Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample.

BACKGROUND: In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS: The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS: A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS: Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.

Thirty- and 90-Day Readmissions After Treatment of Traumatic Subdural Hematoma: National Trend Analysis.

OBJECTIVE: Subdural hematoma (SDH), a form of traumatic brain injury, is a common disease that requires extensive patient management and resource utilization; however, there remains a paucity of national studies examining the likelihood of readmission in this patient population. The aim of this study is to investigate differences in 30- and 90-day readmissions for treatment of traumatic SDH using a nationwide readmission database. METHODS: The Nationwide Readmission Database years 2013-2015 were queried. Patients with a diagnosis of traumatic SDH and a primary procedure code for incision of cerebral meninges for drainage were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS: We identified a total of 14,355 patients, with 3106 (21.6%) patients encountering a readmission (30-R: n = 2193 [15.3%]; 90-R: n = 913 [6.3%]; Non-R: n = 11,249). The most prevalent 30- and 90-day diagnoses seen among the readmitted cohorts were postoperative infection (30-R: 10.5%, 90-R: 13.0%) and epilepsy (30-R: 3.7%, 90-R: 1.1%). On multivariate logistic regression analysis, Medicare, Medicaid, hypertension, diabetes, renal failure, congestive heart failure, and coagulopathy were independently associated with 30-day readmission; Medicare and rheumatoid arthritis/collagen vascular disease were independently associated with 90-day readmission. CONCLUSIONS: In this study, we determine the relationship between readmission rates and complications associated with surgical intervention for traumatic subdural hematoma.

Stent-assisted treatment of unruptured and ruptured intracranial aneurysms: clinical and angiographic outcome.

BACKGROUND: Wide-necked and non-saccular aneurysms are difficult to treat with coil embolization. The use of stents has expanded the role of endovascular treatment. METHODS: A retrospective study of 43 patients with wide-necked, fusiform or blister aneurysms treated with stent-assisted coiling or stent alone. The review of medical files and images allowed retrieval of the following patient characteristics: (1) age and gender; (2) aneurysm characteristics (site, size, status (ruptured versus unruptured)); (3) coils used; (4) type of stent; (5) complications (procedural and delayed); (6) degree of aneurysm occlusion; (7) length of follow-up; and (8) clinical outcome (modified Rankin scale). RESULTS: Most of the aneurysms treated were located in the anterior circulation (60.4%), while posterior circulation aneurysms represented 39.5%. There are 38 (88%) saccular aneurysms, 1 (2%) fusiform aneurysm and 4 (9%) blister aneurysms. Unruptured aneurysms represented 65%, while ruptured aneurysms represented 35%, 21% of which were treated with a stent in the acute stage. Stent-coiling was performed in 90.7% of cases. Stent alone was performed in 9.3% of cases. The overall radiographic complication rate was 11.6%. Clinically manifest procedure-related complication rate was 4.7%. A complete or near complete (residual neck) embolization was achieved initially in 60.4% of cases. Of the 28 patients with a mean follow-up of 20 months, 57.1% showed a complete occlusion and 25% showed a remnant neck on follow-up. CONCLUSION: Stenting facilitates the treatment of wide-necked, fusiform or blister aneurysms. There is an increased rate of delayed aneurysmal occlusion with subsequent follow-up. A significantly higher rate of occlusion was also observed in the subgroup of aneurysms coiled by a combination of hydrocoils and bare platinum coils versus bare platinum coils only. Stents may also be used in the acute phase of ruptured aneurysms in carefully selected patients.