title: Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation.
abstract: BACKGROUND
  Repeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.
  
  
  OBJECTIVE
  To examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.
  
  
  METHODS
  Retrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.
  
  
  METHODS
  We identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.
  
  
  RESULTS
  Our cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2-3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9-10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8-19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4-2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8-7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3-15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.
  
  
  CONCLUSIONS
  Even after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.
authors.affiliation: Department of Orthopaedics, HB7541, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756-0001, USA. Brook.I.Martin@Dartmouth.edu
authors.forename: Brook I
authors.initials: BI
authors.lastname: Martin
authors.forename: Sohail K
authors.initials: SK
authors.lastname: Mirza
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Wickizer
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Heagerty
authors.forename: Alex F
authors.initials: AF
authors.lastname: Lenkoski
authors.forename: Richard A
authors.initials: RA
authors.lastname: Deyo
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019299:Decompression, Surgical / Q000706:statistics & numerical data*; D017586:Diskectomy / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D017116:Low Back Pain / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D012737:Sex Factors; D013123:Spinal Fusion / Q000706:statistics & numerical data*