Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment: Initial steps to reduce ineffective ASD management

Peter G. Passias, Cyrus M. Jalai, Breton G. Line, Gregory W. Poorman, Justin K. Scheer, Justin S. Smith, Christopher I. Shaffrey, Douglas C. Burton, Kai Ming G. Fu, Eric O. Klineberg, Robert Hart, Frank Schwab, Virginie Lafage, Shay Bess

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background Context: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. Purpose: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. Study Design/Setting: A retrospective review was carried out. Patient Sample: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Outcome Measures: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. Methods: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). Results: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. Conclusions: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.

Original languageEnglish (US)
JournalSpine Journal
DOIs
StateAccepted/In press - 2017

Fingerprint

Therapeutics
Lordosis
Propensity Score
Cost Savings
Outcome Assessment (Health Care)
Pain
Counseling
Odds Ratio
Demography
Incidence
Health
Scoliosis
Comorbidity
Body Mass Index
Databases
Physicians
Patient Reported Outcome Measures
Research

Keywords

  • Adult spinal deformity
  • Crossover
  • Disability
  • Non-operative treatment
  • Operative treatment
  • Patient profiling

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment : Initial steps to reduce ineffective ASD management. / Passias, Peter G.; Jalai, Cyrus M.; Line, Breton G.; Poorman, Gregory W.; Scheer, Justin K.; Smith, Justin S.; Shaffrey, Christopher I.; Burton, Douglas C.; Fu, Kai Ming G.; Klineberg, Eric O.; Hart, Robert; Schwab, Frank; Lafage, Virginie; Bess, Shay.

In: Spine Journal, 2017.

Research output: Contribution to journalArticle

Passias, PG, Jalai, CM, Line, BG, Poorman, GW, Scheer, JK, Smith, JS, Shaffrey, CI, Burton, DC, Fu, KMG, Klineberg, EO, Hart, R, Schwab, F, Lafage, V & Bess, S 2017, 'Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment: Initial steps to reduce ineffective ASD management', Spine Journal. https://doi.org/10.1016/j.spinee.2017.06.044
Passias, Peter G. ; Jalai, Cyrus M. ; Line, Breton G. ; Poorman, Gregory W. ; Scheer, Justin K. ; Smith, Justin S. ; Shaffrey, Christopher I. ; Burton, Douglas C. ; Fu, Kai Ming G. ; Klineberg, Eric O. ; Hart, Robert ; Schwab, Frank ; Lafage, Virginie ; Bess, Shay. / Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment : Initial steps to reduce ineffective ASD management. In: Spine Journal. 2017.
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title = "Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment: Initial steps to reduce ineffective ASD management",
abstract = "Background Context: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. Purpose: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. Study Design/Setting: A retrospective review was carried out. Patient Sample: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Outcome Measures: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. Methods: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). Results: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7{\%} (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ({"}+{"}/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. Conclusions: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.",
keywords = "Adult spinal deformity, Crossover, Disability, Non-operative treatment, Operative treatment, Patient profiling",
author = "Passias, {Peter G.} and Jalai, {Cyrus M.} and Line, {Breton G.} and Poorman, {Gregory W.} and Scheer, {Justin K.} and Smith, {Justin S.} and Shaffrey, {Christopher I.} and Burton, {Douglas C.} and Fu, {Kai Ming G.} and Klineberg, {Eric O.} and Robert Hart and Frank Schwab and Virginie Lafage and Shay Bess",
year = "2017",
doi = "10.1016/j.spinee.2017.06.044",
language = "English (US)",
journal = "Spine Journal",
issn = "1529-9430",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from non-operative to surgical treatment

T2 - Initial steps to reduce ineffective ASD management

AU - Passias, Peter G.

AU - Jalai, Cyrus M.

AU - Line, Breton G.

AU - Poorman, Gregory W.

AU - Scheer, Justin K.

AU - Smith, Justin S.

AU - Shaffrey, Christopher I.

AU - Burton, Douglas C.

AU - Fu, Kai Ming G.

AU - Klineberg, Eric O.

AU - Hart, Robert

AU - Schwab, Frank

AU - Lafage, Virginie

AU - Bess, Shay

PY - 2017

Y1 - 2017

N2 - Background Context: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. Purpose: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. Study Design/Setting: A retrospective review was carried out. Patient Sample: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Outcome Measures: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. Methods: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). Results: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. Conclusions: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.

AB - Background Context: Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. Purpose: This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. Study Design/Setting: A retrospective review was carried out. Patient Sample: A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Outcome Measures: Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. Methods: Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). Results: Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. Conclusions: High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings.

KW - Adult spinal deformity

KW - Crossover

KW - Disability

KW - Non-operative treatment

KW - Operative treatment

KW - Patient profiling

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DO - 10.1016/j.spinee.2017.06.044

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JO - Spine Journal

JF - Spine Journal

SN - 1529-9430

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