Variations in Surgical Practice and Short-term Outcomes for Degenerative Lumbar Scoliosis and Spondylolisthesis: Do Surgeon Training and Experience Matter?

Abstract

Abstract Background For diverse procedures, sizeable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. Methods This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-2019. Using data (ICD-10-CM, CPT codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion, a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications, readmissions). Next, we tested for associations between surgeon training (specialty, spine fellowship) and experience (career stage, operative volume) and use of instrumented fusion as well as outcomes. Results Eighty-nine surgeons performed 2,481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopaedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis (49% vs. 33%, odds ratio [OR]=2.3, 95% confidence interval [95% CI] 1.3-4.2, p-value=0.006), as were fellowship trained surgeons (49% vs. 25%, OR=3.0, 95% CI 1.6-5.8; p=0.001)). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR 1.1, 95% CI 1.0-1.2, p<0.05 for both diagnoses) and had lower rates of major in-hospital complications (OR=0.91, 95% CI 0.85- 0.97; p=0.006). Conclusion Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons’ practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons’ careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education.