Introduction: Extended length of hospital stay(LOS), unplanned hospital readmission,
and need for inpatient rehabilitation following spine surgery contribute
significantly to variation in surgical healthcare cost. As novel payment
models shift, the risk of cost over runs from payers to providers,
understanding patient-level risk of these events is critical. We set out to
develop a grading scale that stratifies risk of these costly events after
elective surgery for degenerative lumbar pathologies.
Methods: 6,921 cases prospectively enrolled into the QOD registry were queried
(elective 1-3 level lumbar surgery for degenerative pathology). The
association between pre-operative patient variables and extended
LOS(=7 days), discharge status (inpatient facility vs. home), and 90-day
hospital readmission were assessed by step-wise multivariate logistic
regression. Carolina-Semmes grading scale was constructed using the
independent predictors for LOS (0-8 points), discharge to inpatient
facility (0-10 points), and 90-day re-admission (0-8), its performance
was assessed in the QOD dataset and then confirmed separately after
applying to the Carolina Neurosurgery & Spine Associates[CNSA] and
Semmes-Murphy Clinic sites.
Results: 290 (4.2%) patients required extended LOS, 654 (9.4%) required
inpatient facility rehab, and 474 (6.8%) 90-day hospital readmission.
Variables independently associated with these unplanned events in
multivariate analysis are summarized in Table 1. Increasing point totals
in the Carolina-Semmes scale effectively stratified the incidence of
extended LOS, discharge to facility, and re-admission in both the
aggregate QOD dataset and when subsequently applied to two
practice groups.
Conclusions: For patients undergoing first time elective 1-3 level degenerative lumbar
spine surgery, we introduce the Carolina-Semmes grading scale that
effectively stratifies risk of prolonged hospital stay, need for postdischarge
inpatient facility care, and 90-day hospital readmission. This
scale may be helpful in identifying high-risk patients who may benefit
from preventative health services strategies and education as well as
help structure capitated/bundled care contracts to minimize risk on the
provider.
Patient Care: Risk-stratification for the unplanned events presented here will be helpful in identifying high-risk patients who may benefit from preventative health services strategies and education as well as help structure capitated/bundled care contracts to minimize risk on the
provider.
Learning Objectives: We introduce a novel grading scale to risk-stratify the patients based on
their need for extended LOS, discharge to inpatient rehabilitation facility
and 90-day readmission. Analyses such as these can allow hospitals
and surgeons to risk stratify their practices to allow for more appropriate
third party evaluations of patient outcomes. Furthermore, understanding
and accurately predicting which patients may require additional resource
utilization within a global period after surgery may help facilitate the
creation and implementation of risk-adjusted bundled payment systems
that would more fairly compensate surgeons and hospitals for advanced
services. Regular use of such a predictive model based grading scale
can lead to more informed decision-making when discussing treatment
options and expectations with patients.
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