Age, Procedure Type, and Magnitude of Systemic Disease Predict Length of Stay Following Open Lumbar Spine Surgery
Older age and widespread systemic disease were the only preoperative factors predictive of longer hospital stays following an elective open posterior lumbar spine surgery in a multivariate analysis reported in the June 1 issue of The Spine Journal. No single preoperative comorbidity predicted increased length of stay (LOS) in this study.
“Length of stay has become an important outcome variable for comparing procedures, surgeons, and hospitals. However, it is important to remember that patient-specific factors can increase (or decrease) length of stay as well,” said lead author Jordan A. Gruskay, MD, who conducted the trial while at Yale University School of Medicine. Dr. Gruskay is currently an Orthopaedic Surgery Resident at Hospital for Special Surgery in New York City.
“The authors reported an average hospital stay of 3.6 days for patients undergoing 1 (n=70), 2 (n=26), and 3 (n=7) level primary and revision procedures,” commented Kris B. Siemionow, MD, Chief of Spine Surgery and Professor of Orthopaedics and Neurosurgery at the University of Illinois in Chicago and partner at the Illinois Spine and Scoliosis Center, Homer Glen, Illinois. “These findings are fairly consistent with those we reported for a group of patients undergoing primary 1 level minimally invasive transforaminal lumbar interbody fusion where 78 out of 104 patients had a reported LOS of 4 days ± 2 days,” Dr. Siemionow said.
The study involved 103 patients undergoing elective, open 1 to 3 level posterior lumbar instrumented fusions (with or without decompression) between January 2010 and June 2012 at a single academic institution. The researchers examined whether a variety of preoperative, intraoperative, and postoperative factors predicted LOS following surgery.
The average LOS in the overall group was 3.6±1.8 days with a range from 0 to 12 days. A majority of all patients (79%) had a stay of ≤4 days.
Factors Predictive of Length of Stay Following Open Lumbar Spine Surgery
The only preoperative variables associated with increased LOS were older age (P=0.038) and greater magnitude of systemic disease according to American Society of Anesthesiologists score (P=0.001). Increased LOS was not associated with any single preoperative comorbidity (eg, diabetes, hypertension, malignancy, pulmonary disease). High-risk patients (ie, those with ≥3 comorbidities) were not at increased risk for longer LOS.
On the other hand, a history of heart disease was significantly associated with a decreased hospital stay (P=0.005), possibly owing to a more extensive preoperative workup and closer medical management, the authors noted. Intraoperative complications, including 6 dural tears and 1 pedicle fracture, were not associated with LOS.
Patients with a postoperative complication had a significantly longer average LOS compared with patients with no complications (5.1 vs 2.9 days; P<0.001). The most common postoperative complications included anemia requiring transfusion (n=11), altered mental status (n=8), pneumonia (n=4), hardware complications requiring reoperation (n=3), and renal failure (n=1). In addition, discharged to a subacute/nursing facility was associated with a greater LOS.
The authors noted that the findings are limited by the small sample size and that other clinically important associations may have been missed.
“Length of stay is a complex outcome. Many pre-, peri- and postoperative variables are on the pathway to determining length of stay. These must be considered when using length of stay as an outcome in any comparison,” Dr. Gruskay said.
Can Preoperative Counseling Reduce Length of Stay?
“Expectation management for patients, family and staff is extremely important—studies have shown proper counseling preoperatively can reduce stress and lead to shorter hospitalization,” Dr. Gruskay said. “This information can be used to help schedule time off of work, arrange for transportation, and set-up post-discharge care,” he noted.
“Additionally, findings from this as well as larger database-related research will hopefully be used in the future by Medicare/insurance companies when determining reimbursements (or penalizations) for hospitals and surgeons with different patient populations. For instance, as payment models shift toward pay for performance, surgeons and centers with older and more systemically sick patients should ideally not be penalized for longer average length of stay,” Mr. Gruskay said.
“It has been shown that preoperative counseling before orthopedic procedures can reduce patient stress, leading to a faster recovery and shorter hospitalization,” Dr. Siemionow commented. “Gruskay et al noted that they inform their patients to expect a 3-day postoperative stay after posterior lumbar fusion,” Dr. Siemionow commented.
“The reported findings would suggest that hospital stay is predominantly determined by procedure type, patient age, and magnitude of systemic disease. Would counseling patients to expect a shorter LOS after spine surgery have an impact on observed time to discharge remains to be seen,” Dr. Siemionow said.