• Matthew Piazza, Nikhil Sharma, Benjamin Osiemo, Scott McClintock, Emily Missimer, Diana Gardiner, Eileen Maloney, Danielle Callahan, J Lachlan Smith, William Welch, James Schuster, M Sean Grady, and Neil R Malhotra.
• Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsy-lvania.
• Neurosurgery. 2019 Jul 1; 85 (1): 50-57.

BackgroundBundled care payments are increasingly being explored for neurosurgical interventions. In this setting, skilled nursing facility (SNF) is less desirable from a cost perspective than discharge to home, underscoring the need for better preoperative prediction of postoperative disposition.ObjectiveTo assess the capability of the Risk Assessment and Prediction Tool (RAPT) and other preoperative variables to determine expected disposition prior to surgery in a heterogeneous neurosurgical cohort, through observational study.MethodsPatients aged 50 yr or more undergoing elective neurosurgery were enrolled from June 2016 to February 2017 (n = 623). Logistic regression was used to identify preoperative characteristics predictive of discharge disposition. Results from multivariate analysis were used to create novel grading scales for the prediction of discharge disposition that were subsequently compared to the RAPT Score using Receiver Operating Characteristic analysis.ResultsHigher RAPT Score significantly predicted home disposition (P < .001). Age 65 and greater, dichotomized RAPT walk score, and spinal surgery below L2 were independent predictors of SNF discharge in multivariate analysis. A grading scale utilizing these variables had superior discriminatory power between SNF and home/rehab discharge when compared with RAPT score alone (P = .004).ConclusionOur analysis identified age, lower lumbar/lumbosacral surgery, and RAPT walk score as independent predictors of discharge to SNF, and demonstrated superior predictive power compared with the total RAPT Score when combined in a novel grading scale. These tools may identify patients who may benefit from expedited discharge to subacute care facilities and decrease inpatient hospital resource utilization following surgery.Copyright © 2018 by the Congress of Neurological Surgeons.

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