Regional and Institutional Practice Variations in Decompressive Spine Surgery for Patients with Penetrating Spinal Injury in the United States

OBJECTIVE The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study’s objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States. METHODS This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18–64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery. RESULTS The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%–35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI −0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI −5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1–7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5–8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups. CONCLUSIONS Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.

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305. Differences between postoperative narcotic prescriptions in outpatient lumbar spine surgery between the United States and France

The Spine Journal ◽

10.1016/j.spinee.2019.05.322 ◽

2019 ◽

Vol 19 (9) ◽

pp. S149

Author(s):

Houssam Bouloussa ◽

Soufiane Ghailane ◽

Mohammad Alsofyani ◽

Kamran Majid ◽

Calvin C. Kuo ◽

...

Keyword(s):

United States ◽

Lumbar Spine ◽

Spine Surgery ◽

The United States ◽

Lumbar Spine Surgery

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Descriptive Analysis of State and Federal Spine Surgery Malpractice Litigation in the United States

Spine ◽

10.1097/brs.0000000000002510 ◽

2018 ◽

Vol 43 (14) ◽

pp. 984-990 ◽

Cited By ~ 13

Author(s):

Nitin Agarwal ◽

Raghav Gupta ◽

Prateek Agarwal ◽

Pravin Matthew ◽

Richard Wolferz ◽

...

Keyword(s):

United States ◽

Spine Surgery ◽

Descriptive Analysis ◽

The United States ◽

Malpractice Litigation

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Increased specialization in spine surgery and its implications on delivery and access to care in the United States Healthcare System

AME Medical Journal ◽

10.21037/amj.2018.03.14 ◽

2018 ◽

Vol 3 ◽

pp. 56-56

Author(s):

Howard Young Park ◽

Don Young Park

Keyword(s):

United States ◽

Access To Care ◽

Healthcare System ◽

Spine Surgery ◽

The United States ◽

United States Healthcare

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Trends and Variations in Cervical Spine Surgery in the United States

Spine ◽

10.1097/brs.0b013e31819e2fd5 ◽

2009 ◽

Vol 34 (9) ◽

pp. 955-961 ◽

Cited By ~ 129

Author(s):

Marjorie C. Wang ◽

William Kreuter ◽

Christopher E. Wolfla ◽

Dennis J. Maiman ◽

Richard A. Deyo

Keyword(s):

United States ◽

Cervical Spine ◽

Spine Surgery ◽

The United States ◽

Cervical Spine Surgery

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Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013

Global Spine Journal ◽

10.1177/2192568217694151 ◽

2017 ◽

Vol 7 (3) ◽

pp. 213-219 ◽

Cited By ~ 21

Author(s):

David N. Bernstein ◽

David Brodell ◽

Yue Li ◽

Paul T. Rubery ◽

Addisu Mesfin

Keyword(s):

United States ◽

Lumbar Spine ◽

Spine Surgery ◽

International Classification Of Diseases ◽

The United States ◽

Lumbar Spine Surgery ◽

Economic Downturn ◽

Classification Of Diseases ◽

Lumbar Spinal ◽

The Impact

Study Design: Retrospective database analysis. Objective: The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States. Methods: The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques. Results: From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R2 value between the number of surgeries and the S&P 500 Index was statistically significant ( P ≤ .05). Conclusions: The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends.

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The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States

Neurosurgical FOCUS ◽

10.3171/2020.8.focus20600 ◽

2020 ◽

Vol 49 (5) ◽

pp. E20

Author(s):

Eric W. Sankey ◽

Vikram A. Mehta ◽

Timothy Y. Wang ◽

Tracey T. Than ◽

C. Rory Goodwin ◽

...

Keyword(s):

United States ◽

Spine Surgery ◽

Pedicle Screws ◽

Potential Method ◽

The United States ◽

Medical Liability ◽

Lateral Mass ◽

Malpractice Claims ◽

Procedural Error ◽

Case Closure

Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2–67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4–77.2) months for defendant (surgeon) verdicts (p = 0.117).

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Neuro-Interventional Use of Oral Antiplatelets: A Survey of Neuro-Endovascular Centers in the United States and Review of the Literature

Journal of Pharmacy Practice ◽

10.1177/0897190019854868 ◽

2019 ◽

pp. 089719001985486 ◽

Cited By ~ 2

Author(s):

Salia Farrokh ◽

Kent Owusu ◽

Lucia Rivera Lara ◽

Katharine Nault ◽

Ferdinand Hui ◽

...

Keyword(s):

United States ◽

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Major Complication ◽

Standard Of Care ◽

The United States ◽

Patient Registries ◽

Survey Period ◽

Electronic Survey ◽

Practice Variations

Background: Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients. Objective: We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States. Methods: An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017. Results: A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%). Conclusion: Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.

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