The Impact of Diabetes Mellitus on Length of Stay and Direct Hospital Costs after Minimally Invasive Transforaminal Lumbar Interbody Fusion

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1 The Impact of Diabetes Mellitus on Length of Stay and Direct Hospital Costs after Minimally Invasive Transforaminal Lumbar Interbody Fusion Brittany E. Haws, MD1 ; Benjamin Khechen, BA1; Dil V. Patel, BS1; Ankur S. Narain, MD1; Mundeep S. Bawa, BA1; Harmeet S. Bawa, BA1; Kaitlyn L. Cardinal, BS1; Jordan A. Guntin, BS1; Sailee S. Karmarkar, BS1; Kern Singh, MD1,2 1 2 Department of Orthopaedic Surgery, Rush University Medical Center Professor, Co-Director of the Minimally Invasive Spine Institute at Rush University Medical Center; Founder and President, Minimally Invasive Spine Study Group

2 Disclosures Brittany E. Haws, Benjamin Khechen, Dil V. Patel, Ankur S. Narain, Mundeep S. Bawa, Harmeet S. Bawa, Kaitlyn L. Cardinal, Jordan A. Guntin, Sailee S. Karmarkar Nothing to disclose Kern Singh, MD Board Membership Vital 5 LLC, Avaz Surgical LLC Consultant Depuy, Zimmer, Stryker Royalties Zimmer, Stryker, Pioneer, Lippincott Williams and Wilkins, Thieme, Jaypee Publishing, Slack Publishing Grants Cervical Spine Research Society

3 Introduction Diabetes mellitus (DM) is one of the most prevalent conditions in the United States. In spine literature, DM has been associated with increased risk for postoperative complications, increased length of inpatient stay, and increased costs for a heterogenous mixture of procedure types.

4 Aims and Objectives To determine if the presence of DM as a comorbidity is associated with inpatient length of stay (LOS) or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

5 Methodology Retrospectively review prospectively-maintained database 100 patients that underwent a primary, single-level MIS TLIF for degenerative pathology from 2008 to 2016 Patient groups were propensity matched for age, gender, and comorbidity burden 100 Primary, Single-level MIS TLIF Patients Diabetic N = 50 Non-Diabetic N = 50

6 Methodology Variables Analyzed Patient demographics Operative variables Length of stay Complications Direct hospital costs Statistical Analyses Student s t-test Pearson s Chi-square analysis Multivariate linear regression

7 Results No differences in demographics identified between diabetics and nondiabetics.

8 Results No differences in perioperative characteristics, length of stay, or complication rate between diabetics and nondiabetics.

9 Results No differences in inpatient length of stay between diabetics and nondiabetics following MIS TLIF.

10 Results Diabetic status was not associated with differences in total direct hospital costs or cost subcategories after MIS TLIF.

Discussion Diabetes mellitus was NOT associated with increased length of stay or hospital costs after single-level MIS TLIF Limited operative

11 Discussion Diabetes mellitus was NOT associated with increased length of stay or hospital costs after single-level MIS TLIF Limited operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications, and thus, length of stay and hospital costs in diabetic patients

12 Limitations Other comorbidities were not accounted for in this study. Patients were not substratified by insulin-dependent status or by Hemoglobin A1c levels. Complications after discharge or readmissions were not recorded.

13 Conclusions Diabetes was NOT associated with higher complication rates, length of stay, or hospital costs after primary, single-level MIS TLIF Reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital length of stay and costs

14 References Browne JA, Cook C, Pietrobon R, Bethel MA, Richardson WJ: Diabetes and early postoperative outcomes following lumbar fusion. Spine (Phila Pa 1976) 32: , 2007 Cher EWL, Tay KS, Zhang K, Tan SB, Howe TS, Koh JSB: The Effect of Comorbidities and Age on Functional Outcomes After Total Knee Arthroplasty in the Octogenarian: A Matched Cohort Study. Geriatr Orthop Surg Rehabil 9: , 2018 Epstein NE: Predominantly negative impact of diabetes on spinal surgery: A review and recommendation for better preoperative screening. Surg Neurol Int 8:107, 2017 Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR: Perioperative outcomes and adverse events of minimally invasive versus open posterior lumbar fusion: meta-analysis and systematic review. J Neurosurg Spine 24: , 2016 Golinvaux NS, Varthi AG, Bohl DD, Basques BA, Grauer JN: Complication rates following elective lumbar fusion in patients with diabetes: insulin dependence makes the difference. Spine (Phila Pa 1976) 39: , 2014 Guzman JZ, Iatridis JC, Skovrlj B, Cutler HS, Hecht AC, Qureshi SA, et al: Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery. Spine (Phila Pa 1976) 39: , 2014 Guzman JZ, Skovrlj B, Shin J, Hecht AC, Qureshi SA, Iatridis JC, et al: The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery. Spine (Phila Pa 1976) 39: , 2014 Hey HW, Hee HT: Open and minimally invasive transforaminal lumbar interbody fusion: comparison of intermediate results and complications. Asian Spine J 9: , 2015 Jämsen E, Peltola M, Eskelinen A, Lehto MU: Comorbid diseases as predictors of survival of primary total hip and knee replacements: a nationwide register-based study of operations on patients with primary osteoarthritis. Ann Rheum Dis 72: , 2013 López-de-Andrés A, Hernández-Barrera V, Martínez-Huedo MA, Villanueva-Martinez M, Jiménez-Trujillo I, Jiménez-García R: Type 2 diabetes and in-hospital complications after revision of total hip and knee arthroplasty. PLoS One 12:e , 2017 Maloney PR, Halasz SR, Mallory GW, Grassner L, Jacob JT, Nassr A, et al: The effect of diabetes mellitus on 30-day outcomes following single-level open lumbar microdiscectomy: an aged-matched case-control study. J Neurosurg Sci 61:1-7, 2017 Menke A, Casagrande S, Geiss L, Cowie CC: Prevalence of and Trends in Diabetes Among Adults in the United States, JAMA 314: , 2015 Singh K, Nandyala SV, Marquez-Lara A, Fineberg SJ, Oglesby M, Pelton MA, et al: A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion. Spine J 14: , 2014 Su AW, Habermann EB, Thomsen KM, Milbrandt TA, Nassr A, Larson AN: Risk Factors for 30-Day Unplanned Readmission and Major Perioperative Complications After Spine Fusion Surgery in Adults: A Review of the National Surgical Quality Improvement Program Database. Spine (Phila Pa 1976) 41: , 2016 Tsang ST, Gaston P: Adverse peri-operative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies. Bone Joint J 95-B: , 2013 Walid MS, Newman BF, Yelverton JC, Nutter JP, Ajjan M, Robinson JS: Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost. J Hosp Med 5:E10-14, 2010 Worley N, Buza J, Jalai CM, Poorman GW, Day LM, Vira S, et al: Diabetes as an Independent Predictor for Extended Length of Hospital Stay and Increased Adverse Post-Operative Events in Patients Treated Surgically for Cervical Spondylotic Myelopathy. Int J Spine Surg 11:10, 2017

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