Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy

Abstract

OBJECTIVE In a healthcare landscape in which costs increasingly matter, the authors sought to distinguish among the clinical and nonclinical drivers of patient length of stay (LOS) in the hospital following elective lumbar laminectomy—a common spinal surgery that may be reimbursed using bundled payments—and to understand their relationships with patient outcomes and costs. METHODS Patients ≥ 18 years of age undergoing laminectomy surgery for degenerative lumbar spinal stenosis within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient discharge disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance. RESULTS A total of 1359 eligible patients were included in the authors’ analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a skilled nursing facility (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively. CONCLUSIONS Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or rehabilitation center. These findings point to opportunities to lower costs and improve outcomes associated with elective surgical care. Interventions to optimize surgical scheduling and perioperative care coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing resources as they remain ahead of healthcare reforms.

Neighborhood-level socioeconomic status, extended length of stay, and discharge disposition following elective lumbar spine surgery

“…Our work reinforces research performed by Salas-Vega et al. (2021) [42] , who investigated extended LOS following lumbar laminectomy. Salas-Vega and colleagues found that patients with surgical complications, non-home discharge destinations, and surgery performed later in the week were more likely to have an extended LOS.…”

Time of Discharge and 30-Day Re-Presentation to an Acute Care Setting After Elective Lumbar Decompression Surgery

“…Similarly, Salas-Vega et al 32 recently demonstrated that, in a cohort of patients undergoing lumbar decompression for spinal stenosis, both LOS and total surgical costs increased with lateweek surgeries and discharge to skilled nursing facility or rehabilitation, likely because of diminished availability of inpatient providers, PT/OT, and case management during these times. Our results suggest that weekend discharges are also significantly problematic and result in both decreased odds of prenoon discharge and increased odds of return to acute care within 30 days.…”

Letter: Association of Late Week Nonhome Discharge With Increased Length of Stay in Intracranial Meningioma Resection Patients

“…2,5 A previous study demonstrated patients undergoing spinal surgery later in the week (Thursday/ Friday) and NHD patients both experienced significantly increased LOS even after adjusting for patient comorbidities and other patient factors. 6 Similarly, Dasenbrock et al, 7 found increased patient age, patient race, ASA class, and NHD to be significant predictors of eLOS after craniotomy for tumor resection.…”

“…8 These findings align with conclusions from the literature that optimizing surgical scheduling and care coordination may improve outcomes and lower associated surgical costs. 6,7…”

“…8 These findings align with conclusions from the literature that optimizing surgical scheduling and care coordination may improve outcomes and lower associated surgical costs. 6,7 The study limitations are numerous but primarily consist of the retrospective, single-center, study design and the small sample size of 225 patients. Despite these limitations, our findings provide an opportunity and platform to call attention to a critical, yet ubiquitous, illogical metric used daily to evaluate the surgeon's quality.…”