Clinical outcomes in revision lumbar spine fusions: an observational cohort study

2021 ◽  
pp. 1-9
Author(s):  
Thiago S. Montenegro ◽  
Glenn A. Gonzalez ◽  
Fadi Al Saiegh ◽  
Lucas Philipp ◽  
Kevin Hines ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Lumbar Spine ◽  
Clinical Outcomes ◽  
Revision Surgery ◽  
Functional Outcomes ◽  
Lumbar Fusion ◽  
Improvement Program ◽  
Patient Reported ◽  
Observational Cohort ◽  
The Impact

OBJECTIVE The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries. METHODS This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher’s exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes. RESULTS Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16–2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17–3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs −4.6 ± 6.54, p < 0.01). CONCLUSIONS The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.

The Institute for Healthcare Improvement–NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

2020 ◽  
Vol 33 (6) ◽  
pp. 812-821
Author(s):  
Scott L. Zuckerman ◽  
Clinton J. Devin ◽  
Vincent Rossi ◽  
Silky Chotai ◽  
E. Hunter Dyer ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Discharge Planning ◽  
Lumbar Fusion ◽  
Nonparametric Tests ◽  
Learning System ◽  
Design Quality ◽  
Implementation Phase ◽  
Healthcare Improvement ◽  
The Impact

OBJECTIVENational databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.METHODSThe NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.RESULTSThe novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).CONCLUSIONSThe NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

scholarly journals Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: Assessment of functional outcome following lumbar fusion

2014 ◽  
Vol 21 (1) ◽  
pp. 7-13 ◽  
Author(s):  
Zoher Ghogawala ◽  
Daniel K. Resnick ◽  
William C. Watters ◽  
Praveen V. Mummaneni ◽  
Andrew T. Dailey ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Functional Outcome ◽  
Spinal Fusion ◽  
Lumbar Fusion ◽  
Minimum Clinically Important Difference ◽  
Degenerative Disease ◽  
Psychological State ◽  
Lumbar Spinal Fusion ◽  
Patient Reported ◽  
Lumbar Spinal

Assessment of functional patient-reported outcome following lumbar spinal fusion continues to be essential for comparing the effectiveness of different treatments for patients presenting with degenerative disease of the lumbar spine. When assessing functional outcome in patients being treated with lumbar spinal fusion, a reliable, valid, and responsive outcomes instrument such as the Oswestry Disability Index should be used. The SF-36 and the SF-12 have emerged as dominant measures of general health-related quality of life. Research has established the minimum clinically important difference for major functional outcomes measures, and this should be considered when assessing clinical outcome. The results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome.

Stroke early supported discharge: the impact of patients' characteristics and clinical profile on rehabilitation goal attainment and clinical outcomes

2021 ◽  
Vol 28 (3) ◽  
pp. 1-11
Author(s):  
Ehab Georgy
Keyword(s):  
Clinical Outcomes ◽  
Functional Outcomes ◽  
Goal Attainment ◽  
Clinical Profile ◽  
Specific Patient ◽  
Early Supported Discharge ◽  
Significant Difference ◽  
Clinical Profiles ◽  
Goal Attainment Scale ◽  
The Impact

Background/aims Stroke early supported discharge services were introduced to provide a comprehensive stroke specialist therapy input, while reducing cost of acute care. Early supported discharge services resulted in better health-related outcomes. A consensus has not yet been established regarding specific early supported discharge patient characteristics and clinical profile. The main aim of this study was to establish evidence to support the development of an early supported discharge patient profile (demographics and clinical) and eligibility criteria to enable early supported discharge services achieve their purposes of reducing post-stroke disability and institutionalisation rates. This article outlines the relationship between early supported discharge patients' clinical profiles and clinical outcomes, in terms of disability, goal attainment and institutionalisation rates. Methods A retrospective review of data was implemented to determine whether specific early supported discharge patients' clinical profiles and characteristics correlate with clinical outcomes. Data were collected for patients admitted to the Suffolk Stroke Early Supported Discharge Service between August and October 2016, comprising patients' demographics and clinical profiles, including stroke type, Barthel Index and Modified Rankin Scale. Performance data were collected at the end of the early supported discharge service including therapy frequency and intensity, as well as clinical outcomes including the Goal Attainment Scale. Results Data were collected for 53 patients. Data were analysed for all patients in three groups: goals not achieved; goals achieved; and goals achieved to a higher level), according to the Goal Attainment Scale. A Chi-square test showed no significant difference with regard to sex and stroke side (P=0.27). Analysis of variance revealed no significant difference in age. Conversely, results showed a significant association between goal attainment and the stroke subtype, severity and length of hospital stay. Conclusions Specific clinical characteristics and disease profiles correlate with functional outcomes and could influence goal attainment and functional status. A specific patient cohort seems to benefit the most from early supported discharge services in terms of optimised functional outcomes and recovery.

Abstract P481: Time to Reperfusion Determines Clinical Outcomes Independent of Post Thrombectomy Infarct Volume

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shashvat Desai ◽  
Amin N Aghaebrahim ◽  
James E Siegler ◽  
Andre Monteiro ◽  
Ashutosh P Jadhav ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Clinical Outcomes ◽  
Clinical Improvement ◽  
Functional Outcomes ◽  
Time Window ◽  
Infarct Volume ◽  
Late Time ◽  
Inclusion Criteria ◽  
Ischemic Time ◽  
The Impact

Introduction: Late time window thrombectomy trials demonstrated that good functional outcomes can be achieved up to 24 hours from stroke onset in Slow Progressors (small infarct volume and large penumbral volume). In this study, we aim to investigate whether early (<6 hours) recanalization leads to superior functional outcomes compared to delayed recanalization (>6 hours) amongst patients with similar 24-hour infarct volumes post thrombectomy. Methods: We performed a retrospective analysis of a prospectively maintained LVO stroke thrombectomy database across 3 comprehensive stroke centers. Demographic, clinical, radiological, and outcomes data were analyzed. Inclusion criteria were witnessed onset anterior circulation LVO [internal carotid or middle cerebral artery M1] strokes with a good baseline mRS score (0-1) having achieved success recanalization [mTICI 2b-3] and 24-hour infarct volume of ≤10 ml on CT head or MRI. Univariate and multivariate analysis of the impact of time to recanalization on clinical outcomes was performed. Results: Of the 499 LVO strokes undergoing thrombectomy, 30% (148) met inclusion criteria. Mean age was 70 ±14 and median NIHSS score was 17 (14-21). Early recanalization (<6h) was achieved in 65% (96) of patients. Baseline demographic (age: 73 vs 74, p=0.80) and clinical characteristics (NIHSS:16.5 vs 17, p=0.52; 24-h infarct volume: 4.4 vs 4.2 ml, p=0.60) were comparable between early versus late recanalization patients. Rates of early clinical improvement (24-h NIHSS <6) (71% vs 39%, p=0.0007) and mRS 0-2 at 90 days (68% vs 48%, p=0.019) were higher in early recanalizers compared to late recanalizers. Multivariate analysis including age, NIHSS, time to recanalization, and 24-hour infarct volume identified early recanalization as an independent predictor of mRS 0-2 at 90 days (OR-2.41 95% CI 1.89-4.50). Every 1-hour increase in time to recanalization decreased the odds of 90-day mRS 0-2 by 2.2%. Conclusion: Among patients with similar 24-hour infarct volume post thrombectomy (≤10 ml), shorter time to successful recanalization is associated with significantly higher rates of early clinical improvement and mRS 0-2 at 90 days. Increased penumbral ischemic time may have an impact on outcomes post stroke thrombectomy.

Abstract 8: Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Sarah Song ◽  
Gregg Fonarow ◽  
Wenqin Pan ◽  
DaiWai Olson ◽  
Adrian F Hernandez ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Ischemic Stroke ◽  
Clinical Outcomes ◽  
Early Period ◽  
Quality Improvement Program ◽  
Administrative Claims ◽  
Improvement Program ◽  
All Cause Mortality ◽  
Before And After ◽  
Get With The Guidelines

Background: Get With The Guidelines (GWTG)-Stroke is a national, hospital-based quality improvement program developed by the American Heart Association. While studies have shown a beneficial effect of hospital participation in GWTG-Stroke upon processes of care, whether there are associated improvements in clinical outcomes has not been previously investigated. Methods: From among all acute care US hospitals, we matched 366 hospitals that joined the GWTG-Stroke program between April 2004 and December 2007, with 366 hospitals that did not. Matching was based on ischemic stroke case volume, calendar year, baseline hospital post-stroke 1-year all-cause mortality rates, teaching status, and geographic region. Outcomes of all acute ischemic stroke (AIS) patients admitted to the study hospitals were abstracted from the CMS administrative claims database (65 years and older). Outcomes at matched hospitals were compared in the PRE-GWTG-Stroke period (-540 to -181 days before program launch), RUN-UP period (-180- to -1 day), EARLY period (0 to 180 days) and SUSTAINED period (181 to 540 days). Additional analysis was performed of the entire BEFORE (-540 to -1 days) and AFTER periods (0 to 540 days). The main analytical approach was stratified Cox proportional hazard modeling, with matched site ID at stratum. We adjusted for patient characteristics (age, gender, race, medical history) and hospital characteristics (rural vs. urban, # beds, annual IS discharges.) Results: The study analyzed 88,584 AIS admissions at the 366 GWTG-Stroke hospitals and 85,401 admissions at the 366 matched non-GWTG-Stroke hospitals. In adjusted analysis comparing BEFORE and AFTER periods, GWTG-Stroke hospitals achieved reduced 30 day mortality (30M - HR 0.911, p<0.0001), reduced 1 year mortality (1YM - HR 0.902, p<0.0001), reduced 30 day all-cause rehospitalization (HR 0.956, p=0.013), reduced 30 day stroke rehospitalization (HR 0.927, p=0.038), and reduced 1 year all-cause rehospitalization (HR 0.972, p=0.007). Conversely, matched, non-GWTG-Stroke hospitals showed only reduced 30M (HR 0.954, p=0.010) between the BEFORE and AFTER periods. Comparing the degree of change at GWTG-Stroke with non-GWTG Stroke hospitals, there were greater improvements in discharge to home (DCH), 30M, and 1YM at GWTG-Stroke hospitals in each of the intervention periods: EARLY: DCH, HR 1.090, p<0.0001; 30M, HR 0.894, p=0.0006; 1YM, HR 0.889, p<0.0001; SUSTAINED: DCH, HR 1.097, p<0.0001; 30M, HR 0.934, p=0.004; 1YM, HR 0.918, p<0.0001. Conclusions: Hospitals joining the GWTG-Stroke quality improvement program between 2004-2008 achieved significantly greater improvement in stroke patient outcomes than matched hospitals not joining the program, with lower all-cause mortality at 30 days and 1 year and higher rates of discharge directly to home.

Reporting Catheter-Associated Urinary Tract Infections: Denominator Matters

2011 ◽  
Vol 32 (7) ◽  
pp. 635-640 ◽  
Author(s):  
Marc-Oliver Wright ◽  
Maureen Kharasch ◽  
Jennifer L. Beaumont ◽  
Lance R. Peterson ◽  
Ari Robicsek
Keyword(s):  
Quality Improvement ◽  
Urinary Tract ◽  
Quality Improvement Initiative ◽  
Infection Rates ◽  
Improvement Program ◽  
Nursing Unit ◽  
Accepted Practice ◽  
Device Associated Infection ◽  
Tract Infections ◽  
The Impact

Objective.To evaluate two different methods of measuring catheter-associated urinary tract infection (CAUTI) rates in the setting of a quality improvement initiative aimed at reducing device utilization.Design, Setting, and Patients.Comparison of CAUTI measurements in the context of a before-after trial of acute care adult admissions to a multicentered healthcare system.Methods.CAUTIs were identified with an automated surveillance system, and device-days were measured through an electronic health record. Traditional surveillance measures of CAUTI rates per 1,000 device-days (R1) were compared with CAUTI rates per 10,000 patient-days (R2) before (T1) and after (T2) an intervention aimed at reducing catheter utilization.Results.The device-utilization ratio declined from 0.36 to 0.28 between T1 and T2 (P< .001), while infection rates were significantly lower when measured by R2 (28.2 vs 23.2, P = .02). When measured by R1, however, infection rates trended upward by 6% (7.79 vs. 8.28, P = .47), and at the nursing unit level, reduction in device utilization was significantly associated with increases in infection rate.Conclusions.The widely accepted practice of using device-days as a method of risk adjustment to calculate device-associated infection rates may mask the impact of a successful quality improvement program and reward programs not actively engaged in reducing device usage.

The Clinical Nurse Specialist Role and its Relevance to Vascular Access: A Canadian Perspective

2021 ◽  
Vol 26 (3) ◽  
pp. 25-30
Author(s):  
Andrea Raynak ◽  
Brianne Wood
Keyword(s):  
Quality Improvement ◽  
Clinical Outcomes ◽  
Vascular Access ◽  
Organizational Outcomes ◽  
Clinical Nurse Specialist ◽  
Nurse Specialist ◽  
Care Hospital ◽  
Improvement Project ◽  
Clinical Nurse ◽  
The Impact

Highlights Abstract Purpose: The purpose of this quality improvement study was to examine the impact of a Vascular Access Clinical Nurse Specialist (VA-CNS) on patient and organizational outcomes. Description of the Project/Program: The VA-CNS role was created and implemented at an acute care hospital in Thunder Bay, Ontario, Canada. The VA-CNS collected data on clinical activities and interventions performed from April 1 to March 29, 2019. The dataset and its associated qualitative clinical outcomes were analyzed using deductive content analysis. Furthermore, a cost analysis was performed by the hospital accountant on these clinical outcomes. Outcome: Over a 1-year period, there were 547 patients protected from an unwarranted peripherally inserted central catheter (PICC) insertion among 302 patient consultations for the VA-CNS. A total of 322 ultrasound-guided peripheral intravenous catheters were inserted and 45 PICC insertions completed at the bedside. The cost associated with the 547 patients not receiving a PICC line result in an estimated savings of $113,301. The VA-CNS role demonstrated a positive payback of $417,525 to the organization. Conclusion: The results of this quality improvement project have demonstrated the positive impacts of the VACNS on patient and organizational outcomes. This role may be of benefit and worth its adoption for other health systems with similar patient populations.

Sign in / Sign up

Export Citation Format

Share Document