Repeat surgery after lumbar decompression for herniated disc: The quality implications of hospital and surgeon variation

Brook I. Martin, Sohail K. Mirza, David R. Flum, Thomas M. Wickizer, Patrick J. Heagerty, Alex F. Lenkoski, Richard (Rick) Deyo

Research output: Contribution to journalArticle

40 Citations (Scopus)

Abstract

Background context: Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates. Purpose: To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks. Study design/setting: Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State. Methods: We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years. Results: Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes. Conclusions: Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

Original languageEnglish (US)
Pages (from-to)89-97
Number of pages9
JournalSpine Journal
Volume12
Issue number2
DOIs
StatePublished - Feb 2012

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Intervertebral Disc Displacement
Decompression
Reoperation
Confidence Intervals
Comorbidity
Perioperative Care
Benchmarking
Diskectomy
Surgeons
Quality of Health Care
Insurance
Uncertainty
Registries
Inpatients
Spine
Logistic Models
Demography

Keywords

  • Back pain
  • Decompression
  • Herniated disc
  • Lumbar spine surgery
  • Quality
  • Repeat surgery

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Repeat surgery after lumbar decompression for herniated disc : The quality implications of hospital and surgeon variation. / Martin, Brook I.; Mirza, Sohail K.; Flum, David R.; Wickizer, Thomas M.; Heagerty, Patrick J.; Lenkoski, Alex F.; Deyo, Richard (Rick).

In: Spine Journal, Vol. 12, No. 2, 02.2012, p. 89-97.

Research output: Contribution to journalArticle

Martin, Brook I. ; Mirza, Sohail K. ; Flum, David R. ; Wickizer, Thomas M. ; Heagerty, Patrick J. ; Lenkoski, Alex F. ; Deyo, Richard (Rick). / Repeat surgery after lumbar decompression for herniated disc : The quality implications of hospital and surgeon variation. In: Spine Journal. 2012 ; Vol. 12, No. 2. pp. 89-97.
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AU - Mirza, Sohail K.

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AU - Wickizer, Thomas M.

AU - Heagerty, Patrick J.

AU - Lenkoski, Alex F.

AU - Deyo, Richard (Rick)

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N2 - Background context: Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates. Purpose: To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks. Study design/setting: Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State. Methods: We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years. Results: Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes. Conclusions: Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.

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KW - Back pain

KW - Decompression

KW - Herniated disc

KW - Lumbar spine surgery

KW - Quality

KW - Repeat surgery

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