title: Insurance status and reportable quality metrics in the cervical spine fusion population.
abstract: The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown.
  
  
  
  This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events.
  
  
  
  This is a retrospective cohort design.
  
  
  
  All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included.
  
  
  
  Incidence of HAC and PSI from 1998 to 2011 served as outcome variables.
  
  
  
  We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC.
  
  
  
  We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort.
  
  
  
  Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA. Electronic address: joseph.tanenbaum@case.edu.
authors: Joseph E
authors: JE
authors: Tanenbaum
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9980 Carnegie Ave, Cleveland, OH 44195, USA.
authors: Jacob A
authors: JA
authors: Miller
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106, USA.
authors: Vincent J
authors: VJ
authors: Alentado
authors: Department of Neurosurgery, Johns Hopkins University School of Medicine, 855 N Wolfe St, Baltimore, MD 21205, USA.
authors: Daniel
authors: D
authors: Lubelski
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Anchorage Neurosurgical Associates, Inc., 3831 Piper St S450, Anchorage, AK 99508, USA.
authors: Benjamin P
authors: BP
authors: Rosenbaum
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA.
authors: Edward C
authors: EC
authors: Benzel
authors: Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
authors: Thomas E
authors: TE
authors: Mroz
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology*; D019458:Insurance Coverage; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D011787:Quality of Health Care; D013123:Spinal Fusion / Q000009:adverse effects / Q000191:economics / Q000592:standards*; D014481:United States
keywords: Affordable Care Act; Cervical fusion; Hospital-acquired condition; Insurance status; NIS; Patient safety indicator