Representativeness of the American Spine Registry: a comparison of patient characteristics with the National Inpatient Sample
Authors: Bydon Mohamad , Sardar Zeeshan M. , Michalopoulos Giorgos D. , El Sammak Sally , Chan Andrew K. , Carreon Leah Y. , Norheim Elizabeth , Park Paul , Ratliff John K. , Tumialán Luis , Pugely Andrew J. , Steinmetz Michael P. , Hsu Wellington , Knightly John J. , Ziegenhorn Diane M. , Donnelly Patrick C. , Mullen Kyle J. , Rykowsky Stefan , De Ayushmita , Potts Eric A. , Coric Domagoj , Wang Michael Y. , Qureshi Sheeraz , Sethi Rajiv K. , Fu Kai-Ming , Patel Alpesh A. , Yoon S. Tim , Brodke Darrel , Stroink Ann R. , Bisson Erica F. , Haid Regis W. , Asher Anthony L. , Burton Doug , Mummaneni Praveen V. , Glassman Steven D. 
Published: May 2023

OBJECTIVE
The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS).

METHODS
The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017–2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen’s d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large.

RESULTS
A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017.

CONCLUSIONS
The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.