Factors affecting hospital length of stay following anterior cervical discectomy and fusion

ABSTRACT

 

Study design: Retrospective cohort study.

Background: Several studies focus on the long-term results of anterior cervical discectomy and fusion (ACDF) surgeries, but little information exists regarding how various patient-related, procedure-related, and payer-related variables may affect postoperative hospital length of stay (LOS).

Objective: To determine what factors, if any, contribute to increased hospital LOS in patients who have had an ACDF.

Methods: Retrospective cohort study of 108 consecutive patients who underwent elective ACDF at a Midwest academic medical center. Extensive preoperative, intraoperative, and postoperative data were abstracted and analyzed to identify prognostic factors for an increased LOS. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on hospital LOS.

Results: 103 patients met inclusion and exclusion criteria. The mean LOS for patients undergoing ACDF was 1.98 (± 1.6) days. Only 29% of patients had one level fused. The mean blood loss during surgery was 87.4 ± 99.6 mL. One subject lost 700 mL of blood. Complications, though rare, included uncontrolled postoperative pain (13%), cardiac (6%), pulmonary (4%), and urinary (3%). Covariates included in the final model were age, sex, cardiac complication, urinary complication, and pulmonary complication. Factors that contributed to increased LOS and their associated adjusted mean days were: ≥ 50 years of age (2.5 ± 1.2 days), female gender (2.3 ± 1.2 days), and three particular types of complications. The complications that had the largest effect on increased LOS from least to most severe were cardiac (3.5 ± 1.3 days), urinary (4.7 ± 1.3 days), and pulmonary (5.3 ± 1.3 days).

Conclusions: The information presented in this study may be useful for patients, clinicians, and insurance companies, including precertification and case-management services. Our results can be instrumental in designing future prospective studies using more detailed analyses with more patients, more surgeons, and multiple institutions.

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EDITORIAL PERSPECTIVE

In this new era of quality-of-care concerns and focus on outcomes, the reviewers congratulate Arnold and colleagues for taking on an important subject of complications related to a ‘routine’ procedure and providing a clear and objective reflection on variables of outcomes. By not being selective but rather inclusive of all patients this retrospective study, this study of grade 3 or less ranking on the evidence-base pyramid actually serves a more valuable purpose than a grade 1 prospectively randomized clinical trial. All patients treated with a similar procedure for a similar condition were documented in a registry-style undertaking and to the best ability of the authors relevant data points were recorded.

The reviewers and the authors both agreed that certain data points, such as cardiac events, were probably over reported due to lack of clear operational definitions; whereas others, such as swallowing difficulties, were likely under reported due to lack of study focus and follow-up on this entity.

The reviewers applauded the honesty of the authors and noted the impressive variance of something simple, such as length of stay after routine anterior neck surgery, as well as the difficulty in identifying simple answers to try to prevent complications or potentially decrease length of stay through planned interventions.

From an editorial point of view, this article illustrates an important point: as we enter an era of metrics ubiquitously applied to all aspects of healthcare under the guise of ‘rewarding quality’ we have to realize just how complex our lives are – the variables that influence the length of stay following a simple anterior neck surgery are as perplexing as human life itself. That said, studies such as these are needed to create more meaningful care maps, set realistic expectations with patients and help us represent the complexity of our work better with insurers and regulatory agencies.