Research Article
Open Access
The Impact of Gender on Post-Operative
Length of Stay after Lumbar Decompression
Fusion Surgery Referable to Possible
Comorbidity Factors
Hollis Floyd1*, Mazen Sanoufa2, Joe Sam Robinson3
1Research assistant, masters in marriage and family therapy
2Research fellow, doctor of medicine
3Neurosurgeon, doctor of medicine
2Research fellow, doctor of medicine
3Neurosurgeon, doctor of medicine
*Corresponding author: Hollis Floyd, Masters in Marriage and Family Therapy, Research assistant at Georgia Neurosurgical Institute, United
States.
Received: August 16, 2016; Accepted: September 8, 2016; Published: September 16, 2016
Citation: Floyd H, Sanoufa M, Robinson JS (2016) The Impact of Gender on Post-Operative Length of Stay after Lumbar Decompression Fusion Surgery Referable to Possible Comorbidity Factors. J Rheumatol Arthritic Dis 1(1): 1-4. DOI: http://dx.doi.org/10.15226/2475-4676/1/1/00107
Keywords: Costs; Comorbidities; Complications; Gender; Health
Care Expenditure; Length of Stay; Lumbar Decompression and Fusion
IntroductionTop
Proportionally more healthcare dollars are devoted to the
care of females than their male counterparts (Lassman, Hartman,
Washington, Andrews, & Catlin, 2014); rightfully so, as females
have a greater life expectancy and a special reproductive
burden (Owens, 2008; Vaidya, Gautam, & Karmakar, 2012).
In neurosurgery, some controversy exists as to the influence
of gender on prolonging hospital stay, particularly following
operative intervention for spinal column difficulties (Table 1). To
clarify such issues we conducted the following study.
Methods
A retrospective review of the clinical course of all patients
that underwent elective lumbar spinal fusion procedures by five
neurosurgeons between October 2010 and November 2013 at The
Georgia Neurosurgical Institute was undertaken. Comorbidities,
complications, and other relevant general variables were
obtained. Comorbidities which included twenty four variables
relating to preexisting diseases were collected from patients'
past medical histories and their preoperative evaluation visit
forms (Table 2). Complications were twelve secondary medical
problems that developed during hospital stays that were not
existent prior to the operation (Table 3). Other collected variables
contained age, gender, race, Length of hospital Stay (LOS), Body
Mass Index (BMI), and nine others (Table 4). LOS was measured
from the day of procedure until the time of discharge (up to the
first decimal of a day). As our patient's sample is relatively small
in size, we chose to exclude those outliers who stayed more than
4 standard deviations above the mean length of stay (>25.3 days).
There were only 4 patients that fell into this category. in LOS. Then, the variables that showed more prevalence in one
gender were identified using chi-squared analysis. Finally, each
gender cohort was statistically studied separately in order to
identify which variables lead to a prolonged LOS in each gender
using multivariate linear regression analysis. SPSS-19 software
was used to perform all statistics.
Results
A total number of 334 patients were assessed. The mean ±SD
Table 1: Review of articles published in Pub Med since January 2013
about the impact of gender on length of stay in Spine Procedures.
Paper |
Year |
Study Sample Underwent |
Gender related result |
Herren et al.17 |
2014 |
Posterior lumbar spine fusion procedures |
Male gender was a factor prolonged LOS |
Schoenfeld et al.18 |
2013 |
Spine trauma |
Male gender was a predictor for higher mortality and higher complication rate |
Alosh et al.19 |
2015 |
Anterior cervical spine surgery |
Male gender was an independent predictor of hospital charges and LOS |
Kelly et al.20 |
2014 |
Surgical correction of spondylolisthesis |
Female gender was a factor prolonged LOS |
Yoshihara et al.21 |
2014 |
Surgical treatment of thoracic disc herniation |
Female gender was a risk factor for mortality |
Sharma et al.22 |
2014 |
Spinal cord tumor surgeries |
Female gender was an independent predictor of adverse discharge disposition but not to higher costs |
Wait et al.23 |
2013 |
Cervical or Lumbar spinal fusions |
Gender did not show any impact on LOS |
length of stay was 5.68±4.9 days. After taking out 4 patients who
stayed for more than 25.3 days (4 SDs above the mean LOS), the
mean was found to be 5.3±3.4 days. The remaining 330 patients
were divided into 190 females and 140 males (see tables 1, 2, and
3 for a detailed description). Females stayed for 1 day longer than
males (F=5.7±3.1, M=4.7±3.7; P=0.008).
A history of coronary artery disease was the only variable that showed more prevalence in the male cohort (P=0.041). However, variables that were more prevalent in the female cohort were postoperative anemia severity (P<0.001), vitamin D deficiency (P=0.014), diabetes mellitus (P=.05), hypothyroidism (P=0.005), anxiety disorders (P=0.002), major depressive disorder (P=0.001), obesity (BMI>30, P=0.013), hypotension (P=0.029), severe postoperative respiratory problems (P=0.055), and postoperative psychiatric symptoms (P=0.045).
Variables that showed a significant impact on LOS in the male cohort were postoperative anemia (P=0.033), number of operated levels (P=0.053), developing postoperative infections (P=0.012), postoperative pulmonary embolism (P=0.008), and
A history of coronary artery disease was the only variable that showed more prevalence in the male cohort (P=0.041). However, variables that were more prevalent in the female cohort were postoperative anemia severity (P<0.001), vitamin D deficiency (P=0.014), diabetes mellitus (P=.05), hypothyroidism (P=0.005), anxiety disorders (P=0.002), major depressive disorder (P=0.001), obesity (BMI>30, P=0.013), hypotension (P=0.029), severe postoperative respiratory problems (P=0.055), and postoperative psychiatric symptoms (P=0.045).
Variables that showed a significant impact on LOS in the male cohort were postoperative anemia (P=0.033), number of operated levels (P=0.053), developing postoperative infections (P=0.012), postoperative pulmonary embolism (P=0.008), and
Table 2: The Collected Co morbidities.
|
All patients |
Males |
Females |
Preoperative Anemia (Y/N) |
30.0% |
30.2% |
29.4% |
Myocardial Infarction |
3.7% |
4.3% |
3.2% |
Coronary Artery Disease (other than MI) |
11.0% |
15.0% |
7.9% |
Congestive Heart Failure |
1.5% |
1.4% |
1.6% |
Arrhythmias |
4.8% |
5.7% |
4.2% |
Hypertension |
66.1% |
63.6% |
67.9% |
Respiratory Disorders (other than sleep related) |
26.2% |
23.0% |
28.6% |
Chronic Obstructive Pulmonary Disease |
11.6% |
12.2% |
11.1% |
Sleep Apnea |
10.4% |
12.9% |
8.5% |
Chronic Constipation |
14.2% |
12.9% |
15.3% |
Peptic Ulcer Disease |
2.7% |
2.1% |
3.2% |
Renal Failure |
2.1% |
1.4% |
2.6% |
Diabetes Mellitus |
30.0% |
24.3% |
34.2% |
Hypothyroidism |
18.6% |
11.5% |
23.8% |
Stroke |
5.5% |
4.3% |
6.3% |
Transient Ischemic Attach |
1.8% |
0.7% |
2.6% |
Seizure |
2.1% |
0.7% |
3.2% |
Neuromuscular Disorders |
1.8% |
1.4% |
2.1% |
Memory Loss |
5.5% |
3.6% |
6.8% |
Anxiety Disorders |
20% |
12.1% |
25.8% |
Major Depression |
26.1% |
16.4% |
33.2% |
Arthritis |
58.8% |
61.4% |
56.8% |
Obesity (BMI≥30) |
57.1% |
49.3% |
63.0% |
Morbid Obesity (BMI≥40) |
10.6% |
10.0% |
11.1% |
Total Comorbidities |
5.8 |
5.4 |
6.1 |
Table 3: The Collected Complication.
|
|
All patients |
Males |
Females |
Postoperative Anemia Severity |
No anemia (≥12 in f. / ≥13.5 in m.) |
4.6% |
5% |
4.3% |
Mild Anemia (<12 in f. / <13.5 in m. to ≥10) |
32.3% |
51.8% |
17.7% |
|
Moderate (<10 to ≥8) |
39.1% |
32.4% |
44.1% |
|
Severe (<8) |
24% |
10.8% |
33.9% |
|
Dural Tear/CSF Leak |
|
3.4% |
1.4% |
4.7% |
Fever |
|
24.7% |
20.3% |
22.6% |
Infections (total) |
|
12.2% |
9.4% |
14.2% |
Urinary Tract Infection |
|
3.7% |
2.2% |
4.7% |
Wound Infection |
|
2.4% |
2.2% |
2.6% |
Respiratory Complaints |
|
7.0% |
5.8% |
7.9% |
Pulmonary Embolism |
|
1.2% |
2.2% |
0.5% |
Urinary Retention |
|
2.4% |
1.4% |
3.2% |
Postoperative Psychiatric Symptoms (e.g. hallucination, delirium) |
|
3.0% |
0.7% |
4.7% |
Constipation |
|
12.5% |
9.4% |
14.7% |
Total Number of Complication |
|
2.2 |
2.1 |
2.2 |
postoperative glucose intolerance (P=0.045). However, variables
that showed a significant impact on LOS in the female cohort
were postoperative anemia severity (P=0.029), developing
postoperative urinary retention (P=0.006), postoperative
respiratory complications (P=0.006), spinal dural tear
(P<0.0001), and neuromuscular disorders (P=0.005).
Discussion
Our study demonstrated that females have more
comorbidities than males which might be referable to the
different hormonal structures between genders. Our study also
recognized that the variables that influence LOS in each gender
cohort are different. However, age did not show an independent
influence on LOS in either of the genders, despite females being
significantly older than males in our study. Recognizing this age
disparity, statistical adjustments were accordingly instituted.
Following such statistical adjustment, age by itself did change
gender's impact on LOS.
Another variable that should be discussed is rehabilitation status. Ireland, Kelly, and Cumming (2015) stated that "referral to hospital-based rehabilitation effectively doubles the total LOS," suggesting that anyone who is subject to rehabilitation after their acute hospital stay will have a longer LOS. This suggests that a patient's post-operative rehabilitation status should be taken into account when determining their LOS. It may be that patients
Another variable that should be discussed is rehabilitation status. Ireland, Kelly, and Cumming (2015) stated that "referral to hospital-based rehabilitation effectively doubles the total LOS," suggesting that anyone who is subject to rehabilitation after their acute hospital stay will have a longer LOS. This suggests that a patient's post-operative rehabilitation status should be taken into account when determining their LOS. It may be that patients
Table 4: The Collected General Variables.
|
|
All patients |
Males |
Females |
Length of Hospital Stay (Days) |
|
5.3 |
4.7±3.7 |
5.7±3.1 |
Gender |
|
|
140 (42%) |
190 (57%) |
Age |
|
58.0 |
56.1 ±13 |
58.6 ±9.7 |
>60 years old |
48.8% |
46.4% |
50.5% |
|
Race |
Caucasians |
|
76.4% |
64.2% |
African American |
|
20.7% |
34.7% |
|
Type of Insurance |
Medicare |
|
56.4% |
55.8% |
Medicaid |
|
5.7% |
7.9% |
|
Private Insurance |
|
26.4% |
24.7% |
|
Uninsured |
|
5.0% |
4.7% |
|
Other |
|
5.0% |
6.8% |
|
Number of Operated Levels |
1 |
|
47.1% |
42.1% |
2 |
|
27.1% |
32.6% |
|
3 |
|
16.4% |
15.8% |
|
>3 |
|
9.3% |
9.5% |
|
Body Mass Index (BMI in kg/m2) |
|
31.1 |
30.3 |
31.6 |
Anti-Platelet use |
|
26.4% |
28.3% |
25.0% |
Drain insertion |
|
64.3% |
66.7% |
62.6% |
Cell Saver Use |
|
72.9% |
68.8% |
75.8% |
The Need for Blood Transfusion |
|
10.5% |
7.3% |
12.8% |
Preoperative Hemoglobin Level |
|
13.4 |
14.3 |
12.7 |
Postoperative Hemoglobin Level |
|
9.5 |
10.3 |
8.9 |
Vitamin D (ng/mL) |
|
27.3 |
28.9 |
26.3 |
Vitamin D < 20 |
29.1% |
19.5% |
35.5% |
otherwise able to depart a tertiary care facility are shunted
into a rehabilitation facility because of inadequate domestic
support apparatus. Secondly, in some circumstances, discharge
arrangements may have been expedited, preoperatively, so that
in some cases those patients going to rehabilitation facilities
will leave the hospital sooner than a cohort returning to a home
environment.
Implications for Practice and/or Policy
A past history of anxiety disorders and developing
postoperative psychiatric symptoms occurred more frequently
in females than in males; issues which have been suggested to
cause a prolonged hospital LOS (Stundner, et al., 2013; Zatzick,
et al., 2000). Moreover, studies consistently assert that chronic pain states are more prevalent in patients with anxiety disorders
(Dersh, Polatin, Gatchel, 2000; Lachlan, McWilliams, Cox, 2003;
Demyttenaere, Bruffaerts, Lee, 2007) and depressive disorders
(Banks, Kerns, 1996; Dersh, Polatin, Gatchel, 2000; Von Korff,
et al., 2005; Currie and Wang, 2004). Furthermore, women tend
to have more severe pain scores, and perform more poorly on
tests of cognitive function postoperatively than men (Heyer,
et al., 2000). Also, it was suggested by Korovessis, Pepantis,
Papazisis, and Iliopoulos (2010) that males show significantly
better improvement in their lower back pain scores than their
female counterparts following spine surgery. The psychological,
pain, and cognitive burdens that females must face after surgery
suggest that females are innately inclined to poorer postoperative
outcomes and, thus, an elongated LOS.
In our study cohort females were afflicted with more comorbidites than were males possibly referable to the differing hormonal profile of females that could provide further insight as to why female's have a longer LOS than men. Studies consistently mentioned that estrogen modulates pain sensation via its α and β receptors that spread throughout the central and peripheral nervous systems (Alstergren, Ernberg, Kvarnström, Kopp, 1998; Nomura, et al., 2005; McEwen and Alves, 1999), including the dorsal root ganglia (Papka, et al., 2001), as well as throughout inflammatory cells like monocytes (Phiel, Henderson, Adelman, Elloso, Lett, 2005). The study performed by Craft et al. implicated that estrogen was a stimulant of nociceptive afferents in the peripheral nervous system via different mechanisms (Craft, 2007). Female's inclination to have a higher sensitivity to pain, and their increased tendency to psychiatric distress both could contribute to their elongated LOS.
In our study cohort females were afflicted with more comorbidites than were males possibly referable to the differing hormonal profile of females that could provide further insight as to why female's have a longer LOS than men. Studies consistently mentioned that estrogen modulates pain sensation via its α and β receptors that spread throughout the central and peripheral nervous systems (Alstergren, Ernberg, Kvarnström, Kopp, 1998; Nomura, et al., 2005; McEwen and Alves, 1999), including the dorsal root ganglia (Papka, et al., 2001), as well as throughout inflammatory cells like monocytes (Phiel, Henderson, Adelman, Elloso, Lett, 2005). The study performed by Craft et al. implicated that estrogen was a stimulant of nociceptive afferents in the peripheral nervous system via different mechanisms (Craft, 2007). Female's inclination to have a higher sensitivity to pain, and their increased tendency to psychiatric distress both could contribute to their elongated LOS.
Conclusion
Understanding the differences in gender for different
operative interventions and paying special attention to gender
dissimilarities might be useful to decrease postoperative stay
and, thus, diminish healthcare expenditure.
We suggest additional inquiry into the impact of comorbidities and complications with particular reference as to why certain comorbidities and complications contribute to prolonging female LOS and not male.
We suggest additional inquiry into the impact of comorbidities and complications with particular reference as to why certain comorbidities and complications contribute to prolonging female LOS and not male.
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