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  • ASA Status is Associated with Cost and Length of Stay in Lumbar Laminectomy and Fusion: Results from an Institutional Database

    Final Number:

    Rachel S. Bronheim BA; Jeremy Steinberger MD; Samuel Hunter BA; Sean N Neifert BS; Brian C Deutch BA; Jonathan S. Gal MD; Daniel J. Snyder, BS; John M. Caridi MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: LLF is a commonly performed spine procedure used to treat degenerative spine disorders and deformities by decompressing and stabilizing the lumbar spine. American Society of Anesthesiologists (ASA) physical status classification system was developed to estimate preoperative health, and is indicative of a patient’s medical complexity. Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the US, and ASA status has been shown to be a risk factor for cost and length of stay in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and length of stay following lumbar laminectomy and fusion.

    Methods: An institutional database was utilized to identify patients undergoing lumbar laminectomy and fusion between 2006 and 2016. Univariate comparisons between groups were made using chi-squared tests for categorical variables and t-tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and length of stay following LLF.

    Results: 1,849 patients met inclusion criteria. For every one-point increase in ASA score, ICU length of stay increased by 0.518 days (CI: 0.391-0.646, P<0.001), and hospital length of stay increased by 1.93 days (CI: 1.56-2.29, P<0.001). For every one-point increase in ASA score, direct cost increased by $7,474.62 (CI: 5,861.31-9,087.92, P<0.001) (Table 1).

    Conclusions: ASA status was a predictor of hospital length of stay, ICU length of stay, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged length of stay can allow for more accurate reimbursement adjustment as well as more precise targeting of efficiency and cost effectiveness initiatives in the future.

    Patient Care: Consideration of the ways in which ASA status contributes to increased cost and prolonged length of stay can allow for more accurate reimbursement adjustment as well as more precise targeting of efficiency and cost effectiveness initiatives in the future.

    Learning Objectives: By the end of this session, participants should be able to understand the costs associated with ASA class, and to determine the extent to which ASA status is a predictor of increased cost and length of stay following lumbar laminectomy and fusion (LLF).

    References: [1] DiPaola CP, Molinari RW. Posterior lumbar interbody fusion. The Journal of the American Academy of Orthopaedic Surgeons. 2008;16:130-9. [2] Youssef JA, Orndorff DO, Patty CA, Scott MA, Price HL, Hamlin LF, et al. Current status of adult spinal deformity. Global spine journal. 2013;3:51-62. [3] Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al. Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. The New England journal of medicine. 2016;374:1424-34. [4] Cowan JA, Jr., Dimick JB, Wainess R, Upchurch GR, Jr., Chandler WF, La Marca F. Changes in the utilization of spinal fusion in the United States. Neurosurgery. 2006;59:15-20; discussion 15-20. [5] Weiss AJ, Elixhauser A, Andrews RM. Characteristics of Operating Room Procedures in U.S. Hospitals, 2011: Statistical Brief #170. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. [6] Rajaee SS, Bae HW, Kanim LE, Delamarter RB. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine. 2012;37:67-76. [7] Bae HW, Rajaee SS, Kanim LE. Nationwide trends in the surgical management of lumbar spinal stenosis. Spine. 2013;38:916-26. [8] Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. British journal of anaesthesia. 2014;113:424-32. [9] Fitz-Henry J. The ASA classification and peri-operative risk. Annals of the Royal College of Surgeons of England. 2011;93:185-7. [10] Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. Jama. 1961;178:261-6. [11] Basques BA, Anandasivam NS, Webb ML, Samuel AM, Lukasiewicz AM, Bohl DD, et al. Risk Factors for Blood Transfusion With Primary Posterior Lumbar Fusion. Spine. 2015;40:1792-7. [12] Carreon LY, Glassman SD, Shaffrey CI, Fehlings MG, Dahl B, Ames CP, et al. Predictors of Health-Related Quality-of-Life After Complex Adult Spinal Deformity Surgery: A Scoli-RISK-1 Secondary Analysis. Spine deformity. 2017;5:139-44. [13] Deyo RA, Hickam D, Duckart JP, Piedra M. Complications after surgery for lumbar stenosis in a veteran population. Spine. 2013;38:1695-702. [14] Lim S, Carabini LM, Kim RB, Khanna R, Dahdaleh NS, Smith ZA. Evaluation of American Society of Anesthesiologists classification as 30-day morbidity predictor after single-level elective anterior cervical discectomy and fusion. The spine journal : official journal of the North American Spine Society. 2017;17:313-20. [15] Phan K, Kim JS, Lee NJ, Kothari P, Cho SK. Relationship Between ASA Scores and 30-Day Readmissions in Patients Undergoing Anterior Cervical Discectomy and Fusion. Spine. 2017;42:85-91. [16] Sathiyakumar V, Molina CS, Thakore RV, Obremskey WT, Sethi MK. ASA score as a predictor of 30-day perioperative readmission in patients with orthopaedic trauma injuries: an NSQIP analysis. Journal of orthopaedic trauma. 2015;29:e127-32. [17] Vogt AW, Henson LC. Unindicated preoperative testing: ASA physical status and financial implications. Journal of clinical anesthesia. 1997;9:437-41. [18] Fineberg SJ, Nandyala SV, Marquez-Lara A, Oglesby M, Patel AA, Singh K. Incidence and risk factors for postoperative delirium after lumbar spine surgery. Spine. 2013;38:1790-6. [19] McCormack RA, Hunter T, Ramos N, Michels R, Hutzler L, Bosco JA. An analysis of causes of readmission after spine surgery. Spine. 2012;37:1260-6. [20] Lawson EH, Hall BL, Louie R, Ettner SL, Zingmond DS, Han L, et al. Association between occurrence of a postoperative complication and readmission: implications for quality improvement and cost savings. Annals of surgery. 2013;258:10-8. [21] Kay HF, Sathiyakumar V, Yoneda ZT, Lee YM, Jahangir AA, Ehrenfeld JM, et al. The effects of American Society of Anesthesiologists physical status on length of stay and inpatient cost in the surgical treatment of isolated orthopaedic fractures. Journal of orthopaedic trauma. 2014;28:e153-9. [22] Services CfMM. Office of the Actuary, National Health Statistics Group. National Health Expenditure Data: Projections. 2012. [23] Smith CD. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine-American College of Physicians Curriculum. Annals of internal medicine. 2012;157:284-6. [24] McCarthy IM, Hostin RA, Ames CP, Kim HJ, Smith JS, Boachie-Adjei O, et al. Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study. The spine journal : official journal of the North American Spine Society. 2014;14:2326-33. [25] Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery - the case for restraint. The New England journal of medicine. 2004;350:722-6. [26] Missios S, Bekelis K. Hospitalization cost after spine surgery in the United States of America. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2015;22:1632-7. [27] Zygourakis CC, Liu CY, Wakam G, Moriates C, Boscardin C, Ames CP, et al. Geographic and Hospital Variation in Cost of Lumbar Laminectomy and Lumbar Fusion for Degenerative Conditions. Neurosurgery. 2017;81:331-40. [28] Lad SP, Babu R, Baker AA, Ugiliweneza B, Kong M, Bagley CA, et al. Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis. The Journal of bone and joint surgery American volume. 2013;95:e162. [29] Sharma M, Sonig A, Ambekar S, Nanda A. Discharge dispositions, complications, and costs of hospitalization in spinal cord tumor surgery: analysis of data from the United States Nationwide Inpatient Sample, 2003-2010. Journal of neurosurgery Spine. 2014;20:125-41. [30] Singh K, Nandyala SV, Marquez-Lara A, Fineberg SJ, Oglesby M, Pelton MA, et al. A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion. The spine journal : official journal of the North American Spine Society. 2014;14:1694-701. [31] Puffer RC, Planchard R, Mallory GW, Clarke MJ. Patient-specific factors affecting hospital costs in lumbar spine surgery. Journal of neurosurgery Spine. 2016;24:1-6. [32] Whitmore RG, Stephen JH, Vernick C, Campbell PG, Yadla S, Ghobrial GM, et al. ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs. The spine journal : official journal of the North American Spine Society. 2014;14:31-8. [33] Schoenfeld AJ, Wahlquist TC, Bono CM, Lehrich JL, Power RK, Harris MB. Changes in the care of patients with cervical spine fractures following health reform in Massachusetts. Injury. 2015;46:1545-50. [34] Cullen DJ, Apolone G, Greenfield S, Guadagnoli E, Cleary P. ASA Physical Status and age predict morbidity after three surgical procedures. Annals of surgery. 1994;220:3-9. [35] Ivatury SJ, Louden CL, Schwesinger WH. Contributing factors to postoperative length of stay in laparoscopic cholecystectomy. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2011;15:174-8. [36] Ngui NK, Hitos K, Ctercteko G. Preoperative factors prolonging the length of stay in elective colorectal surgery. ANZ journal of surgery. 2011;81:624-8. [37] Inneh IA, Iorio R, Slover JD, Bosco JA, 3rd. Role of Sociodemographic, Co-morbid and Intraoperative Factors in Length of Stay Following Primary Total Hip Arthroplasty. The Journal of arthroplasty. 2015;30:2092-7. [38] Siemionow K, Pelton MA, Hoskins JA, Singh K. Predictive factors of hospital stay in patients undergoing minimally invasive transforaminal lumbar interbody fusion and instrumentation. Spine. 2012;37:2046-54. [39] Gruskay JA, Fu M, Bohl DD, Webb ML, Grauer JN. Factors affecting length of stay after elective posterior lumbar spine surgery: a multivariate analysis. The spine journal : official journal of the North American Spine Society. 2015;15:1188-95. [40] Hackett NJ, De Oliveira GS, Jain UK, Kim JY. ASA class is a reliable independent predictor of medical complications and mortality following surgery. International journal of surgery (London, England). 2015;18:184-90.

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