Nationwide study of risk factors for reoperation after surgical treatment for degenerative spinal disease in Poland

doi:10.21203/rs.3.rs-1613331/v1

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Nationwide study of risk factors for reoperation after surgical treatment for degenerative spinal disease in Poland

https://doi.org/10.21203/rs.3.rs-1613331/v1

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Background

The aim of the study is to evaluate the reoperation rate after surgical treatment for degenerative spinal diseases (DSD) in Poland and to identify risk factors for reoperation, including comorbidities and other variables.

Methods

A retrospective analysis of hospitalisations in 2018 that were reported to the National Health Fund (NHF) using ICD-10 codes: M43.1, M47, M48, M50, M51, M53 and Diagnosis Related Group (DRG) codes: A22, A23, A27, H51, H52, H53, H55. Reoperations were identified using the same codes provided that they were reported within 365 days after discharge. The analysis involved demographic factors and patient multimorbidity. A logistic regression model was then performed to assess risk factors for reoperation.

Results

In 2018, 38,953 surgical hospitalisations for DSD were reported. A total of 3,942 hospitalised patients (10.12%) needed reoperation within 365 days. Patients requiring reoperation were predominantly women (1.34:1) and the elderly (mean age: 56.66 vs. 53.24). The percentage of reoperations correlated with the multimorbidity rate (from 8.81–15.31%). The risk of reoperation was most increased by concomitant depression, neurological diseases, obesity and older age. The risk of reoperation was reduced by instrumented spinal surgery, operations in a neurosurgical department and hospitalisations other than day-surgery.

Conclusions

Reoperations within the first year of surgical treatment for DSD are common. Identification of risk factors for reoperation, including those related to the presence of comorbidities and the phenomenon of multimorbidity, can be an important tool in reducing the reoperation rate.

degenerative spinal disease

multimorbidity

reoperation

risk factors

spine surgery

Degenerative spinal disease (DSD) is one of the most common musculoskeletal disorders and leading causes of sickness absenteeism. It also contributes significantly to the global burden of disease worldwide. The results of the 2017 Global Burden of Disease Study indicate that low back pain has been and still is the leading cause of disability worldwide [1]. DSD, due to its generation of pain, reduction in physical function and chronic course, significantly reduces patients' quality of life. The treatment of DSD patients is a heavy burden for the healthcare system, including primary healthcare, specialised outpatient healthcare, inpatient treatment and rehabilitation treatment. Low back pain, which is the most common clinical manifestation of DSD in 2000 in the United Kingdom, was the most common single cause of sickness absenteeism, accounting for 12.5% of all days of incapacity for work [2].

According to an analysis of the causes of sickness absenteeism in Poland in 2012–2016, conducted by the Social Insurance Institution, musculoskeletal and connective tissue disorders (which include DSD) were the second cause of sickness absenteeism after pregnancy, childbirth and puerperium. Those diseases accounted for 15.3% of total days of absenteeism, showing a marked increase in the years analysed. The costs of treating DSD consist of both direct medical care costs and indirect costs associated with, among other things, job loss, change of job position, lower income, decreased productivity, restrictions in activities, disability, decreased quality of life, etc. [2]. The lifetime prevalence of complaints associated with DSD is estimated to be up to 80% [2]. The point prevalence rate and annual prevalence rate for low back pain in the general population are estimated to be 18.3% and 38%, respectively [3]. According to analyses conducted as part of the "Maps of Health Needs" project in 2014, 462,000 cases of DSD were reported in Poland. The reported DSD incidence rate was 1.2% and the reported DSD prevalence rate (cases reported from 2009 to 2014) was 9.2%. In 2014, 68,000 hospitalisations for DSD were reported in Polish hospitals. A total of 1001,000 DSD patients were treated and 2004,000 medical consultations were provided. These data refer to services reimbursed by the National Health Fund of Poland (NHF); they do not include services funded from other sources (non-public funds), thus the final rates are underestimated in Poland.

DSD is the most common reason for all spine surgeries [4]. Given the type of lumbar spine pathology in surgically treated patients, the most common indications for surgery in the world include degenerative disc disease (discopathy), spinal canal stenosis and spondylolisthesis, respectively [5]. The data obtained from the "Maps of Health Needs" project (2014) showed that in Poland, out of 68,000 hospitalisations of DSD patients, hospitalisations combined with surgical treatment were 50.1%. Surgical treatment may reduce pain, improve quality of life and overall fitness in many patients, however, it is associated with a risk of complications and adverse events. Surgeries performed for DSD are the most frequently performed surgeries worldwide and they are usually performed several times in the same patient (reoperations) [6, 7]. The dynamic development of spine surgery is due in part to the introduction of several instrumentation systems (spinal implants) on the market. For example, a 220% increase in spinal surgeries using spondylodesis in the USA for the period 1990–2001 is linked to the acceptance of implants, known as intervertebral cages [2].

DSD is an age-dependent disease; in the aging population there is an increase in the percentage of DSD patients. The development of comprehensive medical care, the increase in its availability and advances in anaesthesiology and rehabilitation, combined with the aforementioned demographic phenomenon, result in a systematic increase in the average age of DSD patients eligible for surgery. According to the multicentre analysis from Japan for the period 2004–2015, based on more than 46,000 spine surgeries, there was an increase in the age of operated patients (by approximately 10 years), the percentage of operated patients aged > 70 years, the number of patients operated on DSD, and the number of reoperations [4].

The effectiveness and safety of surgical treatment for DSD are affected by appropriate eligibility of the patient for surgery, their general health status (medical risk factors), experience and knowledge of the surgeon, type of medical equipment in the treatment centre, postoperative care, rehabilitation. Additional factors include psychological, social, economic and occupational determinants of the patient. Given the prevalence of DSD and its social and economic consequences, it is crucial to monitor the quality of treatment for DSD. The reoperation rate is one of indicators of the quality of treatment in surgery. The reoperation is a subsequent, unplanned surgical intervention. It may involve surgical intervention at the same site, at a different site but due to the same condition or repair of complications resulting from the primary surgical procedure [8]. An additional burden of other health problems (multimorbidity) may carry an increased risk of surgical failure in DSD patients, including the need for reoperation. According to the World Health Organization definition, multimorbidity means the co-occurrence of two or more chronic health problems in one person [9]. Multimorbidity is considered a potentially important adverse predictor in DSD patients treated with surgery, however, there is a small number of publications regarding this topic. Their interpretation and, above all, reference to specific outcomes are impeded by the fact that authors use different methods to assess multimorbidity, and their analyses cover a wide range of degenerative spinal disorders (spinal disc herniation, spinal stenosis, spondylolisthesis) treated with various surgical techniques. The overall health status before surgery is a predictor of the clinical outcome of surgery and patient satisfaction [10]. According to the study by Foulongne et al., low multimorbidity (assessed using the Charlson Comorbidity Index) is the only predictor of successful outcome after decompressive laminectomy in patients with lumbar spinal stenosis [11]. Multimorbidity as expressed by the American Society of Anesthesiologists (ASA) Physical Status Score predicts not only treatment outcome and patient satisfaction but also the risk of surgical and general complications after surgery [12].

This study aims to evaluate the reoperation rate after surgical treatment for DSD in Poland and to identify risk factors for reoperation, including comorbidities and other variables.

The following study is a retrospective analysis of adult patients operated on for DSD in 2018 in Poland. The study group was pre-identified provided that patients were hospitalised with a principal diagnosis of DSD defined by ICD-10 codes in accordance with the International Statistical Classification of Diseases and Related Health Problems ICD-10: M43.1, M47, M48, M50, M51, M53 with extensions. Then it was verified whether the patients' hospitalisation was reported using one of diagnosis-related group (DRG) codes: A22, A23, A27, H51, H52, H53, H55. A group of patients meeting both aforementioned conditions was defined as the study group. The group of reoperated patients was identified by the same ICD-10 and DRG codes provided that they were reported not later than 365 days after the end of the primary hospitalisation. The analysis used NHF data concerning the reported inpatient, outpatient, primary healthcare, psychiatric and addiction treatment services, i.e., services reported to the payer in 2017–2019 and relating to prescriptions purchased during the corresponding period. Information concerning patient deaths for the period 2018–2019 was released by the Ministry of Administration and Digitization.

Several risk factors that have a potential impact on the risk of reoperation were defined based on the literature review and the knowledge and experience of a medical expert. Factors related to medical history and pertaining to the patient's demographic profile were included in the analysis as was the profile of the facility where the patient was hospitalised. The first group of risk factors includes variables whose definitions were taken from the article by Elixhauser et al. [13]; they are also included in the Elixhauser Comorbidity Index. The last group of risk factors, the facility profile, includes information concerning, e.g., the range of services provided at the facility, the presence of specific departments or the facility's classification as a teaching hospital.

The statistical analysis included constructing a logistic regression model in which a response variable concerned reoperation for DSD within 365 days of the discharge from hospitalisation associated with the primary surgery, according to explanatory variables. The qualitative variables used in the analysis were recoded for the correct model construction using one-hot encoding. To eliminate the problem of strong multicollinearity, the effect of VIF coefficients was verified and the Pearson's linear correlation coefficients were analysed, as well as the correlation values of any monotonic relationship (including nonlinear relationship) by calculating the Spearman's rank correlation coefficients. The Akaike information criterion algorithm was used for identification of the model that best fits the data and for extraction of explanatory variables that have the greatest impact on the response variable. The model parameters were estimated using the maximum likelihood estimation. Variables found to be very rare among the analysed cohort were excluded from the analysis. To ensure the evaluation of the quality of the model and to control its level of fit to the data, the considered set of observations was randomly divided into a learning (70%) and a testing (30%) part. The quality of the resulting classifiers was evaluated using the Area Under ROC Curve (AUC) measure. The logistic regression analysis resulted in odds ratios (OR) that were calculated together with a 95% confidence interval (CI). P-values less than 0.05 were considered statistically significant. The analysis was performed using Python (version 3.6.5) and R (version 3.6.1) programmes.

This study is part of a project implemented by the Ministry of Health, "Maps of health needs", co-financed by the European Union through the European Social Fund under the Operational Programme Knowledge Education Development (EU grant number: POWR 05.02.00-00-0149/15 − 01). The study was conducted in accordance with the tenets of the Declaration of Helsinki with respect to research involving human subjects. The approval of the Bioethics Committee was not necessary. The study protocol was approved by the Polish Ministry of Health, which is authorised under the law of the Republic of Poland to process NHF data.

There were 38,953 surgical hospitalisations for DSD reported in 2018. Patients of 3,942 hospitalisations (10.12%) needed reoperation not later than 365 days after the hospital discharge (Fig. 1). Figure 2 shows the differences in terms of age distributions compared to surgical hospitalisation for DSD. The mean patient age in the analysed group was 53.59 years. The mean age of patients who underwent reoperation up to one year after hospital discharge was 56.66 years, and the mean age of patients who did not need reoperation was 53.24 years. Figure 3 shows that women were more likely to undergo surgery for DSD than men (134 women compared to 100 men). The mean age of women who needed reoperation was 57.42 years and that of men was 55.62 years. The likelihood of no reoperation decreased evenly within consecutive days of the primary surgery (Fig. 4).

Table 1 shows comorbidities in patients undergoing surgical hospitalisations for DSD. The most common comorbidities in the study group included spontaneous hypertension (12.58% of patients), diabetes mellitus (11.41% of diabetic patients treated with oral medications and 3.14% of diabetic patients treated with insulin) and chronic respiratory diseases (6.15%). The highest reoperation rate was reported for patients with severe malnutrition (24%), lymphomata and haematological cancers (21.13%), however, the number of patients with these diseases was low thus they were not included in the model. The lowest reoperation rate included patients with HIV infection (0%), iron-deficiency anaemia (5.26%) and psychotic disorders (3.16%). There was also an increasing reoperation rate according to the number of diagnosed comorbidities. In the group of patients without comorbidities, the reoperation rate was 8.81%. When patients suffered from 1 or 2 comorbidities, the reoperation rate increased to 11.33%, and when they suffered from at least 3 comorbidities, the rate was 15.31%.

Table 1

Distribution of variables in the study group.
Variable	Number of observations for a given disease	Percentage of patients in the entire study group	The percentage of patients with a certain condition who underwent reoperation within 365 days of the end of the initial hospitalisation
Comorbidity variables
Spontaneous hypertension	4899	12.58%	12.37%
Diabetes treated with oral medications	4443	11.41%	11.77%
Chronic respiratory diseases	2397	6.15%	13.43%
Hypothyroidism	1772	4.55%	11.79%
Depression	1673	4.29%	14.76%
Arrhythmias	1547	3.97%	14.29%
Hypertension associated with organ damage	1304	3.35%	14.19%
Diabetes treated with insulin	1225	3.14%	12.33%
Non-metastatic cancers	1174	3.01%	12.78%
Arthropathies and connective tissue diseases	1152	2.96%	14.15%
Peripheral vascular diseases	1025	2.63%	14.54%
Neurological diseases	748	1.92%	14.71%
Heart failure	520	1.33%	13.85%
Obesity	483	1.24%	15.11%
Alcoholism	463	1.19%	8.42%
Liver diseases	441	1.13%	13.38%
Paralytic syndromes	433	1.11%	7.39%
Renal failure	340	0.87%	12.94%
Valvular heart defects	302	0.78%	13.25%
Drug use	177	0.45%	15.82%
Water-electrolyte imbalance	109	0.28%	14.68%
Coagulopathies	101	0.26%	15.84%
Nutritional-deficiency anaemia	96	0.25%	13.54%
Psychotic disorders	95	0.24%	3.16%
Lymphomata and haematological cancers	71	0.18%	21.13%
Peptic ulcers without bleeding or perforation	62	0.16%	8.06%
Pulmonary circulatory disorders	53	0.14%	9.43%
Metastatic cancers	43	0.11%	18.60%
Iron-deficiency anaemia due to blood loss	38	0.10%	5.26%
Nicotinism	31	0.08%	6.45%
Malnutrition and abnormal weight loss	25	0.06%	24.00%
Disease caused by HIV	3	0.01%	0.00%
Demographic variables
Male	18020	46.26%	9.32%
age: 50–59 years	9329	23.95%	10.30%
age: 60–69 years	9087	23.33%	11.16%
age: 70–79 years	4139	10.63%	13.82%
age: 80–89 years	984	2.53%	16.36%
Place of residence: countryside	13698	35.17%	8.74%
Facility profile
Clinical centres	12323	31.64%	8.51%
Operations performed in a neurosurgical department	27921	71.68%	8.27%
Operations performed in ab orthopaedic department	8324	21.37%	11.65%
Other variables
Surgeries with an implant	15034	38.60%	6.60%
Emergency admission to hospital	6492	16.67%	9.33%
Hospitalisation lasting 1–2 days	4518	11.60%	12.37%
Hospitalisation lasting 3 days	7071	18.15%	6.70%
Hospitalisation lasting 4–7 days	14903	38.26%	6.25%
Hospitalisation lasting more than 7 days	8079	20.74%	7.40%

Table 2 shows 24 variables that were included in the logistic regression model. Other variables were eliminated during initial stages of the analysis. The variables that most strongly increase the likelihood of reoperation include those reporting depression (OR = 1.507, Fig. 5), neurological diseases (OR = 1.426), obesity (OR = 1.401, Fig. 6) and hypertension associated with organ damage (OR = 1.253). Other significant variables that increase the likelihood of reoperation include age (highest likelihood of reoperation for patients aged 70–79 compared to those aged 18–49; OR = 1.225, Fig. 7) and the profile of the facility where the operation was performed (higher likelihood for clinical centres compared to non-clinical ones, OR = 1.101).

Table 2

Results of the logistic regression analysis (AUC for the learning set = 0.687, AUC for the test set = 0.69).
Variable	Coefficient	OR	2.5% OR	97.5% OR	p-value
Metastatic cancers	0.562	1.754	0.677	4.544	0.247
Depression	0.410	1.507	1.266	1.795	< 0.001*
Neurological diseases	0.355	1.426	1.105	1.841	0.006*
Obesity	0.337	1.401	1.019	1.926	0.038*
Hypertension associated with organ damage	0.225	1.253	1.019	1.541	0.033*
Patients aged 70–79	0.203	1.225	1.063	1.412	0.005*
Patients aged 60–69	0.180	1.197	1.070	1.339	0.002*
Patients aged 50–59	0.177	1.194	1.069	1.334	0.002*
Emergency admission to hospital	0.109	1.115	0.995	1.250	0.061
Liver diseases	0.107	1.113	0.777	1.595	0.558
Peripheral vascular diseases	0.105	1.111	0.880	1.403	0.378
Clinical centres	0.096	1.101	1.000	1.213	0.049*
Patients aged 80–89	0.019	1.020	0.805	1.291	0.872
Spontaneous hypertension	-0.048	0.953	0.842	1.079	0.445
Place of residence: countryside	-0.147	0.864	0.790	0.944	0.001*
Surgery with an implant	-0.202	0.817	0.738	0.903	< 0.001*
Operations performed in a neurosurgical department	-0.322	0.724	0.662	0.792	< 0.001*
Constant	-0.779	0.459	0.408	0.516	< 0.001*
Psychotic disorders	-0.880	0.415	0.125	1.380	0.151
Hospitalisation lasting 1–2 days	-1.071	0.343	0.298	0.394	< 0.001*
Iron-deficiency anaemia due to blood loss	-1.281	0.278	0.035	2.174	0.222
Hospitalisation lasting more than 7 days	-1.564	0.209	0.182	0.241	< 0.001*
Hospitalisation lasting 3 days	-1.661	0.190	0.164	0.220	< 0.001*
Hospitalisation lasting 4–7 days	-1.761	0.172	0.152	0.195	< 0.001*

Variables that reduce the likelihood of reoperation include the place of residence (lower likelihood of reoperation in patients living in rural areas compared to those living in urban areas, OR = 0.864), surgery with an implant compared to surgery without an implant (OR = 0.817, Fig. 8), performance of the primary surgery in a neurosurgical department (OR = 0.724) compared to other departments) and 1-2-day, 3-day, 4-7- day or > 7-day hospital stays compared to a one-day surgery (OR = 0.343, 0.19, 0.172 and 0.209, respectively). A detailed analysis of one-day surgeries, which is the reference group for the variables reporting other hospital stays, showed that out of 4,382 operations in this group, 4,324 (98.7%) operations were assessed according to DRG code H55 (arthroscopic and percutaneous spine procedures).

Thanks to the performed analyses, it is possible to conclude that there is a relationship between demographic data, clinical variables defined by Elixhauser, additional variables created for the purpose of this study and the risk of reoperation within 365 days of the hospital discharge after primary surgery for DSD. The reoperation rate for all 38,953 observations was 10.12%. When analysing the distribution of comorbidity variables, it can be observed that the reoperation rate ranged from 3.16–21.13% (Table 1). Based on observations obtained from hospital discharges in Washington State (USA) for the period 1997–2007, Martin et al. estimated the reoperation rate for the period of 1 year after lumbar disc herniation surgery (one of the most common surgeries performed on the spine) to be 6.4% (range from 2.8–12.5%). The risk of reoperation was higher in women and patients with multimorbidity [14].

The logistic regression analysis provided several interesting and practically important observations. There were variables that increased as well as decreased the risk of reoperation. The variables that are associated with a statistically significant increase in the risk of reoperation include:

a) demographic variables

Older age is one of the strongest predictors of reoperation; this is especially true for patients aged 70–79 (OR = 1.225). Park et al., in their study concerning the risk of reoperation for lumbar spondylosis after spinal decompression surgery using different methods of spinal instrumentation (implants), found an association between reoperation and older age / male sex [15]. In contrast, Pereira et al. [16] in their 24-month study found no association between older age and the risk of reoperation in patients with lumbar DSD. However, the risk of reoperation increased significantly with the extent of surgery (the risk was higher for operations involving more than three spinal segments) [16]. With age, there is an increase in the number of health problems and in the sensitivity of the body to adverse effects of external factors while there is a decrease in adaptive capacity of the body and capacity of individual organs and systems. In view of the increasing proportion of elderly patients receiving surgical treatment for DSD worldwide, it is expected to be an increasing number of adverse events, including reoperations in facilities providing healthcare for these patients. Surgical treatment for DSD in elderly patients provides an opportunity for many of them to relieve pain, return to daily activities and regain independence. Reduction of adverse events in elderly patients undergoing surgery is favoured by optimal rebalancing of their health status before the planned operation – operating on patients classified as 1 or 2 on ASA scale [16].

b) clinical variables according to the Elixhauser classification

Depression was a strong risk factor for reoperation, increasing its likelihood by more than 50%. Depression is one of the most important risk factors for persistent postoperative pain (PPS) in spinal surgery [17]. Persistent pain, which negatively affects satisfaction with the outcome of the primary spine surgery, may result in more frequent patient eligibility for reoperation. The possibility of the feedback between DSD and depression should be noted; it is thought that reduced physical fitness (frequently faced by DSD patients) may result in depression and other affective disorders [18]. Maintaining physical activity in older age may reduce the risk of depression and improve self-esteem [9]. Hence, proper treatment of depression may reduce its negative impact on the musculoskeletal system. On the other hand, effective treatment (including surgical one) of DSD symptoms may reduce the incidence or severity of depression and improve quality of life. Obesity was found to be another strong risk factor for reoperation (OR = 1.401). Goyal et al.'s meta-analysis of 32 studies involving 23,415 patients showed that in patients undergoing lumbar spine surgery, obesity increased the risk of complications (OR = 1.34) and reoperation (OR = 1.40). Minimally invasive surgery was not reported to have worse outcomes in obese patients [19]. The increased risk of postoperative complications, including surgical site infection and reoperation in obese patients, may be due to higher level of surgical invasiveness, longer duration of surgery or higher intraoperative blood loss in obese patients [19, 20].

c) other variables

Patients operated on at a clinical centre had higher likelihood of reoperation (OR = 1.101). This observation may be a result of both the higher degree of difficulty of primary surgeries performed at these centres and the generally higher degree of "complexity" of cases. It would be useful to compare the characteristics of patients treated in clinical centres and non-clinical ones, including the surgical techniques used.

The variables that are associated with a statistically significant decrease in the risk of reoperation include:

a) demographic variables

The patient's place of residence is correlated with the risk of reoperation, which is lower for those living in rural areas (OR = 0.864). According to epidemiological data, there is no difference in terms of the prevalence of low back pain in urban and rural residents [3]. The variety of reoperation rates may be rooted in the availability of specialty services, differences in terms of overall health status and socioeconomic conditions, including motivation to working life.

b) other variables

Surgery with an implant was associated with a lower risk of reoperation compared to surgery without an implant (OR = 0.817). This result can be explained by the relatively short follow-up period of 365 days from the date of hospital discharge after the primary surgery. In long-term postoperative follow-up, the use of implants is generally associated with an increased rate of reoperation, contrary to the study presented here [21]. A systematic review conducted by Lang et al. showed similar reoperation rates for decompression alone or decompression plus fusion surgeries for degenerative lumbar diseases. The authors point out, however, that the most common cause of reoperation after spinal decompression surgery is disease of the same spinal segment, whereas reoperation after fusion surgery is most frequently caused by adjacent segment disease [22].

Surgical treatment performed in a neurosurgical department was associated with a lower risk of reoperation compared to surgical treatment performed in another department (OR = 0.724). The study by Seicean et al. found no differences in terms of postoperative complications and reoperation rate after spine surgeries performed by neurosurgeons and orthopaedists; however, the follow-up period was only 30 days in the aforementioned study [23]. In this study, 27,921 (71.7%) patients were treated in the neurosurgical department and 8,324 (21.4%) patients were treated in the orthopaedic department. It is difficult to clearly interpret the observed differences between the aforementioned departments. It is possible that the complexity of spinal disease and thus the extent and scope of surgery for patients operated on in orthopaedic departments are greater (coexisting scoliosis, multilevel spinal instability, etc.), which may be the reason for more frequent reoperations.

Length of hospital stay is a clear predictor of reoperation. The reference point for 1-2-day, 3-day, 4-7-day and > 7-day hospital stays was a one-day surgery, for which the reoperation rate was the highest. The high risk of reoperation in patients who underwent one-day surgery may be explained by the surgery profile. A detailed analysis of one-day surgery cases, which is the reference group for the variables reporting other hospital stays, showed that out of 4,382 operations in this group, 4,324 (98.7%) operations were assessed according to DRG code H55 (arthroscopic and percutaneous spine procedures). These include minimally invasive surgeries such as endoscopic discectomy, IDET, vertebroplasty and thermolesion of intervertebral joints. The reoperation rate in this group of patients may be linked to the limited or short-term effectiveness of surgical procedures. This is especially true in the case of thermolesion or IDET, the main purpose of which is symptomatic management of the pain associated with spinal disease, rather than treatment of the cause of the complaint. The risk of reoperation for > 24h hospitalisations is lower, with the lowest values for 4-7-day hospital stays (OR = 0.172) and the highest values for 1-2-day hospital stays (OR = 0.343).

The presented study is the first such large-scale study concerning reoperation after surgery for DSD in Poland. This is a nationwide survey; the data were obtained from central sources, from the only public payer in Poland - NHF. The analysis included data concerning all publicly funded medical services of patients during the one-year period preceding the primary surgical treatment, which increases the likelihood of identifying comorbidities.

This study has also limitations. This is a retrospective study based on reported data rather than a review of medical records. It is possible that many factors (nicotinism, alcohol, obesity, etc.) are underestimated compared to prospective studies. The subclassification in the anatomical sense (cervical spine, lumbar spine, etc.) and in the pathological sense (spinal stenosis, instability, spinal disc herniation, etc.) is not taken into consideration, and the postoperative follow-up period is 12 months.

Reoperations within the first year after surgical treatment for DSD are common. Identification of risk factors for reoperation, including those related to the presence of comorbidities and the phenomenon of multimorbidity, can be an important tool in reducing the reoperation rate. This is particularly true for chronic diseases where appropriate medical management may enable the patient to be optimally prepared for surgery, minimising the risk of reoperation. When there are several strong risk factors for reoperation, it may be prudent to forgo surgical treatment. It is advisable to plan prospective studies concerning risk factors for reoperation after spine surgery with a longer follow-up period.

DSD - degenerative spinal disease

NHF - National Health Fund of Poland

ASA - American Society of Anesthesiologists

ICD - International Statistical Classification of Diseases and Related Health Problems

DRG - diagnosis-related group

AUC - Area Under ROC Curve

OR - odds ratio

CI - confidence interval

Ethics approval and consent to participate: The study was conducted in accordance with the tenets of the Declaration of Helsinki with respect to research involving human subjects. The approval of the Bioethics Committee was not necessary. The study protocol was approved by the Polish Ministry of Health, which is authorised under the law of the Republic of Poland to process NHF data.
Consent to publish: Not applicable.
Availability of data and materials: NHF data contains confidential patient information and cannot be deposited in publicly available repositories due to local data protection laws. To access the data, please contact the Polish Ministry of Health by sending an email to: [email protected]
Competing interests: The authors declare that they have no competing interests.
Funding: This study is part of a project implemented by the Ministry of Health, "Maps of health needs", co-financed by the European Union through the European Social Fund under the Operational Programme Knowledge Education Development (EU grant number: POWR 05.02.00-00-0149/15-01).
Authors' Contributions: J.S., A.K, and M.K. conceived and designed the experiments. Data was collected by A.K. The analysis was conducted by M.Ż., A.K. and J.S. The first and final drafts were written by J.S., M.Ż., A.W.-Ś., K.K.-K., K.O. and J.G.-L. All authors have approved the submitted version of the manuscript. All authors have agreed both to be personally accountable for the author's own contributions and ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Acknowledgements: Not applicable

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Editorial decision: Reject after review
20 Jul, 2022
Reviewers invited by journal
28 Jun, 2022
Editor invited by journal
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Editor assigned by journal
12 May, 2022
First submitted to journal
01 May, 2022

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Nationwide study of risk factors for reoperation after surgical treatment for degenerative spinal disease in Poland

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