (OR:0.80 CI:0.64-0.98) and fixation to the iliac (OR:0.54 CI:0.41-0.70) both increased likelihood of adverse discharge. Complications most associated with adverse discharge were UTIs (OR:0.34 CI:0.21-0.57) and blood transfusions (OR:0.42 CI:0.34-0.52). Relative to home-discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=0.177). 90-day costs of care were $23,815 in rehab discharges (p<0.001), but again not different in skilled nursing facility discharges (+$6,091, p=0.212).ConclusionsDischarge destination to rehabilitation has a significant impact on cost of thoracolumbar adult spinal deformity surgeries. Patient selection can predict patients at higher risk for discharges to rehab or skilled nursing facility.



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