Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Patients undergoing single-level, posterior-only lumbar fusion with diabetes or cardiovascular disease (n=4680). Intervention: Cardiovascular disease (CHF, PVD, prior MI, prior CVA) or diabetes mellitus (uncomplicated or complicated) vs. Coarsened exact matched (1:1) patients without medical comorbidities. Primary outcome: 90-day all-cause mortality (among multiple co-primary short-term surgical outcomes for cardiovascular disease cohort) (OR 0.50, 95% CI 0.05-5.51, p=0.564).

Q: What does this research mean for the field?

Diabetes and cardiovascular disease are not independently associated with increased risk of short-term complications, readmissions, or mortality following lumbar fusion after controlling for confounding patient and procedural characteristics through exact matching. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Ryan S. Gallagher; Connor Wathen; Ritesh Karsalia; Austin J. Borja; Jianbo Na; Scott D. McClintock; Paul J. Marcotte; James M. Schuster; William C. Welch; Neil R. Malhotra

doi:10.1016/j.wnsx.2024.100410

September 23, 2024World Neurosurgery XOpen Access

Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

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Key result

CVD and diabetes are not associated with increased 90-day mortality after lumbar fusion.

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Why the study?

Further study was needed to evaluate how well current perioperative strategies mitigate the risks of diabetes and heart disease on spine surgery outcomes.

Does the presence of cardiovascular disease or diabetes increase the risk of short-term adverse surgical outcomes, readmissions, and mortality in adult patients undergoing single-level posterior-only lumbar fusion when matched for baseline demographic and procedural covariates?

Key Points

To determine whether diabetes and cardiovascular disease independently worsen short-term outcomes following single-level posterior lumbar fusion after isolating confounders through exact matching.
Retrospective review of 4,680 consecutive patients undergoing single-level, posterior-only lumbar fusion at a single center.
Coarsened exact matching (1:1) based on ten baseline and procedural characteristics produced matched cohorts for cardiovascular disease (n = 192; 96 with disease vs. 96 controls) and diabetes (n = 380; 190 with disease vs. 190 controls).
Short-term outcomes evaluated included intraoperative complications, length of stay, discharge disposition, and 30- and 90-day emergency department visits, readmissions, reoperations, and mortality.
In the matched diabetes cohort, no significant differences were observed for intraoperative complications (OR 2.67, 95% CI 0.71–10.05, p = 0.132), 30-day readmissions (OR 1.07, 95% CI 0.52–2.22, p = 0.853), or 30-day mortality (OR 0.25, 95% CI 0.03–2.24, p = 0.180).
In the matched cardiovascular disease cohort, outcomes did not significantly differ for intraoperative complications (OR 2.50, 95% CI 0.49–12.89, p = 0.257), 30-day readmissions (OR 1.10, 95% CI 0.47–2.59, p = 0.827), or 30-day mortality (OR 0.50, 95% CI 0.05–5.51, p = 0.564).
Length of stay did not differ significantly between matched cardiovascular disease patients (mean 104.8 h) and controls (mean 98.8 h, p = 0.57), or between diabetes patients (mean 88.2 h) and controls (mean 92.4 h, p = 0.25).

Study Design

Type

Cohort (n=4,680)

Multicenter

No

Structured PICO

Does the presence of cardiovascular disease or diabetes increase the risk of short-term adverse surgical outcomes, readmissions, and mortality in adult patients undergoing single-level posterior-only lumbar fusion when matched for baseline demographic and procedural covariates?

P

Population

4,680 consecutive adult patients (4,263 analyzed; matched cohorts: n=192 for cardiovascular disease, n=380 for diabetes) undergoing single-level posterior-only lumbar fusion at a single US academic center, followed for 90 days.

E

Exposure

Single-level, posterior-only lumbar fusion in patients with cardiovascular disease (CHF, PVD, prior MI, or prior stroke; matched n=96) or diabetes (complicated or uncomplicated; matched n=190).

C

Comparator

Single-level, posterior-only lumbar fusion in patients with no medical comorbidities (measured by Charlson Comorbidity Index excluding age), matched 1:1 via coarsened exact matching on 10 covariates: gender, ASA grade, age, smoking history, insurance type, prior surgery, prior surgery in 30 days, length of surgery, BMI, and median household income (matched n=96 for CVD control; matched n=190 for diabetes control).

O

Outcome

Surgical (intraoperative) complications; length of stay; discharge disposition (home vs. non-home); and 30- and 90-day Emergency Department (ED) visits, readmissions, reoperations, and all-cause mortality.hard clinical

Main Result

Odds Ratio: 0.5 (95% CI 0.05–5.51)

p-value: p=0.564

When exactly matched for baseline demographic and clinical covariates such as age and ASA score, pre-existing cardiovascular disease and diabetes do not independently increase the risk of 30- or 90-day adverse outcomes following single-level lumbar fusion surgery.

Limitations

Retrospective analysis with selection bias of patients chosen for surgery
Single academic medical center and specific surgery type limiting generalizability
Relatively low baseline rates of adverse outcomes may limit statistical power
Short-term outcome time frame (30 and 90 days)
Retrospective analysis with potential selection bias of patients already chosen and optimized for surgery
Single-center study evaluating a very specific type of surgery (single-level posterior-only lumbar fusion)
Relatively low baseline rates of adverse outcomes, which may limit statistical power to detect small effects

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Implication

CVD and diabetes may not increase short-term risks after matched lumbar fusion; leaves open prospective confirmation of these null associations.

Abstract

Objectives: Comprehensive preoperative management involves the identification and optimization of medical comorbidities while avoiding excessive healthcare utilization. While diabetes and heart disease are major causes of morbidity that can worsen surgical outcomes, further study is needed to evaluate how well current perioperative strategies mitigate their risks. This study employs an exact matching protocol to isolate the effects of both diabetes and cardiovascular disease on spine surgery outcomes. Methods: 4680 consecutive patients undergoing single-level, posterior-only lumbar fusion were retrospectively enrolled. Univariate logistic regression was performed on comorbidity subgroups, then coarsened exact matching (CEM) was employed for patients with diabetes or cardiovascular disease. Patients were matched 1:1 on ten patient and procedural characteristics known to affect neurosurgical outcomes. Separate pairs of exact-matched cohorts were generated to isolate both cardiovascular disease (matched n = 192), and diabetes (matched n = 380). Primary outcomes were surgical complications; length of stay; discharge disposition (home vs. non-home); and 30- and 90-day Emergency Department (ED) visits, readmissions, reoperations, and mortality. Results: Cardiovascular disease and diabetes subgroups were not associated with short term outcomes after matching to control for confounders. Compared to univariate statistics, this method demonstrates that confounding control variables may drive outcomes more than these comorbidities themselves. Conclusion: Between otherwise exactly matched patients undergoing lumbar fusion, diabetes and cardiovascular disease posed no greater risk of short-term adverse outcomes. This suggests proper selection criteria for surgical candidates and effective current perioperative strategies to mitigate these common comorbidities. Further studies are warranted to assess and optimize the cost-effectiveness of preoperative management for patients with common comorbidities.

Discussion

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Cite This Study

Gallagher et al. (2024) conducted a cohort in Patients undergoing single-level, posterior-only lumbar fusion with diabetes or cardiovascular disease (n=4,680). Cardiovascular disease (CHF, PVD, prior MI, prior CVA) or diabetes mellitus (uncomplicated or complicated) vs. Coarsened exact matched (1:1) patients without medical comorbidities was evaluated on 90-day all-cause mortality (among multiple co-primary short-term surgical outcomes for cardiovascular disease cohort) (OR 0.50, 95% CI 0.05-5.51, p=0.564). Cardiovascular disease and diabetes were not associated with increased 90-day mortality (OR 0.50, p=0.564 and OR 0.25, p=0.180) or other short-term lumbar fusion outcomes after exact matching.

synapsesocial.com/papers/6a8432473b499be099c6b738 https://doi.org/10.1016/j.wnsx.2024.100410

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Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Diabetes and heart disease do not affect short-term lumbar fusion outcomes accounting for other risk factors in a matched cohort analysis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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