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The Spine Blog

Friday, October 20, 2017

The High Cost of Complications in Cervical Spine Surgery

Surgeons typically consider one and two level cervical fusion as relatively low risk surgery with low complication rates. Due to the low rates of complications, studying the outcomes and costs associated with complications in cervical spine surgery is challenging. In order to gain a better understanding of the implications of cervical spine surgery complications, Dr. Culler and colleagues analyzed the Medicare database in order to have a sufficient number of patients to analyze these relatively rare events. From 2013-2014, the Medicare database included over 85,000 patients undergoing one or two level anterior, posterior, or anterior-posterior (AP) cervical fusion for any diagnosis. They included 10 categories of adverse events occurring during the index admission based on ICD-9 coding, ranging from dural tear to death. Overall, about 6% of patients experienced at least one complication. Similar to prior studies, risk factors for complications included age, male gender, non-white race, medical comorbidities, posterior or AP surgery, and a diagnosis of myelopathy, tumor, trauma, or infection. In unadjusted analyses, the incremental cost of having any complications was over $28,000, and the length of stay (LOS) increased by 9 days (compared to a cost of $16,000 and LOS of 2.2 days for those without a complication). In the multivariate analyses adjusted for risk factors, infection was associated with an increased cost of over $42,000 and a 14 day increased LOS, with venous thromboembolism having a similar increase in cost and LOS. Even dural tear, generally viewed as a benign complication, was associated with an increased cost of $10,000 and an increased LOS of 2.5 days.

This paper does a nice job demonstrating the effect of cervical spine surgery complications on cost and LOS. Patients with a complication had a hospitalization cost nearly three-fold higher than those without a complication and stayed in the hospital for an additional 9 days. While the overall rate of complications was relatively low at 6%, the cost associated with these 6% of patients was staggering. Prior to drawing strong conclusions, the limitations of this and all administrative database studies need to be considered. Unlike many prior Medicare database studies, this study included patients under 65 years of age, who were likely receiving Medicare benefits due to dialysis-dependence or as part of Social Security Disability. Given that over 1/3 of the patients in this study were under 65 years old, these findings may not generalize well to the traditional over age 65 Medicare population or the non-Medicare population. Additionally, the authors chose not to analyze adverse events occurring after discharge from the index admission, so most wound infections or hardware problems would not have been captured in the current study. The authors also included trauma, tumor, and infection patients with the degenerative spine population, and these patients had much higher rates of complications. The Medicare database also does not include patient reported outcomes, so it is unclear how complications affected patients in the long-term. Despite these limitations, it is clear that complications in cervical spine surgery are costly. The authors noted that bundled payment programs under consideration by CMS do not reimburse for complications, so hospitals bear the financial risk associated with complications in these models. A major concern is that adoption of such models will result in hospitals choosing not to operate on patients with more severe disease or comorbidities. While this could reduce complications and costs, it would result in the most vulnerable population losing access to care. Risk adjustment models need to be a part of any bundled payment program in order to prevent this unintended sequela.

Please read Dr. Culler’s article on this topic in the October 15 issue. Does this change how you view complications following cervical spine surgery or your thoughts on bundled payment programs? Let us know by leaving a comment on The Spine Blog.

Adam Pearson, MD, MS

Associate Web Editor