Ritesh Karsalia

Study Design: Retrospective cohort study. Objectives: As cancer survival improves, metastatic spinal cancer has become increasingly common worldwide. Given the high resource demands of spinal oncology care, tools to optimize perioperative planning are essential. The objective of the study was to assess the effectiveness of the Risk Assessment and Prediction Tool (RAPT) in predicting post-operative needs in patients undergoing surgery for spinal tumors. Methods: Consecutive patients (n = 384) undergoing spinal oncology surgery were enrolled and prospectively assessed with RAPT. Coarsened exact matching (CEM) was used to retrospectively isolate risk factors associated with outcomes. Enrolled patients with a low RAPT score (≤9, n = 44) were exact matched against high-scoring patients (10-12, n = 44). The primary outcome of interest was post-acute care disposition; secondary outcomes were 30- and 90- day ED visits, readmissions, and reoperations. McNemar’s test was utilized for matched comparisons. Results: A low RAPT score was significantly associated with non-home discharge (OR = 4.33 [1.23, 15.20], P = 0.02) and 30-day readmission (OR = 3.66 [1.02, 13.14], 0.03). Among low-scoring patients, 31.8% required post-acute care (while only 11.3% of high-scoring patients required post-acute care). A low RAPT score was not associated with ER visits, reoperation, or mortality. Isolation of the RAPT walk score alone significantly predicted non-home discharge (OR = 2.8 [1.01, 7.78], P = 0.04). Conclusions: When applied prospectively before spinal cancer surgery, the RAPT tool and its subcomponents effectively predict post-acute care needs. Pre-operative prediction of non-home discharge may help guide in-hospital resource allocation and post-acute care of spinal oncology patients.

Study Design: Retrospective Matched Cohort Study. Objectives: Optimization of medical comorbidities is an essential part of preoperative management. However, the isolated effects of individual comorbidities have not been evaluated within a homogenous spine surgery population. This exact matching study aims to assess the independent effects of cancer on outcomes following single-level lumbar fusions for non-cancer surgery. Methods: 4680 consecutive patients undergoing single-level posterior-only lumbar fusion were retrospectively enrolled. Univariate statistics and coarsened exact matching (CEM) were computed to evaluate outcomes between cancer patients and those without comorbidities. Results: By logistic regression, malignancy conferred a higher risk of surgical complication ( P = 0.016, OR = 2.64, CI = [1.200,5.790]), 30- and 90- day readmission ( P = 0.012, OR = 2.025, CI = [1.170-3.510]; P < 0.001, OR = 2.34, CI = [1.430, 3.830], respectively), 90-day reoperation ( P < 0.001, OR = 2.16, [1.110, 4.200]), and death at 90-days ( P = 0.032, OR = 8.27, CI = [1.200, 56.850]). After matching, malignancy was associated with increased odds of incidental durotomy (6 vs 0 cases, P = 0.048) and death at both 30 and 90 days (both: OR = 8.0, P = 0.020, CI = [1.00, 63.960]). No cases of durotomy occurred in cases with mortality in the matched sample, suggesting independent relationships. There were no differences in length of stay, non-home discharge, ED evaluation, readmission, or reoperations. Conclusion: Among otherwise exact-matched patients undergoing single level lumbar fusion, history of malignancy conferred a higher risk of short-term mortality, but not other outcomes suggestive of surgical failure. Increased mortality after lumbar fusion should be studied further and may play a role in surgical decision-making and patient discussions.

Background: Prior studies suggest that patients with essential tremor (ET) have increased rates of healthcare utilization, but the reason for this increased use is unknown. The objective of this study was to evaluate the reasons for healthcare use among ET patients. Methods: This was a retrospective cross-sectional study of ET patients with an admission or emergency department (ED) visit at a tertiary health system from 2018–2023. Patients were matched on an encounter level with control patients based on propensity scores incorporating age, sex, race, and co-morbid conditions. The primary outcome was the odds of an encounter for each diagnostic category comparing ET patients with matched controls. Results: Only inpatient admissions for neurologic diagnoses were more likely for ET compared to control patients (odds ratio (OR) 3.73, 95% confidence interval (CI) 2.54 – 5.49, p < 0.001). Once admissions related to the surgical treatment of tremor were excluded, admissions for neurologic diagnoses were equally likely among ET and control patients (OR 0.96, 95% CI 0.59 – 1.57, p = 0.88). Discussion: Surgical treatment of tremor appears to be a key driver of healthcare use among ET patients. Future investigations should examine the pattern of healthcare use of ET patients before and after surgery. Highlights Prior studies have shown increased healthcare use among essential tremor (ET) patients. The objective of this study was to evaluate the reasons for healthcare use among ET patients compared to matched control patients. Surgical treatment of tremor was found to be a key driver of healthcare use among ET patients.

Study Design: Retrospective Matched Cohort Study. Objectives: Low median household income (MHI) has been correlated with worsened surgical outcomes, but few studies have rigorously controlled for demographic and medical factors at the patient level. This study isolates the relationship between MHI and surgical outcomes in a lumbar fusion cohort using coarsened exact matching. Methods: Patients undergoing single-level, posterior lumbar fusion at a single institution were consecutively enrolled and retrospectively analyzed (n = 4263). Zip code was cross-referenced to census data to derive MHI. Univariate regression correlated MHI to outcomes. Patients with low MHI were matched to those with high MHI based on demographic and medical factors. Outcomes evaluated included complications, length of stay, discharge disposition, 30- and 90 day readmissions, emergency department (ED) visits, reoperations, and mortality. Results: By univariate analysis, MHI was significantly associated with 30- and 90 day readmission, ED visits, reoperation, and non-home discharge, but not mortality. After exact matching (n = 270), low-income patients had higher odds of non-home discharge (OR = 2.5, P = .016) and higher length of stay (mean 100.2 vs 92.6, P = .02). There were no differences in surgical complications, ED visits, readmissions, or reoperations between matched groups. Conclusions: Low MHI was significantly associated with adverse short-term outcomes from lumbar fusion. A matched analysis controlling for confounding variables uncovered longer lengths of stay and higher rates of discharge to post-acute care (vs home) in lower MHI patients. Socioeconomic disparities affect health beyond access to care, worsen surgical outcomes, and impose costs on healthcare systems. Targeted interventions must be implemented to mitigate these disparities.

BACKGROUND AND OBJECTIVES: Race has implications for access to medical care. However, the impact of race, after access to care has been attained, remains poorly understood. The objective of this study was to isolate the relationship between race and short-term outcomes across patients undergoing a single, common neurosurgical procedure. METHODS: In this retrospective cohort study, 3988 consecutive patients undergoing single-level, posterior-only open lumbar fusion at a single, multihospital, academic medical center were enrolled over a 6-year period. Among them, 3406 patients self-identified as White, and 582 patients self-identified as Black. Outcome disparities between all White patients vs all Black patients were estimated using logistic regression. Subsequently, coarsened exact matching controlled for outcome-mitigating factors; White and Black patients were exact-matched 1:1 on key demographic and health characteristics (matched n = 1018). Primary outcomes included 30-day and 90-day hospital readmissions, emergency department (ED) visits, reoperations, mortality, discharge disposition, and intraoperative complication. RESULTS: Before matching, Black patients experienced increased rate of nonhome discharge, readmissions, ED visits, and reoperations (all P < .001). After exact matching, Black patients were less likely to be discharged to home (odds ratio [OR] 2.68, P < .001) and had higher risk of 30-day and 90-day readmissions (OR 2.24, P < .001; OR 1.91, P < .001; respectively) and ED visits (OR 1.79, P = .017; OR 2.09, P < .001). Black patients did not experience greater risk of intraoperative complication (unintentional durotomy). CONCLUSION: Between otherwise homogenous spinal fusion cohorts, Black patients experienced unfavorable short-term outcomes. These disparities were not explained by differences in intraoperative complications. Further investigation must characterize and mitigate institutional and societal factors that contribute to outcome disparities.