BACKGROUND
United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines.
OBJECTIVE
To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications.
METHODS
All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance.
RESULTS
A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not.
In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors.
CONCLUSION
This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.
Spinal cord injury (SCI) can be a complex injury pathology with high rates of morbidity and mortality. Care for the patient with spinal cord injury is dictated by their neurological status and the structural morphology of their injury and begins with prehospital management, thorough neurological assessment, and advanced imaging. Often surgical intervention is required for fracture stabilization and decompression of spinal cord pressure. Vigilance needs to remain high after surgery as SCI patients are at increased risk for multiple medical complications as a result of their injuries. Focused, comprehensive care delivered by the hospitalist and care team can facilitate improved outcomes.
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