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- Title
Evaluation of the Effectiveness and Efficiency of Two Hemostatic Utilization Strategies in Cervical and Lumbar Fusion Procedures.
- Authors
De Nava, Manuel G. Ramirez Lopez; Deutsch, Harel; Khanna, Nitin
- Abstract
Introduction: Bleeding is an anticipated consequence of surgical procedures. In spine surgery the need for effective and rapid bleeding control is critical in maintaining the surgeon's ability to visualize the field and avoid complications such as nerve injury and dural tears. During the past few decades, cervical and lumbar fusion procedure rates have escalated rapidly and now constitute 52% and 39%, respectively, of the 470 000 spine fusion procedures performed in 2011 (http://www.hcup-us.ahrq.gov/nisoverview.jsp). Given the high prevalence of cervical/lumbar procedures and the escalating costs of healthcare, there is increasing pressure on stakeholders to improve the efficiency of care and achieve cost containment through reductions in surgical time, transfusion need/utilization, hospital days, and perioperative morbidity. Hemostatic agent(s) selection is based on a number of factors with surgeons' often choosing between a flowable agent such as Floseal only (FO) or in combination with gelatin and thrombin (F+G/T). Specifically, some tend to utilize FO while others utilize other hemostatic agents initially and reserve their use of Floseal as a "last line of defense" when other agents fail to provide adequate hemostasis. Across a broad list of ICD-9 coded spine surgeries, a recent large retrospective database analysis of 15 105 propensity score-matched cases found significant clinical and economic advantages to the use of FO as compared to F+G/T (Ikeme et al. 2017). Data subanalyses were performed to identify the potential clinical and economic implications of these findings in cervical/lumbar procedures. Material and Methods: Cervical or lumbar fusion procedures (ICD 81.00, 81.02, 81.03, 81.30, 81.32, 81.33, 81.04-0.8, 81.34-38) performed between October 2010 and September 2015 with charges for FO or F+G/T were identified from the Premier's United States Perspective Hospital Database. Propensity-score match (1:1) was performed to match each F0 subject with a F+G/T subject and minimize treatment bias. Data were extracted to compare outcome variables of blood product administration (ie, intra-, peri-, and post-operative transfusion, pure blood/packed red blood cell transfusions), complication outcomes (ie, blood loss-related, severe, or other complications), and healthcare resource utilization (ie, hospital length-of-stay [LOS], surgery time, hemostat volume). Results: 14 021 cervical/lumbar FO and F+G/T matched pairs were compared. The FO compared with the F+G/T cohort exhibited significantly (p < 0.0001) lower rates of intraoperative transfusion (1.3% vs. 2.4%), perioperative transfusion (1.5% vs. 2.8%), postoperative transfusion (1.6% vs. 3.0%), and pure-blood/pRBC transfusion (2.2% vs. 4.3%). No between-cohort differences were observed in blood-loss complications, severe complications, or other complications. Healthcare resource utilization was significantly (p < 0.0001) lower in the FO vs. F+G/T cohort, with a mean reduction in hospital stay of 0.5 days, a 38-minute reduction in surgery time, and a 12-mL reduction in hemostat volume. Conclusion: In cervical/lumbar fusion cases, these findings indicate that the use of Floseal alone as compared to its use with Gelatin/Thrombin is associated with significant clinical benefits including less transfusion utilization and economic benefits of reduced hospital length-of-stay, surgery time, and hemostat volume use. These findings have significant implications for patient outcomes and healthcare cost, hence the need for well-controlled, clinical and cost-consequence studies to further elucidate these preliminary findings is necessary.
- Publication
Global Spine Journal, 2018, Vol 8, p170S
- ISSN
2192-5682
- Publication type
Article
- DOI
10.1177/2192568218771030