Factors Associated With Short Length of Stay After Long Fusions for Adult Spinal Deformity: Initial Steps Toward Developing an Enhanced Recovery Pathway

Abstract

Study design: Retrospective cohort study.

Objectives: The identification of case types and institutional factors associated with reduced length of stay (LOS) is a key initial step to inform the creation of clinical care pathways that can assist hospitals to maximize the benefit of value-based payment models. The objective of this study was to identify preoperative, intraoperative, and postoperative factors associated with shorter than expected LOS after adult spinal deformity (ASD) surgery.

Methods: A retrospective cohort study was performed of 82 patients with ASD who underwent ≥5 levels of fusion to the pelvis between 2013 and 2018. A LOS <6 days was determined as a basis for comparison, as 5.7 days was the "expected LOS" generated through Poisson regression modeling of the sample. Clinical, radiographic, surgical, and postoperative factors were compared between those staying ≥6 days (L group) and <6 days (S group). Logistic regression was used to identify factors associated with LOS <6 days.

Results: A total of 35 patients were in group S (42.7%). Gender, age, body mass index, ASA (American Society of Anesthesiologists) class, and use of preoperative narcotics, revision surgery, day of admission, and surgical complications did not vary between the cohorts (P > .05). Mild-moderate preoperative sagittal deformity (sagittal Schwab modifiers 0 or +), lower estimated blood loss (<1200 mL), fewer levels fused (7 vs 10 levels), shorter operating room time, procedure end time before 15:00, and no intensive care unit stay, were associated with short LOS (P < .05). Only 1 major medical complication occurred in the short LOS group (P < .05).

Conclusions: This study identifies the ASD "case phenotype," intra-, and postoperative benchmarks associated with shorter LOS, providing targets for pathways designed to reduce LOS.

Keywords: deformity; degenerative; lumbar; sagittal alignment.

Figure 1.

Case example of patient/case “phenotype” that may be eligible for a short-stay adult deformity pathway. A 52-year-old woman with a 2-year history of progressive lower back pain radiating into the left buttock. Medical history significant for osteoporosis and intermittent supraventricular tachycardia. The patient underwent T10-pelvis posterior spinal fusion with Smith-Peterson osteotomies performed from L1-L5. Total operative time was 3 hours and 27 minutes, and the case ended at 17:00. The patient spent the first postoperative night in the post-anesthesia care unit and was transferred to floor on postoperative day (POD) 1. She walked 5 feet with physical therapy on POD 1. On POD 3, the patient was transfused 1 unit of packed red blood cells for anemia due to acute blood loss. The patient walked 150 feet on POD 3 and was discharged home on the morning of POD 5.