Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database
Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database
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DOI：
10.3171/2020.11.spine201442
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发表时间：
2021-07-01
影响因子：
2.8
通讯作者：
Bisson, Erica F.
中科院分区：
文献类型：
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作者：
Mummaneni, Praveen, V;Bydon, Mohamad;Bisson, Erica F.
目的：优化患者术后出院已被证明可以影响患者的恢复和医院/医生的工作流程，并降低医疗成本。在目前的研究中，作者试图通过使用国家脊柱注册中心确定颈椎病手术后非常规出院的风险因素。方法：查询2016年至2018年期间接受颈椎病手术的患者的质量结局数据库颈椎模块。非常规出院定义为出院至急性期后护理（康复）、非急性期护理或另一家急性期护理医院。一个多变量logistic回归预测模型，使用一系列的人口统计学，临床，手术，和患者报告的结果characteristics.RESULTS：在1114例患者确定，11.2%（n = 125）有一个非常规放电。在单变量分析中，非常规出院的患者更可能是老年人（年龄≥ 65岁，70.4% vs 35.8%，p < 0.001），非洲裔美国人（24.8% vs 13.9%，p = 0.007）和医疗保险（75.2% vs 35.1%，p < 0.001）。在年龄小于65岁的患者中，非常规出院的患者更可能失业（70.3%比36.9%，p < 0.001）。总的来说，非常规出院的患者更可能出现运动功能障碍（73.6% vs 58.7%，p = 0.001），更可能在就诊时出现非独立性运动障碍（50.4% vs 14.0%，p < 0.001）。在多变量逻辑回归分析中，与非常规出院几率较高相关的因素包括非裔美国人种族（vs白色，OR 2.76，95% CI 1.38-5.51，p = 0.004），医疗保险覆盖率（与私人保险相比，OR 2.14，95% CI 1.00-4.65，p = 0.04），就诊时非独立性（OR 2.17，95% CI 1.17-4.02，p = 0.01），基线改良日本骨科协会重度脊髓病评分（0-11 vs中度12-14，OR 2，95% CI 1.07-3.73，p = 0.01）和后路手术入路（OR 11.6，95% CI 2.12-48，p = 0.004）。与非常规出院几率较低相关的因素包括手术节段较少（1 vs 2-3节段，OR 0.3，95% CI 0.1-0.96，p = 0.009）和基线生活质量较高（EQ-5D评分，OR 0.43，95% CI 0.25-0.73，p = 0.001）。在预测因子重要性分析中，基线生活质量（EQ-5D评分）被确定为最重要的预测因子（Waldchi（2）= 9.8，p = 0.001）;然而，在将变量分为不同类别后，社会经济和人口特征（年龄、种族、性别、保险状况、就业状况）被确定为非常规出院的最重要驱动因素结论：研究结果表明，社会经济和人口统计学特征，包括年龄，种族，性别，保险和就业可能是颈椎病手术后非常规出院的最重要驱动因素。
OBJECTIVE: Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.METHODS: The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.RESULTS: Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age >= 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald chi(2) = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).CONCLUSIONS: The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.