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Preparing for Bundled Payments in Cervical Spine Surgery

Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay?

Kalakoti, Piyush, MD; Gao, Yubo, PhD; Hendrickson, Nathan R., MD; Pugely, Andrew J., MD

doi: 10.1097/BRS.0000000000002825
HEALTH SERVICES RESEARCH
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Study Design. Retrospective, observational study.

Objective. To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS).

Summary of Background Data. Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability.

Methods. A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated.

Results. In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05.

Conclusion. Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources.

Level of Evidence: 3

The study investigates the impact of patient, hospital, and procedural characteristics on hospital costs and length of hospital stay (LOS) in elective anterior cervical discectomy and fusion. Patients with higher comorbidities adversely affected costs and LOS. Marginal impact of several comorbidities and procedures on outcomes are quantified using robust statistical techniques.

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

Address correspondence and reprint requests to Andrew J. Pugely, MD, Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA 52242; E-mail: andrew-pugely@uiowa.edu

Received 3 May, 2018

Revised 24 June, 2018

Accepted 17 July, 2018

An abstract of the work was presented at the 45th Annual Meeting of the Cervical Spine Research Society at Hollywood, Florida. Other than the abstract, there are no directly related manuscripts or abstracts, published or unpublished, by any authors of this article.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

No relevant financial activities outside the submitted work.

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