Update on Pediatric Procedure Targeted Modules: Spinal Fusion Procedures Brian Brighton, MD, MPH Carolinas Healthcare System/Levine Childrens

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1 Update on Pediatric Procedure Targeted Modules: Spinal Fusion Procedures Brian Brighton, MD, MPH Carolinas Healthcare System/Levine Childrens Hospital Charlotte, NC

2 Disclosures I have no financial disclosures

3 Variation in practice patterns and resource utilization for spinal fusion procedures across children s hospitals Brian K Brighton, MD, MPH, Charlotte, NC Debra A Liebrecht, RN, CPHQ, Aurora, CO CarolAnn H Gelder, RN, MSN, Philadelphia, PA Jacqueline M Saito, MD, St. Louis, MO Douglas C Barnhart, MD, MSPH, Salt Lake City, UT Shawn Rangel, MD, MSCE, Boston, MA POSNA, 2016

4 Background and Rationale Spinal fusion procedures within the American College of Surgeons NSQIP-Pediatric program demonstrate institutional variability and high morbidity rates. Development of procedure specific variables within the NSQIP-P platform would allow for better understanding of outcomes, risk stratification and resource utilization in spinal fusion procedures. A specific aim of this study is to identify patient variables and practice patterns that lead to variation in the care of children with spinal deformity.

5 Participating Hospitals American Family Children s Hospital Ann & Robert H. Lurie Children s Hospital Arkansas Children s Hospital BC Children's Hospital Boston Children's Hospital Children s Hospital Colorado Children s Hospital of the King s Daughters Children's Healthcare of Atlanta Children's Hospital and Medical Center Omaha Children's Hospital of Alabama Children's Hospital of Georgia Children's Hospital of Michigan Children's Hospital of Philadelphia Children's Hospital of San Antonio Children's Hospital of Wisconsin Cincinnati Children s Hospital Connecticut Children's Medical Center Cook Children's Medical Center Dell Children's Medical Center of Central Texas East Tennessee Children's Hospital Fairview Health Services, on behalf of Amplatz Golisano Children s Hospital Helen DeVos Children's Hospital Joe DiMaggio Children's Hospital Johns Hopkins Hospital Le Bonheur Children's Hospital Levine Children s Hospital Maine Medical Center Medical University of South Carolina Monroe Carell Jr. Children's Hospital at Vanderbilt Nationwide Children s Hospital Nemours/Alfred I. dupont Hospital for Children Penn State Hearshey Medical Center Primary Children s Hospital Riley Hospital for Children at Indiana University Health Seattle Children's Hospital St. Louis Children's Hospital Texas Children's Hospital The Children s Mercy Hospital The University of Iowa Children s Hospital University of Maryland Hospital for Children Wake Forest Baptist Health, Brenner Children s Hospital Yale New-Haven Children's Hospital

6 Methods

7 Spinal Fusion Procedure Targeted Variables Pre-operative data Classification of spinal deformity (Idiopathic/Congenital/Neuromuscular/Syndromic/Kyphosis/Other) Preoperative MRI (Y/N) Intra-operative resource utilization Intraoperative use of neuromonitoring (Y/N) Intraoperative use of antibiotics in the wound or bone graft (Y/N) Intraoperative use of antifibrinolytics (Y/N) Post-operative resource utilization Length of stay in ICU (Number of days)

8 Hospital practice variation and resource utilization

9 2016 Spinal Fusion Report January 1, 2016-December 31, cases from 93 hospitals Median 37 cases Utilization rates as well as risk adjusted models for Morbidity, Neurological injury, SSI and pneumonia

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13 Aggregate Utilization Rate 31.3%

14 Aggregate Utilization Rate 91.8%

15 Aggregate Utilization Rate 76.0%

16 Aggregate Utilization Rate 79.6%

17 Aggregate Utilization Rate 40.9%

18 Aggregate Utilization Rate 32.1%

19 Aggregate Utilization Rate 51.1%

20 Aggregate Utilization Rate 30.4%

21 Aggregate Utilization Rate 70.9%

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23 Complication Rates of Pediatric Spinal Deformity Surgery: Report of 4481 Cases Prospectively Collected Across North American Children s Hospitals Brian Brighton, Kelly VanderHave, Brian Scannell, Michael Glotzbecker, Jay Shapiro, Suken Shah Spine Safety Summit 2017, EPOSNA, 2017 SRS 2017

24 Background and Rationale Spinal fusion procedures within the American College of Surgeons NSQIP- Pediatric (NSQIP-P) program are associated with high morbidity rates. Procedure targeted variables for spinal fusion procedures within the NSQIP-P platform were developed to better understand patient related factors and adverse events. The purpose of the study was to examine the complication rates associated with with treatment of spinal deformity at hospitals participating in NSQIP- Pediatric.

25 Methods In addition to the traditional program variables, data was collected specifically related to spinal fusion procedures including: Etiology of spinal deformity Neurologic injuries Reoperation rates at 30 days Surgical site infection rates at 30 and 90 days Classification of spinal deformity and related complications for prospectively collected spinal fusion procedures collected in were analyzed.

26 Patient Cohort Results 4,481 patients from 43 hospitals collected from April 1, December 31, Posterior spinal fusions accounted for a majority of the cases (98.2%) compared to anterior procedures (1.8%) Mortality: 6 deaths were reported (3 in the neuromuscular cohort and 1 each in the syndromic, congenital and kyphosis groups)

27 Classification of Spinal Deformity

28 Spinal Fusion 30 and 90 SSI Rates Idiopathic (2927) NM (731) Congenital/ Structural (339) Kyphosis (224) Syndromic (178) Unclassified (82) SSI 30 Days 0.68% (20) 5.06% (37) 0.59% (2) 2.23% (5) 4.49% (8) 3.45% (2) 1.65% (74) Superficial SSI 30 Days 0.38% (11) 2.87% (21) 0.29% (1) 0.45% (1) 1.69% (3) 0.00% (0) 0.83% (37) Deep SSI 30 Days 0.31% (9) 2.19% (16) 0.29% (1) 1.79% (4) 2.81% (5) 3.45% (2) 0.83% (37) TOTAL (4481) SSI 90 Days* 1.20% 7.11% 1.18% 3.13% 5.06% 3.45% 2.43% Overall SSI rates at 30 days were 1.65% (range 0.68% in idiopathic scoliosis to 5.06% neuromuscular scoliosis) and at 90 days were 2.43% (range 1.20% in idiopathic scoliosis and 7.11% neuromuscular scoliosis)

29 Postoperative Neurological Deficit New Neurological Deficit Idiopathic (2927) NM (731) Congenital/ Structural (339) Kyphosis (224) Syndromic (178) Unclassified (82) 1.47% (43) 1.09% (8) 4.42% (15) 3.13% (7) 2.24% (4) 0.00% (0) 1.72% (77) TOTAL (4481) Spinal Cord Injury 0.34% (10) 0.55% (4) 0.59% (2) 1.34% (3) 1.12% (2) 0.00% (0) 0.47% (21) The incidence of new neurological deficits was 1.72% (highest in the congenital scoliosis cohort at 4.42%) with a 0.47% overall incidence of spinal cord injury.

30 Bleeding Events Idiopathic (2927) NM (731) Congenital/ Structural (339) Kyphosis (224) Syndromic (178) Unclassified (82) Bleeding Event 3.04% (89) 24.49% (179) 10.03% (34) 5.80% (13) 12.92% (23) 4.88% (4) 7.63% (342) TOTAL (4481) Bleeding events (defined as transfusions >25mL/kg) occurred in 7.63% of patients (significantly higher in the neuromuscular population with 24.5% versus 3.04% of patients with idiopathic scoliosis)

31 Spinal Fusion 30 Day Readmission and Unplanned Reoperation Rates Idiopathic (2927) NM (731) Congenital/ Structural (339) Kyphosis (224) Syndromic (178) Unclassified (82) Readmission 30 days 2.63% (77) 9.99% (73) 1.47% (5) 3.57% (8) 4.49% (8) 2.44% (2) 3.88% (174) TOTAL (4481) Unplanned reoperation 30 Days 1.71% (50) 6.70% (49) 1.77% (6) 5.80% (13) 8.99% (16) 0.00% (0) 3.04% (136) Overall 30 day readmission rates 3.88% (range 2.63% in idiopathic scoliosis to 9.99% neuromuscular scoliosis) Unplanned reoperation rates at 30 days were 3.04% (range 1.71% in idiopathic scoliosis and 8.99% syndromic scoliosis)

32 Conclusions Inherent complications exist in the treatment of pediatric spinal deformity, but variability was identified in this large, prospectively collected sample Complications such as SSI, readmission and reoperation were highest in the neuromuscular scoliosis group, and neurologic deficit after surgery was highest in the congenital scoliosis group. Quality improvement efforts should be targeted towards reducing specific complications in identified at-risk populations.

33 Significance Analysis of complication rates for spinal fusion procedures for specific patient populations allows surgeons and families to have informed discussions around risks when deciding upon surgery. In addition, the collection of procedure-targeted variables allows for improved measures of risk stratification, risk adjustment and improved outcomes in spinal deformity surgery.

34 Thank you Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system. Avedis Donabedian