1. Does Multidisciplinary Team Approach Improve Patient Outcomes: Impact of High-Risk Committee Inclusion on Adult Spinal Deformity Patient Outcomes

BACKGROUND CONTEXT High-risk committees have recently been instituted at many hospitals, in an effort to minimize operative risk and recruit a multidisciplinary discussion. Both surgical and medical risk factors can lead to the occurrence of adverse events and prolonged recovery course. Little consensus has been reached as to whether inclusion into high risk committees improve patient outcomes. PURPOSE To investigate impact of high-risk multidisciplinary committee on adult spinal deformity (ASD) patient outcomes after corrective surgery. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 560 ASD patients. OUTCOME MEASURES HRQL, Complications. METHODS Operative ASD patients (scoliosis >20°, SVA>5cm, PT>25°, or TK>60°) with available baseline (BL) and 2-year (2Y) data were included. Determination of high risk was assessed by inclusion in the Multidisciplinary Committee (HRC): BMI > 40; HgbA1c >8; Severe Scoliosis (>75°); Severe Kyphosis (> 75°); Anterior-posterior cervical fusion 3+ level; Anterior-posterior lumbar fusion 4+ levels; 8+ Level Instrumented Fusion; 3 Column Osteotomy, Vertebrectomy, and/or ACR; Revision of Anterior Approach to Same Level; Severe Myelopathy; Severe Osteoporosis. Patients stratified by high risk (HRC) vs not meeting criteria then propensity score matched for baseline Charlson Comorbidity Index. Baseline demographics including comorbidities, frailty and surgical invasiveness were tested by means comparison. Multivariable logistic regression controlling for baseline deformity and frailty index score used to assess rates of complications and revision surgery. RESULTS A total of 483 ASD patients met inclusion (64.5yrs±9.0, 78%F, BMI: 27.9 kg/m2 ±6.0, CCI: 1.9 ±1.7), with 331 meeting HRC inclusion after matching. With respect to baseline deformity, the NHRC was more deformed in SVA (69.6 vs 52.9mm, p=.003), PI-LL (18.4° vs 12.3°, p<.001), and PT (25.3° vs 22.0°, p<.001), with increasing surgical invasiveness score (p<.001). HRC patients underwent significantly less osteotomies, particularly 3CO, compared to NHRC (34% vs 65%, p.05). Both groups had comparable rates of mortality (p>.05). Patients not meeting HRC had higher rates of major (20% vs 9%), mechanical (20% vs 10%), and overall complications (65% vs 48%, all p<.05). Importantly, patients with HRC had significantly greater chances of experiencing cardiopulmonary complications 90 days after surgery (OR 2.33 [1.01, 1.68], p.05). CONCLUSIONS High-risk committees present surgeons with opportunity for improved multidisciplinary collaboration for perioperative optimization. However, our study found that the use of a high-risk committee does not predict reduced complications postoperatively and instead favors patients with less severe deformity without medical comorbidities, thus reducing the overall complexity of cases operated. Surgical planning preoperatively should focus instead on medical optimization through greater collaboration with nonsurgical physicians, such as cardiopulmonary specialists. FDA Device/Drug Status This abstract does not discuss or include any applicable devices or drugs. High-risk committees have recently been instituted at many hospitals, in an effort to minimize operative risk and recruit a multidisciplinary discussion. Both surgical and medical risk factors can lead to the occurrence of adverse events and prolonged recovery course. Little consensus has been reached as to whether inclusion into high risk committees improve patient outcomes. To investigate impact of high-risk multidisciplinary committee on adult spinal deformity (ASD) patient outcomes after corrective surgery. Retrospective cohort study. A total of 560 ASD patients. HRQL, Complications. Operative ASD patients (scoliosis >20°, SVA>5cm, PT>25°, or TK>60°) with available baseline (BL) and 2-year (2Y) data were included. Determination of high risk was assessed by inclusion in the Multidisciplinary Committee (HRC): BMI > 40; HgbA1c >8; Severe Scoliosis (>75°); Severe Kyphosis (> 75°); Anterior-posterior cervical fusion 3+ level; Anterior-posterior lumbar fusion 4+ levels; 8+ Level Instrumented Fusion; 3 Column Osteotomy, Vertebrectomy, and/or ACR; Revision of Anterior Approach to Same Level; Severe Myelopathy; Severe Osteoporosis. Patients stratified by high risk (HRC) vs not meeting criteria then propensity score matched for baseline Charlson Comorbidity Index. Baseline demographics including comorbidities, frailty and surgical invasiveness were tested by means comparison. Multivariable logistic regression controlling for baseline deformity and frailty index score used to assess rates of complications and revision surgery. A total of 483 ASD patients met inclusion (64.5yrs±9.0, 78%F, BMI: 27.9 kg/m2 ±6.0, CCI: 1.9 ±1.7), with 331 meeting HRC inclusion after matching. With respect to baseline deformity, the NHRC was more deformed in SVA (69.6 vs 52.9mm, p=.003), PI-LL (18.4° vs 12.3°, p<.001), and PT (25.3° vs 22.0°, p<.001), with increasing surgical invasiveness score (p<.001). HRC patients underwent significantly less osteotomies, particularly 3CO, compared to NHRC (34% vs 65%, p.05). Both groups had comparable rates of mortality (p>.05). Patients not meeting HRC had higher rates of major (20% vs 9%), mechanical (20% vs 10%), and overall complications (65% vs 48%, all p<.05). Importantly, patients with HRC had significantly greater chances of experiencing cardiopulmonary complications 90 days after surgery (OR 2.33 [1.01, 1.68], p.05). High-risk committees present surgeons with opportunity for improved multidisciplinary collaboration for perioperative optimization. However, our study found that the use of a high-risk committee does not predict reduced complications postoperatively and instead favors patients with less severe deformity without medical comorbidities, thus reducing the overall complexity of cases operated. Surgical planning preoperatively should focus instead on medical optimization through greater collaboration with nonsurgical physicians, such as cardiopulmonary specialists.