Predictors of Nonelective Surgery for Spinal Metastases

Insights From a National Database

Hammad A. Khan, BS; Nicholas M. Rabah, BS; Vikram Chakravarthy, MD; Raghav Tripathi, MPH; Ajit A. Krishnaney, MD

Disclosures

Spine. 2021;46(24):E1334-E1342. 

In This Article

Results

After applying survey-level weights, our cohort included an estimated 21,950 patients, of whom 7070 (32.2%) received elective surgery and 14,880 (67.8%) received nonelective surgery for spinal metastases. Patients receiving nonelective surgery were on average of similar age to those receiving elective surgery (61.09 ± 13.10 vs. 60.40 ± 14.57, P= 0.120). Approximately 61% of patients in the nonelective group were male compared to 56% of patients in the elective group (P = 0.002). Patients treated non-electively more frequently presented with myelopathy (52.0% vs. 29.2%, P < 0.001) and major or extreme loss of function (79.1% vs. 61.3%, P < 0.001). Patients receiving nonelective surgery were more often of non-white race (31.4% vs. 19.2%, P < 0.001) and nonprivate insurance status (63.8% vs. 54.9%, P < 0.001). On average, patients in the nonelective cohort also had a greater number of comorbidities (Table 1). Specifically, patients receiving nonelective surgery were observed to have a higher frequency of alcohol abuse, coagulopathy, congestive heart failure, deficiency anemia, drug abuse, and liver disease (P < 0.001 for all) (Table 2).

After adjusting for baseline covariates, multivariable analysis revealed several factors that were independently associated with nonelective surgery. Patients aged 35 to 64 years (odds ratio [OR] = 1.61, 95% confidence interval [CI]: 1.30–1.99, P < 0.001) had higher odds of receiving nonelective surgery compared to those aged 65 years. Patients classified as black (OR = 1.38, 95% CI: 1.03–1.84, P= 0.032) or other race (OR = 1.50, 95% CI: 1.13–1.98, P = 0.005) were more likely to receive nonelective surgery compared to their white counterparts. Having public (OR = 1.56, 95% CI: 1.26–1.93, P < 0.001) or selfpay/other insurance (OR = 2.09, 95% CI: 1.38–3.15, P < 0.001) resulted in higher odds of receiving nonelective surgery compared to having private insurance. Belonging to the lowest (OR = 1.40, 95% CI: 1.06–1.84, P = 0.019) and second-lowest income quartiles (OR = 1.31, 95% CI: 1.01–1.71, P= 0.041) was associated with increased odds of undergoing non-elective surgery compared to belonging to the highest income quartile. Residing in a large metropolitan area (OR = 1.26, 95% CI: 1.04–1.53, P= 0.021) was associated with increased odds of receiving nonelective surgery compared to residing in a small metropolitan/micropolitan/rural area. Weekend admission (OR = 10.93, 95% CI: 6.68–17.87, P< 0.001) was associated with greater odds of non-elective surgery compared to weekday admission, as was having three to five (OR = 1.75, 95% CI: 1.46–2.10, P< 0.001) or six or more comorbidities (OR = 2.94, 95% CI: 2.07–4.16, P < 0.001). Patients presenting with myelopathy (OR = 2.10, 95% CI: 1.75–2.52, P < 0.001) had greater odds of receiving nonelective surgery than those without. Patients suffering from major (OR = 4.22, 95% CI: 1.20–14.81, P = 0.025) or extreme loss of function (OR = 4.32, 95% CI: 1.21–15.45, P = 0.025) were more likely to receive non-elective treatment compared to those with minor loss of function. Patients who were treated at medium (OR = 2.12, 95% CI: 1.40–3.21, P < 0.001) or large hospitals (OR = 2.34, 95% CI: 1.60–3.42, P < 0.001) were more likely to receive nonelective surgery than their counterparts at small hospitals. Nonelective surgery for spinal metastases was less likely to be performed in the Midwest (OR = 0.64, 95% CI: 0.46–0.89, P = 0.008) and South (OR = 0.57, 95% CI: 0.42–0.77, P < 0.001) compared to the Northeast (Table 3).

The rate of perioperative complications was comparable between groups (10.5% nonelective vs. 9.1% elective, P = 0.103). In-hospital mortality (2.25% vs. 1.13%, P = 0.013) and nonroutine discharge (75.8% vs. 49.4%, P< 0.001) occurred more frequently in patients treated nonelectively. The median hospital LOS for patients treated nonelectively was 8.37 days (IQR: 5.62–12.92), compared to 4.67 days (IQR: 2.54–7.39) for those treated electively (P < 0.001). Patients treated nonelectively incurred higher hospitalization costs, with a median cost of $39,456 (IQR: $24,984–58,796) compared to $31,902 (IQR: $18,703–50,989) for those treated electively (P< 0.001) (Table 4). After adjusting for baseline covariates, nonelective surgery was associated with greater odds of nonroutine discharge (OR = 2.50, 95% CI: 2.09–2.98, P < 0.001) and extended LOS (OR = 2.45, 95% CI: 1.91–3.16, P < 0.001) compared to elective surgery (Table 5).

processing....