Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery
Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. Objective: Compare long-term clinical success and cost-utility between patients achie...
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MDPI AG
2023-08-01
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| Series: | Journal of Clinical Medicine |
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| Online Access: | https://www.mdpi.com/2077-0383/12/17/5565 |
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| author | Peter G. Passias Tyler K. Williamson Jamshaid M. Mir Justin S. Smith Virginie Lafage Renaud Lafage Breton Line Alan H. Daniels Jeffrey L. Gum Andrew J. Schoenfeld David Kojo Hamilton Alex Soroceanu Justin K. Scheer Robert Eastlack Gregory M. Mundis Bassel Diebo Khaled M. Kebaish Richard A. Hostin Munish C. Gupta Han Jo Kim Eric O. Klineberg Christopher P. Ames Robert A. Hart Douglas C. Burton Frank J. Schwab Christopher I. Shaffrey Shay Bess on behalf of the International Spine Study Group |
| author_facet | Peter G. Passias Tyler K. Williamson Jamshaid M. Mir Justin S. Smith Virginie Lafage Renaud Lafage Breton Line Alan H. Daniels Jeffrey L. Gum Andrew J. Schoenfeld David Kojo Hamilton Alex Soroceanu Justin K. Scheer Robert Eastlack Gregory M. Mundis Bassel Diebo Khaled M. Kebaish Richard A. Hostin Munish C. Gupta Han Jo Kim Eric O. Klineberg Christopher P. Ames Robert A. Hart Douglas C. Burton Frank J. Schwab Christopher I. Shaffrey Shay Bess on behalf of the International Spine Study Group |
| author_sort | Peter G. Passias |
| collection | DOAJ |
| description | Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. Objective: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. Study Design/Setting: Retrospective cohort study of a prospectively collected multicenter database. Methods: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. Results: A total of 930 patients were considered. Following PSM, 253 “optimal” (O) and 253 “not optimal” (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, <i>p</i> = 0.021) and major mechanical complications (12% vs. 22%, <i>p</i> = 0.002), and less reoperations (23% vs. 33%, <i>p</i> = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both <i>p</i> < 0.001) at two years. Conclusions: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success. |
| first_indexed | 2024-03-10T23:19:52Z |
| format | Article |
| id | doaj.art-ce508e3358b5473b93033b07d2ce202c |
| institution | Directory Open Access Journal |
| issn | 2077-0383 |
| language | English |
| last_indexed | 2024-03-10T23:19:52Z |
| publishDate | 2023-08-01 |
| publisher | MDPI AG |
| record_format | Article |
| series | Journal of Clinical Medicine |
| spelling | doaj.art-ce508e3358b5473b93033b07d2ce202c2023-11-19T08:22:24ZengMDPI AGJournal of Clinical Medicine2077-03832023-08-011217556510.3390/jcm12175565Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity SurgeryPeter G. Passias0Tyler K. Williamson1Jamshaid M. Mir2Justin S. Smith3Virginie Lafage4Renaud Lafage5Breton Line6Alan H. Daniels7Jeffrey L. Gum8Andrew J. Schoenfeld9David Kojo Hamilton10Alex Soroceanu11Justin K. Scheer12Robert Eastlack13Gregory M. Mundis14Bassel Diebo15Khaled M. Kebaish16Richard A. Hostin17Munish C. Gupta18Han Jo Kim19Eric O. Klineberg20Christopher P. Ames21Robert A. Hart22Douglas C. Burton23Frank J. Schwab24Christopher I. Shaffrey25Shay Bess26on behalf of the International Spine Study Group27Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USADepartments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USADepartments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USADepartment of Neurosurgery, University of Virginia, Charlottesville, VA 22904, USADepartment of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USADepartment of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USADepartment of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USADepartment of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USADepartment of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY 40202, USADepartment of Orthopedic Surgery, Brigham and Women’s Center for Surgery and Public Health, Boston, MA 02120, USADepartments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USADepartment of Orthopaedic Surgery, University of Calgary, Calgary, AB T2N 1N4, CanadaDepartment of Neurosurgery, University of California, San Francisco, CA 94143, USADivision of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USADivision of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USADepartment of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USADepartment of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USADepartment of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX 75243, USADepartment of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USADepartment of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USADepartment of Orthopedic Surgery, University of California Davis, Sacramento, CA 95819, USADepartment of Neurosurgery, University of California, San Francisco, CA 94143, USADepartment of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA 98122, USADepartment of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USADepartment of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USASpine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USADepartment of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USARocky Mountain Scoliosis and Spine, Denver, CO 80124, USABackground: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. Objective: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. Study Design/Setting: Retrospective cohort study of a prospectively collected multicenter database. Methods: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. Results: A total of 930 patients were considered. Following PSM, 253 “optimal” (O) and 253 “not optimal” (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, <i>p</i> = 0.021) and major mechanical complications (12% vs. 22%, <i>p</i> = 0.002), and less reoperations (23% vs. 33%, <i>p</i> = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both <i>p</i> < 0.001) at two years. Conclusions: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.https://www.mdpi.com/2077-0383/12/17/5565adult spinal deformitycost-utilitycomplicationscomplex realignmentMedicareclinical improvement |
| spellingShingle | Peter G. Passias Tyler K. Williamson Jamshaid M. Mir Justin S. Smith Virginie Lafage Renaud Lafage Breton Line Alan H. Daniels Jeffrey L. Gum Andrew J. Schoenfeld David Kojo Hamilton Alex Soroceanu Justin K. Scheer Robert Eastlack Gregory M. Mundis Bassel Diebo Khaled M. Kebaish Richard A. Hostin Munish C. Gupta Han Jo Kim Eric O. Klineberg Christopher P. Ames Robert A. Hart Douglas C. Burton Frank J. Schwab Christopher I. Shaffrey Shay Bess on behalf of the International Spine Study Group Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery Journal of Clinical Medicine adult spinal deformity cost-utility complications complex realignment Medicare clinical improvement |
| title | Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery |
| title_full | Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery |
| title_fullStr | Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery |
| title_full_unstemmed | Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery |
| title_short | Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery |
| title_sort | are we focused on the wrong early postoperative quality metrics optimal realignment outweighs perioperative risk in adult spinal deformity surgery |
| topic | adult spinal deformity cost-utility complications complex realignment Medicare clinical improvement |
| url | https://www.mdpi.com/2077-0383/12/17/5565 |
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