Date of Award

2017

Document Type

Dissertation

Degree Name

Doctor of Health Administration

College

College of Health Professions

First Advisor

Kit N. Simpson

Second Advisor

Scott Davis

Third Advisor

W. Bryan Wilent

Fourth Advisor

James S Zoller

Abstract

Objective: To explore the relationship between the utilization rates of Intraoperative Neuromonitoring (IONM) across hospitals, and the impact on surgical outcomes of 30- day readmission (30DRR) and length of stay (LoS) for lower risk, non-complex spinal procedures. The following questions will be addressed: 1) Will hospitals with a high rate (> 67th percentile) of IONM use for low risk spinal surgeries have lower LoS than hospitals with low use (< 33rd percentile) of IONM?; 2) Will hospitals with a high rate (> 67th percentile) of IONM use for low risk spinal surgeries have lower 30DRR than hospitals with low use (< 33rd percentile) of IONM?; 3) High surgical volume hospitals with high IONM use rate (>67th) during low risk will have lower 30-day readmission rates than similar high volume hospitals with low IONM use; and, 4) Will high surgical volume hospitals with high IONM use rate (>67th) during low risk will have lower 30-day readmission rates than similar high volume hospitals with low IONM use? Methods: A retrospective analysis of multi-state hospital billing data was conducted utilizing the 2012 Agency for Healthcare Quality and Research (AHRQ), Healthcare Cost and Utilization Project (HCUP) Statewide Inpatient Databases (SID) for Florida, Massachusetts, New York, and Washington. Multivariable and gamma distributed, generalized linear log linked, regression models were used to test the association between hospital IONM utilization and hospital outcomes of 30DRR and LoS, respectively. Results: Hospitals in the top thirtile of IONM utilization had a 14.9% lower chance (OR of .851, p value .001) of a 30-day readmission and no significant difference in LoS, when compared to the bottom thirtile of IONM hospitals users, for surgeries within the Diagnostic Related Groups (DRGs) of 460 and 473. Hospitals in the subgroup of top 50th percentile of hospitals in the state by surgical volume had 8.3% lower chance (OR of .917, p value .023) of 30-day readmission when compared to the subgroup of bottom 50th percentile of all surgeries, and a small difference in mean LoS, 0.3 days (95% CI 3.04-3.09, 2.74-2.78). Discussion: Comparing the top thirtile of IONM utilizing hospitals to the bottom third of utilization hospitals reduced the chances of 30-day readmission by 14.9% for less complex and lower risk spinal procedures (DRGs 460 and 473). Additionally, this 14.9% lower chance of a 30-day readmission were further supported by the findings that surgical volume made no significant difference in this result. The top 50th percentile subgroup of all hospital spine surgeries was analyzed and yielded an 8.3% lower chance of incurring a 30-day readmission when compared to the bottom 50th percentile subgroup. Ultimately, the significant difference in 30DRR for the top thirtile of hospital IONM utilizers should not be attributed to organizational surgical volume alone, thus further supporting IONM’s influence in reducing 30DRR. Additional research is warranted to further assess the association between IONM and LoS. In general, adjusted estimations of mean LoS did not yield any differences for high or low IONM utilizing hospitals across lower risk, less complex procedures. For the top and bottom 50th percentile subgroups, there was a moderate increase in LoS for the top 50th percentile (0.3days) Further exploration of IONM’s utility is warranted, and ideally these analyses will be based on prospective, longitudinal datasets and registries with more detailed documentation. This expanded information would allow for more analytical and clinical control for the largely unstandardized practice of IONM.

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