713224 - Re-Defining "Never Events" in Elective Spine Surgery: Are Existing Hospital Acquired Conditions Really Reasonably Preventable

Thursday, February 27, 2020

1:40 PM – 1:45 PM

Location: 208

Participants should be aware of the following financial/non-financial relationships:

Claire White-Dzuro, BA: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Peter G. Passias, MD: AlloSource (Individual(s) Involved: Self, Products/Services: Financial Support): Financial Support; Globus Medical (Individual(s) Involved: Self, Products/Services: Paid Presenter or Speaker): Paid Presenter or Speaker; Medicrea (Individual(s) Involved: Self, Products/Services: N/a): Paid consultant; SpineWave (Individual(s) Involved: Self, Products/Services: Paid Consultant): Paid consultant; The Cervical Spine Research Society (Individual(s) Involved: Self, Products/Services: Grant): Grant; Zimmer Biomet (Individual(s) Involved: Self, Products/Services: Paid Presenter or Speaker): Paid Presenter or Speaker

Cole Bortz, BA: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Avery Brown: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Katherine E. Pierce, BS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Haddy Alas, BS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Shaleen Vira, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Bassel Diebo, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Brian J. Neuman, MD: Depuy synthes (Individual(s) Involved: Self, Products/Services: Research):

Michael Gerling, MD: Allosource (Products/Services: Other financial or material support)Cervical Scoliosis Research Society (Products/Services: Research support)Globus Medical (Products/Services: Paid presenter or speaker)Medicrea (Products/Services: Paid consultant)SpineWave (Products/Services: Paid consultant)Zimmer (Products/Services: Paid presenter or speaker)

Irene Chern: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Waleed Ahmad, MS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sara Naessig, BS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Brendan H. Jackson-Fowl, ScM: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Background: Established as a part of the Affordable Care Act, the Hospital Acquired Condition (HAC) Reduction Program incentivizes hospitals to reduce the incidence of reasonably preventable complications, or “never events”. Currently, 11 adverse events are recognized as HACs; however, there is controversy regarding the distinction between avoidable and unavoidable complications and HACs, especially in surgical spine populations.

Purpose: Assess the impact of HACs and spine-related surgical complications on clinical outcome metrics.

Study Design/Setting: Retrospective review

Patient Sample: 226,383 elective spine surgery patients

Outcome Measures: HAC rates; rates of extended length of stay (LOS), reop, readmission

Methods: Elective spine surgery patients>18yrs were identified in the National Surgical Quality Improvement Program (NSQIP) database 2005-2015. HACs were identified: superficial or deep surgical site infection (SSI), venous thromboembolism (VTE), and urinary tract infection (UTI). Relationships between HAC type and the development of other postop adverse events, including extended (>75th percentile) LOS, readmission, reoperation, and other complications, were assessed using chi-squared and independent samples t-tests, as appropriate. Frailty was calculated and defined frailty score>0.27, as published. Binary logistic regression assessed the relationship between frailty and odds of developing a HAC.

Results: 226,383 elective spine surgery patients (57±14yrs, 48%F) were included. Overall, 62% of procedures involved decompression and 57% involved fusion. Following surgery, mean LOS was 3.1±5.7 days, and 3.5% patients developed at least one HAC, including SSI (1.4%), UTI (1.3%) and VTE (0.9%). Patients with one or more HACs had higher rates of reoperation (HAC: 24% vs No HAC: 2%, p<0.001), readmission (73% vs 57%, p<0.001), and extended LOS (61% vs 24%, p<0.001) than those that did not develop a HAC. Across HACs, there was significant variation in mean LOS, with VTE patients having the most prolonged LOS (10±12 days), followed by UTI (8±10) and SSI patients (6±8, p<0.001). SSI patients had the highest rates of readmission (82%), followed by VTE (73%) and UTI patients (65%, p<0.001). Other common adverse events were excessive blood loss leading to transfusion (6.3%), pneumonia (0.8%), sepsis (0.7%), prolonged (>48hr) ventilator use (0.5%), unplanned intubation (0.5%), wound disruption (0.2%), and peripheral nerve injury (0.1%). Compared to patients with HACs, patients with peripheral nerve injuries had higher rates of readmission (69% vs 31%, p<0.001), and patients with pneumonia had higher rates of extended LOS (86% vs 72%, p<0.001). Patients with peripheral nerve injuries did not differ from HAC patients in rates of reoperation (14% vs 11%, p=0.485) or extended length of stay (71% vs 72%, p=0.950). Frailty predicted increased odds of developing SSI (OR:1.8 [1.7-2.0]), UTI (OR:2.1 [2.0-2.4]), VTE (OR:1.5 [1.3-1.6]), and any HAC (OR:1.8 [1.7-1.9]).

Conclusions: Compared to “never events,” adverse events like peripheral nerve injury and hospital-acquired pneumonia were associated with equivocal rates of reoperation and extended LOS, as well as significantly higher rates of readmission. Frailty was associated with increased odds of developing a HAC following spine surgery. These results seemingly cast doubt on the definition of SSI, UTI, and VTE as reasonably avoidable HACs following spine surgery, especially for frail patients.

Presenting Author(s)

Claire White-Dzuro, BA

Clinical Researcher
NYU Langone Health

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

Peter G. Passias, MD

Associate Professor NYU School of Medicine
NYU Langone Orthopedic Hospital

Disclosure: AlloSource : Financial Support (Status: Ongoing); Globus Medical : Paid Presenter or Speaker (Status: Ongoing); Medicrea : Paid consultant (Status: Ongoing); SpineWave : Paid consultant (Status: Ongoing); The Cervical Spine Research Society : Grant (Status: Ongoing); Zimmer Biomet : Paid Presenter or Speaker (Status: Ongoing)
Cole Bortz, BA

Research Fellow
NYU Langone Orthopedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Avery Brown

Medical Student
NYU Langone Orthopedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Katherine E. Pierce, BS

Research Fellow
NYU Langone Orthopedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Haddy Alas, BS

Medical Student
NYU Langone Orthopaedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Shaleen Vira, MD

Assistant Professor, Orthopaedic Surgery & Neurosurgery
UT Southwestern Medical Center

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Bassel Diebo, MD

Orthopaedic Surgery Resident
SUNY Downstate Department of Orthopaedic Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Brian J. Neuman, MD

Assistant Professor
Johns Hopkins Medicine Department of Orthopaedic Surgery

Disclosure: Depuy synthes (Individual(s) Involved: Self, Products/Services: Research):
Michael Gerling, MD

Spine Surgeon
NYU Langone Orthopaedic Hospital

Disclosure: Allosource (Products/Services: Other financial or material support)Cervical Scoliosis Research Society (Products/Services: Research support)Globus Medical (Products/Services: Paid presenter or speaker)Medicrea (Products/Services: Paid consultant)SpineWave (Products/Services: Paid consultant)Zimmer (Products/Services: Paid presenter or speaker)
Irene Chern

Research Assistant
NYU Langone Orthopaedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Waleed Ahmad, MS

N/A
NYU Langone Orthopedic Hospital

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Sara Naessig, BS

Researcher
New York University Langone Medical Center

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Brendan H. Jackson-Fowl, ScM

Intern
NYU Langone Orthopedic Spine Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.