Association of Safety-Net hospital status and hospital outcomes following ACDF or PCDF for CSM

Introduction: Safety net hospitals (SNH) serve a large proportion of patients with Medicaid or without insurance. However, few prior studies have addressed the impact of SNH status on outcomes following anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for cervical spondylotic myelopathy (CSM). The aim of this study was to assess the association between SNH status outcomes following ACDF or PCDF for CSM.

Methods: A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample Database. All adult patients (≥18 years old) undergoing elective ACDF or PCDF for CSM, identified using ICD-10-CM coding, were stratified by SNH status. Hospitals in the top quartile of Medicaid/uninsured patient admissions were defined as SNHs while all other hospitals were defined as Non-SNHs (N-SNHs). Patient demographics, treating hospital characteristics, comorbidities, operative variables, adverse events (AEs), LOS, discharge disposition, and costs were assessed. Multivariate analyses were performed to identify independent predictors of prolonged LOS, non-routine discharge disposition, and increased costs for ACDF and PCDF.

Results: Of the 49,945 study patients, 34,195 (68.5 %) underwent ACDF and 15,750 (31.5 %) underwent PCDF. Within the ACDF and PCDF cohorts, 8,025 patients (23.5 %) and 4,120 (26.2 %) were treated at SNHs, respectively. Mean LOS was significantly greater in the SNH cohorts for both procedures (ACDF: N-SNH: 2.43 ± 3.12 days vs SNH: 2.94 ± 4.13 days, p < 0.001; PCDF: N-SNH: 4.36 ± 4.28 days vs SNH: 5.41 ± 8.67 days, p = 0.002), as were mean costs (ACDF: N-SNH: $20,991 ± $12,126 vs SNH: $22,412 ± $15,302, p = 0.010; PCDF: N-SNH: $25,835 ± $16,812 vs SNH: $28,945 ± $29,166, p = 0.010). A significantly greater proportion of patients in the ACDF cohort treated at SNHs experienced non-routine discharges (N-SNH: 10.9 % vs SNH: 13.9 %, p = 0.006). On multivariate analysis for both procedures, SNH status was not significantly associated with extended LOS [ACDF: p = 0.097; PCDF: p = 0.158], non-routine discharge [ACDF: p = 0.288; PCDF: p = 0.246], or increased costs [ACDF: p = 0.664; PCDF: p = 0.593].

Conclusions: While our study found patients treated at SNHs with ACDF or PCDF for CSM had significantly longer mean LOS, greater mean costs, and increased non-routine discharge rates than N-SNHs, on multivariate analysis SNH status was not found to be independently associated with these adverse outcomes.