The first abstract is going to be presented by Dr. Owiyocho Adogwa. The title of the abstract is Interdisciplinary Care Model Decreases Use of Critical Care Services After Corrective Surgery for Adult Degenerative Scoliosis. The author block, Aladin, and please forgive me for maybe messing up names, Els Madisi, Amanda Serjig-Sketter, Michelle Ungeli, Aaron Tarnaski, Victoria Vuong, Salid Khalid, and the advanced practice provider Jessica Moreno, Joseph Chang, Isaac Karikari, and Carlos Begley. Thank you very much. I actually just came from the Spine Section Executive Committee looking at interdisciplinary modeling for patients undergoing these big operations, and they're actually dedicating a tremendous number of resources just to optimize how we take care of these patients. I have a particular academic and clinical interest in this, and I hope to show you in the next couple slides. I won't take up too much of your time, that optimizing these patients in a multidisciplinary fashion certainly is in the best interest, not only for the patient, the providers, and certainly for the healthcare system. Those are my mentors there. There is no doubt that healthcare costs are rising. We've seen this in the press. It's a huge political issue at this time, and it affects us all in what we can offer our patients on long term. If you look at some of the numbers here, 560% increase in total healthcare expenditure since 1980, healthcare costs greater than 16% of GDP, 70% of total healthcare costs spent in the last six months of life. If you look at critical care services, 15% of total hospital beds, ICU beds, and this number continues to increase. So if you create these beds, these beds are most likely to be filled, and these are very, very expensive beds in the hospital. Occupancy rates of 68%. This is very generous because I can tell you that our facility, we have a 28-bed dedicated neurosurgical intensive care unit that's 100% full almost 100% of the time. Annual cost of $82 billion, close to 1% of total GDP, 20 to 28% of total inpatient costs. For instance, my interest is in academic spying. The vast majority of those patients go home in a relatively timely fashion, but when they have prolonged hospital stays, you can imagine that's very expensive. And then one, ICU day is equivalent in terms of cost to four to six non-ICU stays, so it's very expensive. Some of the drivers, age, comorbidities, severity of illness, cardiopulmonary complications, emergency surgery and variations in practice. And all the patients are disproportionately affected by all of these complications that I just noted. If you look at the shifting demographics of certainly the United States, I think this mirrors most other countries in the world. The vast majority of the fastest growing subpopulation are going to be patients 65 and over, and if you look at the patients 85 and over, those patients continue to increase. That population continues to increase significantly. From a neurosurgery and spying standpoint, we operate on more of these patients than we ever have done in the past. We can do these operations safely. At least that's what we think, but I'll show you that that's not necessarily the case when you come to some of the big operations. So with an increased population of elderly adults, they're living longer, they have more arthritis and degeneration of their back. There's an increased prevalence of adult spinal deformity. This is some of the recent papers we have. Some of the recent numbers show that 65 to 70 percent of all adults over the age of 65 have some degree of adult spinal deformity. This causes significant pain, adversely affects the quality of life, and these patients are living longer, and they're asking us to operate on them for improved quality of life. So what are the reasons for an operation? This is what life does to you. This is what we do to patients, prolonged life and better quality of life, and the vast majority of these patients who survive these operations go on to have very good outcomes, but I'll tell you that it's a very challenging process to actually get them through. So this is a recent slide that was presented at the Scoliosis Research Society, and the outcomes and complication rates are sobering. If you read neurosurgery and orthopedic spine publications, they'll suggest the complication rates are anywhere from 46 percent, but I argue that that's different. This is a multi-institutional database looking at multiple providers, multiple surgeons, multiple hospitals, and the complication rates were absolutely sobering, 10 to 86 percent complication rates with a wide variety of variation in between, and these were unplanned readmissions, strokes, DBTs, PEs, blindness, wound infections, and even death in a few instances. So if you think about the healthcare costs and inter-bundle payments, what's societal appetite for these levels of complications? Can we continue to be siloed in how we take care of these patients? So we had some interesting ideas that hopefully will achieve the dual purpose of improving outcomes and decreasing complications. Can we take care of these patients and optimize them in a preoperative setting to really improve the outcomes? So we came up with a geriatric neurosurgical care model, and in actuality, this model is actually broader than this. We've included the pain service folks, we've included the social workers in the preoperative setting, and multiple other disciplines to evaluate these patients. So to give you a sense of how it works, if a patient comes and decides to have an operation, we decide the patient's a candidate for surgery. All of these services and all the stakeholders are at the table, and everybody has a red flag to say this patient's not ready for surgery, optimized for surgery. So what are the goals? Identify patients who are high risk for surgery, optimize the nutritional status. Sixty percent of elderly patients undergoing spine surgery are malnourished at the time of surgery, hence the reason why they have wound infections and some of the other stuff. Again, it's through a single multidisciplinary visit, identify and mitigate risk factors for complications. And in this particular model, we wanted to get the geriatric service involved really to help us in co-management after surgery and seeing these patients daily and helping them through the duration of the hospital stay. So this is what the traditional model looks like for most neurosurgeons and orthopedic spine surgeons. This is the patient presents the clinic, they evaluate it multiple times, they decide we decide that they're candidates for an operation, the anesthesiologist see them. If you're in a facility that has a pre-op anesthesia clinic, the patient then proceeds to surgery, and after surgery we have the surgical team and the nursing help to take care of these patients. This is the model that we propose, where we integrate technical expertise across multiple services to improve the outcomes of these patients, and a lot of these processes are facilitated by advanced practice providers. So a patient comes in to have surgery, we decide that they're candidates for surgery in one multidisciplinary visit, they see the social worker to anticipate some of the discharge needs, they see nursing care to understand some of the unique challenges of these patients, then the anesthesiologist see them, geriatric services see them. In our model we've also included the pain service, the nutritional services, anybody who needs to see this patient to improve their outcomes are part of this visit in a pre-operative setting. Now everybody also has a red flag. You can raise a red flag and say this patient is not optimized for surgery, and in that case we don't proceed with an operation. We proceed with surgery, and in a multidisciplinary fashion we take care of these patients, and I think that the outcome so far, and I'll show you some preliminary data, has been relatively promising. So the objective was does it work? This is just the preliminary data. Does it work? Does it improve outcomes? And does it decrease the rate of ICU transfers, certainly in the post-operative setting? So this is a prospective study. We looked at 100 patients, compared them to the preceding 25 percent, 25 cases, and we collected data that you'll often collect for studies of this magnitude, clinical presentation, demographics, school morbidity information, indications for surgery, radiographic data, and more and more we're collecting patient-reported outcomes data to really understand how these patients are doing with surgery, not just the radiographic outcomes that make us happy, but did we actually improve the pain and quality of life of these patients? Basic inclusion criteria, you had to be over the age of 65, evidence of adult spinal deformity, real non-surgical treatment, underwent multilevel decompression and fusion. We excluded patients who had revision surgery or who had oncologic cases. This is a busy slide, but what we have tried to do is capture in the preoperative setting all the variables that we think affect outcomes in neurosurgical patients. You know, we looked at gender, we looked at age, we looked at BMI, some other social issues like depression and anxiety that we know in spine certainly outbiases and affects this patient's outcomes. But the take-home point from this slide is when you look at the 100 patients that we looked at, looked at the preceding cases, there are really no differences in the baseline comparisons. We're really comparing apples to apples, big surgery to big surgery. When you look at some of the postoperative outcomes here, this is where this is what got our hospital system excited. This is where we're starting to see a lot of movement. The length of hospital stay is down by 31 percent, and I'll show you in a subsequent study where these patients are going, and the readmission rates aren't any higher. So you look at six days compared to 8.7 days. That's better for the patient, that's better for their families, it's better for the hospital, better for the surgeons. If you look at the ICU transfers, and my suspicion is as we accrue more patients, we will see the rate of ICU transfers as we optimize our model is actually going to go down exponentially. So 25 percent of patients who were evaluated in this multidisciplinary fashion required a transfer to an ICU versus 40 percent of these numbers were statistically significant. When you look at some of the other metrics that I think are relatively important for patients undergoing surgery of this magnitude, delirium, ileus, MIPE, DVTs, I really didn't see any statistically significant differences here. Again, I think as we enroll more of these patients in and we compare them to larger sample size that we might see some movement here. I will tell you that there is a Hawthorne effect going on here, that we have a very optimized data-driven model, and when I compare this data to the national data that we collect for the Scoliosis Research Society, this data is significantly superior to what they have in terms of the outcomes that they experience. It looks something like DVTs and PEs, for instance, they're looking at orders of 30 or 40, even 50 percent in some centers. And this is one of the take-home slides. We looked into the multivariate regression model. We looked at all the variables that were independently predictive of a transfer to an intensive care unit, and we put those variables in a regression model. And what this shows is if these patients undergo these big operations at centers that do not implement multidisciplinary care, certainly for us, based on our data, they were eightfold more likely to require transfer to the intensive care unit. So if patients are undergoing these big operations managed just by the surgeons and the nursing staff, those patients are more likely to require transfer to an intensive care unit, they're more likely to stay in the hospital longer, they're more likely to consume more healthcare resources, and the patient satisfaction data shows that those patients are also going to be dissatisfied with the outcome. So in conclusion, this model, at least for this variable, suggests that interdisciplinary co-management works, and that when integrated, we integrate technical expertise across multiple disciplines that we can significantly reduce not only the length of hospital stay, but the decrease in healthcare resource utilization and cost. Thank you.

Interdisciplinary Care Model

Critical Care Services

Corrective Surgery

Adult Degenerative Scoliosis

Geriatric Neurosurgical Care Model