Discharge home or a postop facility? What does the data show?
A new, multi-center study has generated new data about longer term post op facilities for adult spinal deformity patients. Their work, “Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery,” appears in the May 1, 2024 edition of Spine.
“This paper emanated from ongoing research by the International Spine Study Group,” stated co-author Pierce Nunley, M.D., director of the Spine Institute of Louisiana, to OTW. “There has been a longstanding question of the utility of non-home discharge vs home discharge. We were part of the Medicare Bundle program that shed a light on the high costs of overutilization and began to find ways for patients to be able to transition from the hospital directly to a home environment.”
“Combined with heightened awareness surrounding the COVID pandemic, we believed there may not be as much a need for rehab and skilled nursing facilities and therefore queried out prospective database to see the results.”
The researchers looked at surgically treated adult spinal deformity patients who were prospectively enrolled in a multicenter study, assessing them for “non” or “home” status following hospital discharge. “Non” was further divided into “rehab” or “skilled nursing facility.” They then matched “non” patients to “home” patients, leaving 158 patients for evaluation.
Dr. Nunley: “The study was conducted at 11 centers with 18 surgeons that worked with the patients, therapists, and social workers to determine the best discharge placement. It is important to point out that we used propensity score matching to match the identified non-home and home patients to reduce the influence of confounding variables.”
Patients in the “non” and “home” had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay. Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for “non” versus “home” and similar for “rehab” (N=64) versus skilled nursing facility (N=42) versus “home”. At 1-year and minimum 2-year follow-up points, those in the “home” group demonstrated similar to better patient-reported outcome scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus “non”, “rehab”, and skilled nursing facility.
“There does not appear to be a clear benefit of non-home discharge after adult spinal deformity surgery,” said Dr. Nunley to OTW. “Note that this study was not randomized, thus some of the data was not as granular as we would like. We clearly believe that certain patients need to discharge to skilled nursing facility and rehab, so the message is not to have this paper be used for denial of care.”
“It used to be ‘one size fits all’ and most adult spinal deformity patients would go to rehab. This is no longer necessary. The message is really to individualize each discharge and work more actively to see if the patient is able to be discharged safely home. That takes the surgeons being actively involved in these expectations starting before surgery during the surgical consultation. Setting these expectations with the patients and very importantly, the family as well, is crucial.”
