Next speaker is Dr. Paul Park. Talk, Risk Factors Associated with 90-Day Readmissions after Degenerative Lumbar Fusion, an Examination of the Michigan Spine Study Improvement Collaborative Registry. Thank you. I appreciate the opportunity to give this presentation. And some of my talk actually echoes what the previous speaker just spoke about in the use of registry data. Here are my disclosures. None of them are relevant to this discussion. So I'm going to talk about readmission to the hospital, which really negatively impacts the patient experience and is very costly. So Jencks, et al., first evaluated this back in 2004. He was one of the first, I think, researchers who really looked at it in any depth. And he looked at 12 million Medicare beneficiaries and estimated a cost of readmission at $17.4 billion. And this was published in the New England Journal of Medicine. It was a big article at the time. In 2011, another analysis was done. And based on this analysis of 3.3 million, so readmissions, the cost was $41.3 billion. I don't have any current data, but I assume if we did the analysis now, it would be quite a bit more. So it's very expensive. And because of that, it's a focus for cost containment. Today, most studies have really evaluated 30-day readmissions. And I think that's due to the measure of databases that are used that are mostly at 30 days. But an evaluation of a 90-day period, however, I think, would allow a more comprehensive assessment of factors associated with readmission. So that was the purpose of this article. And we really looked at a number of fusion surgery patients alone rather than whole decompressions. So the Michigan Spine Surgery Improvement Collaborative Registry is a prospective multi-center and a spine specific database. And it's fully funded by Blue Cross Blue Shield of Michigan. So it's insurance funded, but they actually have really no control of the database. They don't look at the data at all. But they fund millions of dollars to provide funds for data collection. So we have abstractors at every site that are fully funded. So to acquire data and enter it into a database. I think we have more participating institutions. And this is neurosurgery and orthopedic surgery as well. And we have a wide swath of private and academic institutions. So the data from this registry was analyzed. And we looked at two separate issues. One, the reasons for readmission. So if a patient got admitted, what was the reason for it? And then I looked at risk factors that may have predisposed them for readmission. So the analysis is pretty straightforward. And I'm not going to dwell on the details. When you're looking at about the 10,000 patients who were evaluated during this time period, again, these are all lumbar fusion patients for degenerative disease. We had about 900 readmissions, 9% in a nine-day period. The most common specified reasons for readmissions were pain, surgical side infection, and radicular symptoms. And radicular symptoms is actually kind of something new. So a lot of times it gets lumped under pain. But because this is a spine-specific database, that was a separate category. When we're looking at risk factors, so those are the reasons for readmissions. These are the risk factors associated with readmission. There's a host of risk factors. And again, we have a lot of variables. And we do analysis. We tend to have quite a few significant variables. And one is race. Another one is more than four levels fused. So that's not surprising. Diabetes, also not surprising. And surgery length were all risk factors for increased risk for readmission. Conversely, factors associated with decreased risk of readmission were discharge to home. And that just could be a surrogate of a healthier patient, private insurance, ambulation, same day of surgery, and spinal stasis. So these are just our tables. They just reiterate the results here. And the bolded variables are the ones that were statistically significant. I want to highlight that this analysis was done on 7,000 of the 10,000 patients. And these are patients with complete data. And this is a problem with registry data. Even with fully funded abstractors whose only job is to collect data, we still didn't have complete data. It was about 70%. And so if they were missing even one variable, we like not to use it in the analysis. So I just want to spend a little time on looking at the reasons for remissions, because they could be potentially modifiable. Pain is one. And I think we don't do a good job with postoperative pain management. I like the thought, I think we do. But I think we could improve upon that. And there are various modalities, like multimodal therapies that have recently been shown to decrease narcotic consumption and length of stay. And this is mostly inpatient hospital stay. And these would be like different modalities like lysosomal bupivacaine, ivitalinol, just a combination of modalities that decrease that pain level. And data suggests it does decrease it. And there's not much data at discharge, whether this continues as an outpatient. But I think it may be an area that can be looked at. Patient education is another one. If you educate your patient on how to manage their pain and what to do if it's unmanageable, we may prevent an ER sort of visit and subsequent readmission. With a new opioid epidemic that's all in the news now, and new laws, it's going to be interesting to look at what the remission rates will be. In Michigan, we have a new law where, after an operation, they can only get seven days of a narcotic on discharge. So, you know, no big deal if it's a discectomy, but what about our deformity patients? And a lot of patients take a little bit more than prescribed early on. And I could see this as being an area where readmissions may spike. Surgical site infection commonly noted. And I think the previous speaker noted that as a cause for readmission. I think we're going to do a lot to prevent this. I mean, we do a lot of these measures. The CDC comes out with guidelines on measures that have actually pretty good evidence behind it. And I like to think, when I scan this, that we do a lot of them, but I don't use an antibiotic-coated suture for closure, which actually is recommended. So I think that more can be done to prevent surgical site infection. Looking at predictors, you know, there's a host of predictors, and some of them are obvious, like coronary artery disease, which can increase physiological stress, and diabetes, well known to be a risk factor for infection. This just highlights the need to optimize these conditions prior to surgery. For decreased likelihood of readmission, really early ambulation, and we think this is more for, you know, if you mobilize early, you have less chance of DVTs, pneumonias, could decrease your risk of readmission. So, and early ambulation in this study was day zero. So, limitations, incomplete data, and beyond the 30% where we didn't have data for the specified reasons for admissions, there was a number where it really wasn't specified accurately. And patients readmitted to different institutions could potentially be missed. So, in conclusion, 90 readmissions to the hospital occurred in about 90% of cases. Among the many causes for readmission, most frequent reasons included pain, wound infection, and radicular symptoms, and these could be areas of focus in terms of reducing readmissions. Similarly, with the risk factors, such as medical conditions, such as coronary disease, diabetes, it just highlights the need to optimize these and take glycemic control during hospitalization and discharge. Thank you.

90-day readmissions

degenerative lumbar fusion

risk factors

reasons for readmission

postoperative pain management