Tanenbaum Joseph E, Lubelski Daniel, Rosenbaum Benjamin P, Thompson Nicolas R, Benzel Edward C, Mroz Thomas E
Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA.
Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.
Spine J. 2016 May;16(5):608-18. doi: 10.1016/j.spinee.2015.12.090. Epub 2016 Jan 11.
Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown.
This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies.
A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States.
We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission.
Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition.
Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results.
From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition.
This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion.
寰枢椎融合术用于矫正常继发于创伤性骨折、唐氏综合征或类风湿性关节炎的寰枢椎不稳。年龄和合并症对寰枢椎融合术后疗效的影响尚不清楚。
本研究旨在更好地了解寰枢椎融合术后疗效及费用的趋势和预测因素，并确定未来前瞻性研究应纳入的混杂变量。
对美国全国住院患者样本（NIS）的数据进行回顾性分析，NIS是一个具有全国代表性的、涵盖所有支付方的住院诊断和手术数据库。
纳入1998年至2011年间接受寰枢椎融合术（国际疾病分类第九版临床修订本代码81.01）且入院时年龄在18岁及以上的所有患者。
结局指标包括住院费用、住院时间（LOS）、住院死亡率和出院处置情况。
采用一系列单变量分析评估寰枢椎融合术后疗效的预测因素。p值小于0.2的预测因素纳入最终多变量模型。最终多变量模型纳入后，在α水平为0.05时具有显著性的因素为疗效的独立预测因素。采用逻辑回归确定住院死亡率和出院处置情况的预测因素，采用线性回归确定住院费用和住院时间的预测因素。使用出院权重以得出可推广的结果。
1998年至2011年，记录了8914例住院病例，其中在住院期间进行了寰枢椎融合术。在这些住院病例中，8189例（91.9%）符合纳入标准。在研究样本中，62%为白人患者，大多数患者由医疗保险承保（47.2%）或拥有私人医疗保险（35.6%）。根据NIS和埃利克斯豪泽合并症指数定义，最常见的合并症是高血压（43.2%）。研究人群的住院死亡率为2.7%，中位住院时间为6.0天。每次住院的中位总费用（经通胀调整）为73561美元。48.9%的患者出院回家。住院死亡率的显著预测因素包括年龄增加、急诊或紧急入院、周末入院、充血性心力衰竭、凝血障碍、抑郁症、电解质紊乱、转移性癌症、神经系统疾病、瘫痪和非出血性消化性溃疡。这些变量中的许多也被发现是住院时间、住院费用和出院处置情况的预测因素。
本研究发现，年龄较大和合并症负担较重的患者术后死亡几率更高，出院后被转至其他护理机构，住院时间更长，寰枢椎融合术后住院费用更高。
