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P64. Initiation of a standardized escalation pain protocol after 1-2 level lumbar fusion reduces in-hospital opioid consumption
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Proceedings of the 34th Annual Meeting of the North American Spine Society / The Spine Journal 19 (2019) S158−S194 ePosters: Socioeconomics/Industrial/Ergonomics
P64. Initiation of a standardized escalation pain protocol after 1-2 level lumbar fusion reduces in-hospital opioid consumption Portia Steele, ACNP-BC1, Jeffrey L. Gum, MD1, Morgan Brown, MS2, Christy L. Daniels, MS1, Mladen Djurasovic, MD1, Charles H. Crawford III, MD1, Steven D. Glassman, MD1, Leah Y. Carreon, MD, MSc1; 1 Norton Leatherman Spine Center, Louisville, KY, US; 2 Norton Healthcare, Louisville, KY, US BACKGROUND CONTEXT: Our previous study showed that prescribing patterns, more than surgery invasiveness or patient factors, affect postoperative opioid consumption. Since then we have instituted a Standard Escalation Pain Protocol (SEPP): patients receive 0-60 Morphine Milligram Equivalents (MME) above their baseline pre-op MME after surgery. PURPOSE: The purpose of this study is to evaluate how prescribing patterns affect immediate postoperative opioid consumption in patients undergoing 1- to 2-level posterior lumbar interbody fusion with a navigated or robotic-assisted, midline exposure (MIDLIF). STUDY DESIGN/SETTING: Single surgeon consecutive series. PATIENT SAMPLE: Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified. OUTCOME MEASURES: In-hospital opioid consumption. METHODS: Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified and divided into two cohorts: patients who had surgery before the institution of SEPP (PreSEPP) and those who had surgery after (PostSEPP). Length of stay and daily opioid consumption were extracted by EMR data analysts unaware of the purpose of the study. RESULTS: The PreSEPP (N=34) and PostSEPP (N=27) patients were similar at baseline in age, sex distribution, ASA grade, BMI and smoking status. Pre-Op (2.2 vs 3.6, p=0.630) and Post-op Day-0 (POD-0, 52.5 vs 38.8, p=0.192) MME consumption was similar between the two groups. At POD-1, cumulative MME consumption was higher in the Pre-SEPP (131.7) compared to the PostSEPP group (76.0, p=0.004) and this was maintained up to discharge (54% total MME reduction). Length of stay was also longer in the PreSEPP (1.97 days) compared to the PostSEPP group (1.37 days, p=0.004). CONCLUSIONS: The use of a standard escalation pain protocol decreases in-hospital opioid consumption by 54% and shortens length of stay after 1-2 level lumbar spinal fusion. Similar to our previous study, prescribing pattern is an important factor affecting post-op opioid consumption. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.488
P65. Drivers for non-home discharge in 1,502 patients undergoing 1-2 lumbar fusions Jeffrey L. Gum, MD1, Portia Steele, ACNP-BC1, Charles H. Crawford III, MD1, Mladen Djurasovic, MD1, R. Kirk Owens II, MD1, Morgan Brown, MS2, Christy L. Daniels, MS1, Steven D. Glassman, MD1, Leah Y. Carreon, MD, MSc1; 1 Norton Leatherman Spine Center, Louisville, KY, US; 2 Norton Healthcare, Louisville, KY, US BACKGROUND CONTEXT: Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the postdischarge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE: To identify factors associated with being discharged to a nonhome location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning.
STUDY DESIGN/SETTING: Retrospective chart review. PATIENT SAMPLE: Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES: Non-home discharge. METHODS: Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS: A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p<0.000) was longer and total hospital direct cost ($21,204 vs $17,518, p<0.000) was higher in NH patients compared to those discharged to home. CONCLUSIONS: Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.489
P66. An analysis of Medicare reimbursement rates in spine surgery: 2000-2018 Jack Haglin, BS1, Jakub Godzik, MD2, Tyler Cole, MD3, Kent Richter, BS4, Luis M. Tumialan, MD5, Alan H. Daniels, MD6; 1 Scottsdale, AZ, US; 2 Phoenix, AZ, US; 3 Palo Alto, CA, US; 4 Mayo Clinic School of Medicine, Scottsdale, AZ, US; 5 Barrow Brain and Spine, Scottsdale, AZ, US; 6 Warren Alpert Medical School of BU/RI Hospital, Providence, RI, US BACKGROUND CONTEXT: Considering fluctuating policy, variance in proposed payment models, and the presence of ever-rising health care costs, there is noted financial uncertainty regarding health care in the US. Despite this, there has been relatively few studies regarding reimbursement models and trends in reimbursement rates. A comprehensive understanding of such trends is important as continued progress is made to advance agreeable reimbursement models in spine surgery. PURPOSE: The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2018. STUDY DESIGN/SETTING: Analysis of a publicly-available, government-compiled reimbursement database. OUTCOME MEASURES: Annual reimbursement rates across 15 commonly performed spine surgery procedures. METHODS: The National Surgery Quality Improvement Project (NSQIP) database (2016) was queried to determine the 15 most performed spine surgery procedures. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each of the top 15 most utilized CPT codes in spine surgery, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2018 US dollars (USD) utilizing changes to the consumer price index (CPI). The R-squared and both average annual and the total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures. RESULTS: After adjusting for inflation, the average physician reimbursement for all procedures decreased by 25.8% from 2000 to 2018. The greatest mean decrease was seen in anterior cervical arthrodesis (-32.1%), while the smallest mean decrease was in vertebral body excision (-13.3%). From
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
Proceedings of the 34th Annual Meeting of the North American Spine Society / The Spine Journal 19 (2019) S158−S194 ePosters: Socioeconomics/Industrial/Ergonomics
P64. Initiation of a standardized escalation pain protocol after 1-2 level lumbar fusion reduces in-hospital opioid consumption Portia Steele, ACNP-BC1, Jeffrey L. Gum, MD1, Morgan Brown, MS2, Christy L. Daniels, MS1, Mladen Djurasovic, MD1, Charles H. Crawford III, MD1, Steven D. Glassman, MD1, Leah Y. Carreon, MD, MSc1; 1 Norton Leatherman Spine Center, Louisville, KY, US; 2 Norton Healthcare, Louisville, KY, US BACKGROUND CONTEXT: Our previous study showed that prescribing patterns, more than surgery invasiveness or patient factors, affect postoperative opioid consumption. Since then we have instituted a Standard Escalation Pain Protocol (SEPP): patients receive 0-60 Morphine Milligram Equivalents (MME) above their baseline pre-op MME after surgery. PURPOSE: The purpose of this study is to evaluate how prescribing patterns affect immediate postoperative opioid consumption in patients undergoing 1- to 2-level posterior lumbar interbody fusion with a navigated or robotic-assisted, midline exposure (MIDLIF). STUDY DESIGN/SETTING: Single surgeon consecutive series. PATIENT SAMPLE: Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified. OUTCOME MEASURES: In-hospital opioid consumption. METHODS: Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified and divided into two cohorts: patients who had surgery before the institution of SEPP (PreSEPP) and those who had surgery after (PostSEPP). Length of stay and daily opioid consumption were extracted by EMR data analysts unaware of the purpose of the study. RESULTS: The PreSEPP (N=34) and PostSEPP (N=27) patients were similar at baseline in age, sex distribution, ASA grade, BMI and smoking status. Pre-Op (2.2 vs 3.6, p=0.630) and Post-op Day-0 (POD-0, 52.5 vs 38.8, p=0.192) MME consumption was similar between the two groups. At POD-1, cumulative MME consumption was higher in the Pre-SEPP (131.7) compared to the PostSEPP group (76.0, p=0.004) and this was maintained up to discharge (54% total MME reduction). Length of stay was also longer in the PreSEPP (1.97 days) compared to the PostSEPP group (1.37 days, p=0.004). CONCLUSIONS: The use of a standard escalation pain protocol decreases in-hospital opioid consumption by 54% and shortens length of stay after 1-2 level lumbar spinal fusion. Similar to our previous study, prescribing pattern is an important factor affecting post-op opioid consumption. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.488
P65. Drivers for non-home discharge in 1,502 patients undergoing 1-2 lumbar fusions Jeffrey L. Gum, MD1, Portia Steele, ACNP-BC1, Charles H. Crawford III, MD1, Mladen Djurasovic, MD1, R. Kirk Owens II, MD1, Morgan Brown, MS2, Christy L. Daniels, MS1, Steven D. Glassman, MD1, Leah Y. Carreon, MD, MSc1; 1 Norton Leatherman Spine Center, Louisville, KY, US; 2 Norton Healthcare, Louisville, KY, US BACKGROUND CONTEXT: Provisions in the Patient Protection and Affordable Care Act (PPAC) include alternative payment models that shift away from fee-for-service reimbursement and provide incentives to improve value. These reimbursement models could incorporate the postdischarge facility care and it is therefore important to identify drivers of additional cost, especially in the setting of unexpected non-home discharge. PURPOSE: To identify factors associated with being discharged to a nonhome location after an elective 1-2 level instrumented lumbar fusion that, if identified, can be useful to allow for early post-discharge planning.
STUDY DESIGN/SETTING: Retrospective chart review. PATIENT SAMPLE: Patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. OUTCOME MEASURES: Non-home discharge. METHODS: Hospital administrative database and electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018. Discharge disposition was determined as home vs non-home (NH). A regression analysis was used to determine associations between NH discharge and an underserved zip code, ASA grade, marital status, race, insurance type, smoking status, BMI, number of levels, approach and revision surgery. RESULTS: A total of 1,502 patients (601; 40% male) were included with a mean age of 57.5 years. The majority were discharged home (1,216; 81%). Of the 286 (19%) not discharged home, the majority went to a skilled nursing facility (248). Factors associated with a NH discharge were living in an underserved zip code, not being married, being on government insurance, having more levels fused, higher BMI and older age. Length of stay (5.64 vs 3.03 days, p<0.000) was longer and total hospital direct cost ($21,204 vs $17,518, p<0.000) was higher in NH patients compared to those discharged to home. CONCLUSIONS: Patients living in an underserved zip code, not married, higher BMI, older, and having government insurance are more likely to be discharged to a non-home facility after undergoing 1-2 instrumented lumbar fusions. Identification and early intervention to place these patients even before admission may decrease the length of hospital stay and cost. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.489
P66. An analysis of Medicare reimbursement rates in spine surgery: 2000-2018 Jack Haglin, BS1, Jakub Godzik, MD2, Tyler Cole, MD3, Kent Richter, BS4, Luis M. Tumialan, MD5, Alan H. Daniels, MD6; 1 Scottsdale, AZ, US; 2 Phoenix, AZ, US; 3 Palo Alto, CA, US; 4 Mayo Clinic School of Medicine, Scottsdale, AZ, US; 5 Barrow Brain and Spine, Scottsdale, AZ, US; 6 Warren Alpert Medical School of BU/RI Hospital, Providence, RI, US BACKGROUND CONTEXT: Considering fluctuating policy, variance in proposed payment models, and the presence of ever-rising health care costs, there is noted financial uncertainty regarding health care in the US. Despite this, there has been relatively few studies regarding reimbursement models and trends in reimbursement rates. A comprehensive understanding of such trends is important as continued progress is made to advance agreeable reimbursement models in spine surgery. PURPOSE: The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2018. STUDY DESIGN/SETTING: Analysis of a publicly-available, government-compiled reimbursement database. OUTCOME MEASURES: Annual reimbursement rates across 15 commonly performed spine surgery procedures. METHODS: The National Surgery Quality Improvement Project (NSQIP) database (2016) was queried to determine the 15 most performed spine surgery procedures. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each of the top 15 most utilized CPT codes in spine surgery, and reimbursement data was extracted. All monetary data was adjusted for inflation to 2018 US dollars (USD) utilizing changes to the consumer price index (CPI). The R-squared and both average annual and the total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures. RESULTS: After adjusting for inflation, the average physician reimbursement for all procedures decreased by 25.8% from 2000 to 2018. The greatest mean decrease was seen in anterior cervical arthrodesis (-32.1%), while the smallest mean decrease was in vertebral body excision (-13.3%). From
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.