Our next presentation, An Interdisciplinary Neurosurgery Geriatric Co-Care Model Reduces Time to Initiation of Postoperative Oral Narcotic Pain Regimen in Elderly Patients Undergoing Deformity Correction Surgery. The presenting author is Owocho Odagwa. I'm sorry if I'm butchering your name. That's okay. I get it all the time. And then the author block, Aladin Elmadisi, Michael Angole, Amanda Sergesetter, Jessica Moreno, Victoria Vuong, Joseph Chang, Isaac Kakeri, and Carlos Begley. So Jessica Moreno is the advanced practice provider who really did a lot of the work here. Unfortunately, she couldn't be here. So that's the reason I'm up here. So I'd like to obviously thank the committee for letting us give this presentation. No disclosures. You saw the slide earlier on. This shows the changing demographics of the U.S. population, the increase in the subpopulation of the age of 65, and certainly in patient population. Over the age of 85, these patients, if you look at the number of fusion surgeries that we're doing and complex reconstructions that we're doing, they're happening with increased frequency in the elderly patient population. We have published extensively on reoperations and primary surgery in elderly patients. And we have demonstrated that if done properly with the right teams, that these patients go on to do very well. And those results were sort of mirrored by some of the multi-institutional studies that were just published. This is a study out of the International Spinal Deformity Study Group. This is the largest spinal deformity group in the world. It's a multidisciplinary group. And they just published a study maybe a couple years ago that really changed the paradigm for how we thought about these patients. On the left here, you see a scale with the Alzheimer's Disability Index. On the right, you see a chart with the back pain scores. And what they showed here, you have pre-op and post-op, and the Alzheimer's Disability Index really measures the degree of functional disability in these patients. How disabled are they before surgery? How disabled are they after surgery? And what you can see here, there's a statistically significant difference across the board, across all age groups with deformity correction surgery. What was surprising, the greatest beneficiaries of the surgery are elderly patients between the age of 65 and 85 years old. When you look at the pain scores, we saw the exact same thing. These patients were genuinely doing very well with an operation once, you know, when they went through the entire healing process. But it's a game of, you know, high stakes, high reward. The complication rates, like I suggested in my prior slide, in my prior talk, were very sobering. This is a slide, this is a chart from that study that showed that three out of four elderly patients undergoing deformity correction surgery have at least a major or minor complication. Somewhere close to 25 or 30 percent of these patients have a major complication. And the mortality rates after these operations are, our numbers aren't very reliable, but anywhere from 1 to 2 percent, depending on the centers you are. Complications that we see, blood loss, DVTs, PEMIs, ultramenostasis, pneumonia, and so on and so forth. Some of the, one of the major drivers as we thought about this in a more scientific way as a group was of post-op complications, immobility. And we thought that prolonged IV analgesic use contributed to increased perioperative complications that we saw, and it made sense. You know, the prolonged IV analgesic use, those patients have an increase in immobility-related complications, DVTs, PEMIs, ulcers. There was a delay to ambulation, which you heard from the prior slide, leads to inferior outcomes, increased incidence of delirium, pneumonias. And so, in contrast to that, we thought that if we can get these patients of these IV analgesics much earlier, that they'll go on to have a decrease in the prevalence or incidence of these infections, of these complications, and certainly improve the chance of a good outcome. This is the model I described earlier. I wouldn't belabor the point, but as you know, the goal is just to, through one multidisciplinary visit, really optimize these patients for surgery, identify risk factors, and mitigate those risk factors for complications in a multidisciplinary fashion for all these patients in the post-operative, perioperative setting. This is the same chart I showed earlier, same model, so I'm not going to belabor the point. The objective here was, does this multidisciplinary team, do they decrease the incidence, do they accelerate, sorry, the transitions to oral analgesics, decrease perioperative complications, and decrease the length of hospital stay? And we have gone through, in a very systematic way, to look at all the things that we think contribute to a patient post-operative complications, and in a scientific way, trying to find ways to optimize those. And I'll show you some of the data. It's a prospective study. We looked at all patients who enrolled in this co-care program. We collected the variables that one would collect for a study of this nature, clinical presentation, demographics, comorbidities, patient-reported outcomes, and we also collected data on patients who were co-monitored by the geriatric service. As I said earlier, we also have the pain service, the nutritional services, and so on, that also participate in this multidisciplinary model. Patients were dichotomized into two groups, so if you were transitioned off intravenous analgesics within 24 hours, you were classified in the early oral narcotics group, and if you were oral analgesic group, and after 24 hours, you were put into the cohort of patients who were transitioned, quote-unquote, in a later fashion. At baseline, the early means you were transitioned, you were transitioned within 24 hours. Delayed means you were transitioned after 24 hours. You could see at baseline, we had 70 patients in the early cohort, we had 52 patients in the late cohort. There was really no statistically significant difference in all the baseline variables that we collected just to ensure that we're comparing apples to apples between both cohorts of patients. When we look at the operative variables, there were no difference, so the patients in the late cohort weren't having bigger surgeries or longer operations. The operative times were about the same. The blood loss was, though higher in the late cohort, was not statistically significant. There was no incidence of spinal cord injury or nerve injury, and the incidence of durotomies, which is really insignificant because we let those patients ambulate the next day after surgery, was no statistically significant difference. We look at the postoperative complication. This was interesting. We looked at this data, and I was surprised that we didn't have an increase in the incidence of, say, delirium that was statistically significant. But really, the data shows, certainly from this small pilot, that in the perioperative setting, we didn't necessarily see a difference between both cohorts of patients, and the incidence of delirium, urinary tract infections, ileus, MI, DVTs, PE, and this is symptomatic DVTs or PE, obviously, or sensory motor deficits. But here's where we found some differences. When you look at the early cohort, the number of days from surgery to ambulation, 1.6 days. So on average, after these big operations, they ambulated 1.6 days after surgery. The number of feet ambulated on day of discharge was about 101 feet. Now, we track this very systematically. The physical therapists were part of this initiative, and they track this and document this in a single place, so we can all caption and follow this. The length of hospital stay was 5.9 days, and to give you some perspective, when you look across the country, the length of hospital stay for a T to the pelvis to iliofusion is on the order of 8 to 10 days if they go home versus a skilled nursing facility. But look at the discharge to home. 54% of patients who were treated in a multidisciplinary fashion were discharged directly home. 40% went to a skilled nursing facility, 6% to an acute rehab, and the readmission rates of 10%. The readmission rate is important because if you prematurely send patients home, they come back, as you know, they bounce back quickly within the first 30 days of surgery. Look at the cohort of patients in the late transition cohort. The number of days from discharge to ambulation almost increased by 30%. The number of feet ambulated wasn't significantly different. The length of hospital stay prolonged by 7.6 days from 5.9 days. The percentage of patients discharged home, and this is important. You can get patients out of the hospital, you can get them home. You save the society money, you save the health system money by not sending these patients to a skilled nursing facility. Actually, when you look at the total cost of care for spine patients, a lot of that cost goes on to occur, as we incur, in the post-operative setting. So 54% of patients were discharged to a skilled nursing facility, 8% to an acute rehab, and the readmission rates were no different. So we multidisciplinary fashion, we get patients up early, we get them discharged home. The vast majority of them go on to do very well. And I'll show you the pain scores afterwards to show you that these patients are inferiorly managed when it comes to a pain standpoint. When you look at the pain scores, and we track these patients at baseline 6 weeks, 3 months, 12 months, and 24 months, you could see at baseline they were significantly disabled. At 6 weeks, there was no statistically significant difference. And certainly at 3 months, they all had no different, they had significant improvement in their pain, but there was no difference between the cohorts of patients. When you look at, this is a regression model looking at all the variables that were important in the univariate analysis, and if you were not part of a core management team, you were more likely, three-fold more likely to stay on IV analgesics in a prolonged fashion compared to if you're part of a multidisciplinary team. So the take-home message, I think, and we discussed this extensively, is if you enroll these patients in these multidisciplinary setups, that they actually go on to do very well. It's a cost saving for the hospital, certainly for providers, and certainly patients are happier. So, in conclusion, it suggests that the interdisciplinary model facilitates early transition to oral analgesics, decreases the length of hospital stay for elderly patients undergoing these big reconstructions. Thank you.

Owocho Odagwa

interdisciplinary neurosurgery geriatric co-care model

postoperative oral narcotic pain regimen

elderly patients

deformity correction surgery