RESUMEN
STUDY DESIGN: Statewide retrospective cohort study using prospectively collected data from the Spine Care and Outcomes Assessment Program, capturing â¼75% of the state's spine fusion procedures. OBJECTIVE: The aim of this study was to estimate the variation in patient-reported outcomes (PROs) 1 year after elective lumbar fusion surgery across surgeons and hospitals; and to discuss the potential impact of guiding patient selection using a PRO prediction tool. SUMMARY OF BACKGROUND DATA: Despite an increasing interest in incorporating PROs as part of the move toward value-based payment and to improve quality, limited evidence exists on how PROs vary across hospitals and surgeons, a key aspect of using these metrics for quality profiling. METHODS: We examined patient-reported functional improvement (≥15-point reduction in the Oswestry Disability Index [ODI]) and minimal disability (reaching ≤22 on the ODI) 1 year after surgery in 17 hospitals and 58 surgeons between 2012 and 2017. Outcomes were risk-adjusted for patient characteristics with multiple logistic regressions and reliability-adjusted using hierarchical models. RESULTS: Of the 737 patients who underwent lumbar fusion (mean [SD] age, 63 [12] years; 60% female; 84% had stenosis; 70% had spondylolisthesis), 58.7% achieved functional improvement and 42.5% reached minimal disability status at 1 year. After adjusting for patient factors, there was little variation between hospitals and surgeons (maximum interclass correlation was 3.5%), and this variation became statistically insignificant after further reliability adjustment. Avoiding operation on patients with <50% chance of functional improvement may reduce current surgical volume by 63%. CONCLUSION: Variations in PROs across hospitals and surgeons were mainly driven by differences in patient populations undergoing lumbar fusion, suggesting that PROs may not be useful indicators of hospital or surgeon quality. Careful patient selection using validated prediction tools may decrease differences in outcomes across hospitals and providers and improve overall quality, but would significantly reduce surgical volumes. LEVEL OF EVIDENCE: 3.
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Hospitales/normas , Vértebras Lumbares/cirugía , Medición de Resultados Informados por el Paciente , Enfermedades de la Columna Vertebral/cirugía , Fusión Vertebral/tendencias , Cirujanos/normas , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Enfermedades de la Columna Vertebral/epidemiología , Fusión Vertebral/métodos , Resultado del Tratamiento , Washingtón/epidemiologíaRESUMEN
Importance: Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery. Objective: To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement. Design, Setting, and Participants: This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017. Main Outcomes and Measures: Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more. Results: A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator). Conclusions and Relevance: The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.
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Pierna , Dolor de la Región Lumbar/cirugía , Vértebras Lumbares/cirugía , Modelos Teóricos , Dolor/cirugía , Medición de Resultados Informados por el Paciente , Fusión Vertebral , Estudios de Cohortes , Femenino , Predicción , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Resultado del TratamientoRESUMEN
STUDY DESIGN: A retrospective analysis. OBJECTIVE: To quantify the risks of surgery and explore the associations of early perioperative complications with patient demographics and surgical variables. SUMMARY OF BACKGROUND DATA: Long fusions extending from the thoracic spine to the pelvis in adults are increasingly common. Currently, there are few studies detailing the overall risks of such comprehensive reconstructions or how preoperative demographics may be associated with potential complications. METHODS: A retrospective study was performed at two tertiary referral institutions. Preoperative patient demographics and intraoperative surgical variables were analyzed to explore the potential association with outcomes. The outcomes recorded were death, length of hospital and intensive care unit (ICU) stay, discharge to a rehabilitation facility, major medical complications, neurologic deficits, and the additional unplanned surgeries that patients subsequently underwent. RESULTS: One hundred three consecutive patients underwent a fusion extending from the thoracic spine to the pelvis for degenerative conditions from 2003 to 2007. There was a 4% mortality rate. The mean hospital stay and mean ICU stay was 12 ± 7 and 2.7 ± 4 days, respectively. Fifty-eight percent of patients were discharged to a rehabilitation facility. Twelve percent of patients experience at least one major medical complication. Seventeen percent of patients had a documented new persistent neurologic deficit that was still present at the final clinic visit. Thirty-five percent of patients underwent at least one unplanned return to the operating theater. There were no perioperative demographics or surgical variables that had a statistically significant association with mortality. Major medical complications were associated with the American Society of Anesthesiologists' (ASA) score (P = 0.030) and the Charlson Comorbidity Index (P = 0.028) but not age (P = 0.273). CONCLUSION: Complex spine reconstruction involving fusions from the thoracic spine to the pelvis continues to be a high-risk procedure in spite of more advanced surgical and perioperative techniques.
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Pelvis/cirugía , Complicaciones Posoperatorias/mortalidad , Fusión Vertebral/mortalidad , Vértebras Torácicas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Fusión Vertebral/efectos adversos , Fusión Vertebral/métodosRESUMEN
BACKGROUND: Ipsilateral talar and calcaneal fractures represent a rare combination injury that has only recently been reported in the literature with small case series. OBJECTIVE: To identify the commonly observed fracture patterns, complications, and outcomes of a consecutive series of patients with ipsilateral talar and calcaneal fractures. METHODS: Forty-five cases of ipsilateral talus and calcanal fractures were identified from an orthopaedic trauma registry at a University-based, level I trauma center for retrospective review. MAIN OUTCOME MEASUREMENTS: Post-operative complications, the need for secondary surgery, and the visual analogus pain score. RESULTS: Five patients were treated with an early below knee amputation (BKA). Five patients were treated with a primary subtalar arthrodesis. Twenty-eight of the 35 patients who did not undergo early BKA or primary subtalar arthrodesis developed subtalar arthritis. Five patients had deep wound complications. Four patients had talar body collapse from avascular necrosis. There were 13 open fractures of which 8 resulted in an eventual BKA. The mean visual analogus pain score for the patient population was 4.0. CONCLUSION: The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. Subtalar arthritis was a common finding regardless of treatment. Open fractures frequently resulted in a below knee amputation.
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Artritis/diagnóstico por imagen , Calcáneo/lesiones , Fracturas Óseas , Osteonecrosis/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Astrágalo/lesiones , Adolescente , Adulto , Anciano , Amputación Quirúrgica/métodos , Amputación Quirúrgica/estadística & datos numéricos , Calcáneo/diagnóstico por imagen , Calcáneo/cirugía , Femenino , Fijación Interna de Fracturas/métodos , Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Osteonecrosis/cirugía , Dimensión del Dolor , Radiografía , Estudios Retrospectivos , Astrágalo/diagnóstico por imagen , Astrágalo/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
An academic orthopedic residency program can have a significant impact on the burden of musculoskeletal disease in low- and middle-income countries. Such an exposure may also enhance the education of a resident. A 17-question electronic survey was developed to quantify the interest of orthopedic residents in pursuing an elective international rotation. The survey, which gathered resident demographic data and interest in pursuing an elective international orthopedic rotation, was sent to (and completed by) all 38 University of Washington orthopedic residents during academic year 2007-2008. More than 60% (23/38) of residents indicated they would be willing to commit to an international rotation; an additional 24% (9/38) indicated they would be very interested. Almost 40% of residents had participated in international medical volunteerism before entering residency. Among residents, there is a clear interest in pursuing an international rotation to complement their education in the United States.
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Actitud del Personal de Salud , Educación de Postgrado en Medicina/métodos , Intercambio Educacional Internacional , Internado y Residencia/organización & administración , Ortopedia/educación , Estudiantes de Medicina , Encuestas de Atención de la Salud , Intercambio Educacional Internacional/estadística & datos numéricosRESUMEN
The treatment of rheumatoid arthritis has improved dramatically in recent years with the advent of the latest generation of disease-modifying antirheumatic drugs. Despite these advances, in some patients inflammation is not diminished sufficiently to prevent irreversible musculoskeletal damage, thus requiring surgical intervention to reduce pain and improve function. In these cases, the orthopaedic surgeon frequently encounters patients on a drug regimen consisting of nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, and biologic agents (disease-modifying antirheumatic drugs). Consultation with a rheumatologist is recommended, but the surgeon also should be aware of these medications that could potentially affect surgical outcome. Prudent perioperative management of these drugs is required to optimize surgical outcome. A balance must be struck between minimizing potential surgical complications and maintaining disease control to facilitate postoperative rehabilitation of patients with rheumatoid arthritis.