Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals.

Study Design: Retrospective cohort study.
Objective: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system.
Methods: Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs.
Results: A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions ( P < .001) per level fused; the CH performed more interbody fusions ( P = .007). Cost of performing microdiscectomy ( P < .001) and laminectomy ( P = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy ( P < .001) and laminectomy with single-level fusion ( P < .001), but trended toward significance for laminectomy without fusion ( P = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH ( P = .019).
Conclusions: We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.
Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Gelb is a board member and fellowship committee chair for AOSpine NA. He receives payment for lectures and for development of educational presentations from AOSpine NA. He receives royalties from DePuy Synthes Spine and Globus Medical. He has stock in the American Society for Investigative Pathology. Dr Koh receives payment for consultancy from Biomet. His institution receives RO1 grant money from the National Institutes of Health. Dr Ludwig is a board member for Globus Medical, the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the Cervical Spine Research Society, and the Society for Minimally Invasive Spine Surgery. He is a paid consultant for DePuy Synthes, K2M, and Globus Medical. He receives payment for lectures and travel accommodations from DePuy Synthes and K2M. He receives payment for patents and royalties from DePuy Synthes and Globus Medical. He has stock in Innovative Surgical Designs and the American Society for Investigative Pathology. He receives research support from AO Spine North America Spine Fellowship support, Pacira Pharmaceutical, and AOA Omega Grant. He is a board member of Maryland Development Corporation. He receives royalties from Thieme, Quality Medical Publishers. He is on the governing board of Journal of Spinal Disorders and Techniques, The Spine Journal, and Contemporary Spine Surgery. The authors have no further potential conflicts of interest to disclose.
(© The Author(s) 2019.)