Hospital and surgeon variation in complications and repeat surgery following incident lumbar fusion for common degenerative diagnoses.
OBJECTIVE
To identify factors that account for variation in complication rates across hospitals and surgeons performing lumbar spinal fusion surgery.


METHODS
Discharge registry including all nonfederal hospitals in Washington State from 2004 to 2007.


METHODS
We identified adults (n = 6,091) undergoing an initial inpatient lumbar fusion for degenerative conditions. We identified whether each patient had a subsequent complication within 90 days. Logistic regression models with hospital and surgeon random effects were used to examine complications, controlling for patient characteristics and comorbidity.


RESULTS
Complications within 90 days of a fusion occurred in 4.8 percent of patients, and 2.2 percent had a reoperation. Hospital effects accounted for 8.8 percent of the total variability, and surgeon effects account for 14.4 percent. Surgeon factors account for 54.5 percent of the variation in hospital reoperation rates, and 47.2 percent of the variation in hospital complication rates. The discretionary use of operative features, such as the inclusion of bone morphogenetic proteins, accounted for 30 and 50 percent of the variation in surgeons' reoperation and complication rates, respectively.


CONCLUSIONS
To improve the safety of lumbar spinal fusion surgery, quality improvement efforts that focus on surgeons' discretionary use of operative techniques may be more effective than those that target hospitals.
The Geisel School of Medicine at Dartmouth, Hanover, NH 03756-0001, USA. Brook.I.Martin@Dartmouth.edu
Brook I
BI
Martin
Sohail K
SK
Mirza
Gary M
GM
Franklin
Jon D
JD
Lurie
Todd A
TA
MacKenzie
Richard A
RA
Deyo
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006739:Hospital Administration / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008483:Medical Assistance / Q000706:statistics & numerical data; D008875:Middle Aged; D019636:Neurodegenerative Diseases / Q000601:surgery*; D009985:Orthopedics / Q000379:methods / Q000706:statistics & numerical data*; D061214:Patient Safety; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D058996:Quality Improvement / Q000458:organization & administration; D012086:Reoperation; D012720:Severity of Illness Index; D012737:Sex Factors; D013123:Spinal Fusion / Q000009:adverse effects* / Q000379:methods; D013997:Time Factors; D014861:Washington