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OBJECTIVE: Posterior lumbar interbody fusion (PLIF) and/or transforaminal lumbar interbody fusion (TLIF), referred to as "PLIF/TLIF," is a commonly performed operation for lumbar spondylolisthesis. Its long-term cost-effectiveness has not been well described. The aim of this study was to determine the 5-year cost-effectiveness of PLIF/TLIF for grade 1 degenerative lumbar spondylolisthesis using prospective data collected from the multicenter Quality Outcomes Database (QOD). METHODS: Patients enrolled in the prospective, multicenter QOD grade 1 lumbar spondylolisthesis module were included if they underwent single-stage PLIF/TLIF. EQ-5D scores at baseline, 3 months, 12 months, 24 months, 36 months, and 60 months were used to calculate gains in quality-adjusted life years (QALYs) associated with surgery relative to preoperative baseline. Healthcare-related costs associated with the index surgery and related reoperations were calculated using Medicare reimbursement-based cost estimates and validated using price transparency diagnosis-related group (DRG) charges and Medicare charge-to-cost ratios (CCRs). Cost per QALY gained over 60 months postoperatively was assessed. RESULTS: Across 12 surgical centers, 385 patients were identified. The mean patient age was 60.2 (95% CI 59.1-61.3) years, and 38% of patients were male. The reoperation rate was 5.7%. DRG 460 cost estimates were stable between our Medicare reimbursement-based models and the CCR-based model, validating the focus on Medicare reimbursement. Across the entire cohort, the mean QALY gain at 60 months postoperatively was 1.07 (95% CI 0.97-1.18), and the mean cost of PLIF/TLIF was $31,634. PLIF/TLIF was associated with a mean 60-month cost per QALY gained of $29,511. Among patients who did not undergo reoperation (n = 363), the mean 60-month QALY gain was 1.10 (95% CI 0.99-1.20), and cost per QALY gained was $27,591. Among those who underwent reoperation (n = 22), the mean 60-month QALY gain was 0.68 (95% CI 0.21-1.15), and the cost per QALY gained was $80,580. CONCLUSIONS: PLIF/TLIF for degenerative grade 1 lumbar spondylolisthesis was associated with a mean 60-month cost per QALY gained of $29,511 with Medicare fees. This is far below the well-established societal willingness-to-pay threshold of $100,000, suggesting long-term cost-effectiveness. PLIF/TLIF remains cost-effective for patients who undergo reoperation.
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Objectives: An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort. Methods: Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury. Results: Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months. Conclusions: After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed. Level of evidence: IV. Trial registration number: NCT02119182.
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This Viewpoint discusses reforms to the 340B Drug Pricing Program to focus revenues from the program on lower-income and uninsured patients.
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Reforma dos Serviços de Saúde , Humanos , Estados Unidos , Reforma dos Serviços de Saúde/legislação & jurisprudência , COVID-19/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: Despite profound medico-socio-legal consequences of traumatic brain injury (TBI) from intimate partner violence and domestic violence (IPV/DV), the incidence and acute outcomes of concurrent IPV/DV-TBI are not well understood. We examined US IPV/DV patients with/without TBI (IPV/DV-TBI; non-TBI) using the National Trauma Data Bank. We hypothesized IPV/DV-TBI would be associated with elevated morbidity. METHODS: National Trauma Data Bank Trauma Quality Programs Participant Use Files years 2018 to 2021 were queried for patients aged ≥18 years with IPV/DV using International Classification of Diseases, Tenth Revision external cause codes. TBI/non-TBI was defined using International Classification of Diseases, Tenth Revision diagnosis codes. TBI severity was defined by the Glasgow Coma Scale (severe = 3-8, moderate = 9-12, and mild = 13-15). Outcomes were intensive care unit (ICU) admission, in-hospital mortality, length of stay (LOS), and discharge home. Multivariable regressions examined associations between TBI and outcomes, controlling for sociodemographic and injury severity variables. RESULTS: Of 3891 IPV/DV-related cases, 31.1% were IPV/DV-TBI. Cranial injuries included skull fracture (30.2%), subdural (19.8%), subarachnoid (13.4%), and epidural (1.1%) hemorrhage, contusion (8.1%), and cerebral edema (3.3%). In IPV/DV-TBI, mild/moderate/severe TBI proportions were 87.4%/4.3%/8.3%, with mean LOS 11.5 ± 10.9/14.4 ± 27.3/5.0 ± 7.7-days and mortality 0.9%/22.5%/28.6%, respectively. Compared with non-TBI, IPV/DV-TBI had more female (77.2%/64.6%, P < .001) and fewer Black patients (28.9%/36.6%, P < .001), more ICU admissions (20.9%/7.5%, P < .001) and mortality (4.1%/1.8%, P < .001), longer LOS (5.3 ± 9.5/4.5 ± 6.4-days, P = .008), and decreased discharge home (79.8%/83.8%, P = .005). Multivariable regressions confirmed the associations between TBI and ICU admission (adjusted odds ratio [aOR] = 4.29, 95% CI [3.46-5.33]), mortality (aOR = 3.20 [1.99-5.15]), LOS (adjusted mean difference = +1.22 [0.68-1.76]), and inability to discharge home (aOR = 0.57 [0.46-0.71]). CONCLUSION: One-third of US IPV/DV-related trauma cases have TBI, comprising predominantly female patients. Black patients with IPV/DV-related trauma were overrepresented compared with US census estimates. IPV/DV-TBI had increased ICU admissions, LOS, in-hospital mortality, and inability to discharge home compared with non-TBI. Investigating morbidity risk factors and providing sociomedical resources during acute care are critically needed in this vulnerable population.
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BACKGROUND: Although many molecules have been investigated as biomarkers for spinal cord injury (SCI) or ischemic stroke, none of them are specifically induced in central nervous system (CNS) neurons following injuries with low baseline expression. However, neuronal injury constitutes a major pathology associated with SCI or stroke and strongly correlates with neurological outcomes. Biomarkers characterized by low baseline expression and specific induction in neurons post-injury are likely to better correlate with injury severity and recovery, demonstrating higher sensitivity and specificity for CNS injuries compared to non-neuronal markers or pan-neuronal markers with constitutive expressions. METHODS: In animal studies, young adult wildtype and global Atf3 knockout mice underwent unilateral cervical 5 (C5) SCI or permanent distal middle cerebral artery occlusion (pMCAO). Gene expression was assessed using RNA-sequencing and qRT-PCR, while protein expression was detected through immunostaining. Serum ATF3 levels in animal models and clinical human samples were measured using commercially available enzyme-linked immune-sorbent assay (ELISA) kits. RESULTS: Activating transcription factor 3 (ATF3), a molecular marker for injured dorsal root ganglion sensory neurons in the peripheral nervous system, was not expressed in spinal cord or cortex of naïve mice but was induced specifically in neurons of the spinal cord or cortex within 1 day after SCI or ischemic stroke, respectively. Additionally, ATF3 protein levels in mouse blood significantly increased 1 day after SCI or ischemic stroke. Importantly, ATF3 protein levels in human serum were elevated in clinical patients within 24 hours after SCI or ischemic stroke. Moreover, Atf3 knockout mice, compared to the wildtype mice, exhibited worse neurological outcomes and larger damage regions after SCI or ischemic stroke, indicating that ATF3 has a neuroprotective function. CONCLUSIONS: ATF3 is an easily measurable, neuron-specific biomarker for clinical SCI and ischemic stroke, with neuroprotective properties. HIGHLIGHTS: ATF3 was induced specifically in neurons of the spinal cord or cortex within 1 day after SCI or ischemic stroke, respectively. Serum ATF3 protein levels are elevated in clinical patients within 24 hours after SCI or ischemic stroke. ATF3 exhibits neuroprotective properties, as evidenced by the worse neurological outcomes and larger damage regions observed in Atf3 knockout mice compared to wildtype mice following SCI or ischemic stroke.
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Fator 3 Ativador da Transcrição , Biomarcadores , AVC Isquêmico , Neurônios , Traumatismos da Medula Espinal , Animais , Feminino , Humanos , Masculino , Camundongos , Fator 3 Ativador da Transcrição/metabolismo , Fator 3 Ativador da Transcrição/genética , Biomarcadores/metabolismo , Biomarcadores/sangue , Modelos Animais de Doenças , AVC Isquêmico/metabolismo , AVC Isquêmico/genética , AVC Isquêmico/sangue , Camundongos Knockout , Neurônios/metabolismo , Traumatismos da Medula Espinal/metabolismo , Traumatismos da Medula Espinal/genética , Traumatismos da Medula Espinal/complicaçõesRESUMO
OBJECTIVE: Policy concern and debate surround the concept of overlapping spine surgery. Overlapping surgery specifically refers to nonessential portions of the case or noncutting time overlap. This differs from concurrent surgery, in which critical portions of the procedure overlap. Here the authors explore the barriers for safe and efficient overlapping surgery in academic spinal deformity practice. METHODS: Over a 24-month period, cases of spinal deformity, degenerative cases, anterior cervical discectomy and fusions (ACDFs), and laminectomy were reviewed for duration in operating room (OR) prior to surgery, duration of cutting time, duration in OR after surgery, turnover duration, and time delay from initial start time. Standard degenerative cases were referenced as 1-2 ACDFs as well as 1- to 2-level laminectomy surgery. The blocks of time between two consecutive cutting periods were investigated to determine the feasibility of overlapping an additional surgery. Specifically, the authors compared the blocks of time that include the postsurgery period, the turnover period, and the presurgery period to cutting periods. RESULTS: One hundred twenty-six complex spinal deformity procedures and 85 degenerative cases (including 49 ACDFs and 36 laminectomies) from one center and one neurosurgeon were reviewed. These procedures were performed between September 2019 and December 2021 with a 3-month gap in military deployment. On average, the procedure's duration for cases of deformity was 236.5 minutes, for cases of ACDFs it was 84 minutes, and for cases of laminectomies it was 105.5 minutes. The block of noncutting time while the patient was in the OR showed no difference from the surgical cut time. The turnover time between cases was 52.35 minutes. Of 100 cases scheduled as the first case of the day, 94 had a delay to the OR averaging 18.2 minutes. CONCLUSIONS: The data in this study indicate that estimates for pre- and postsurgical times alone are not sufficient to allow for overlapping surgery. The average cut-time duration of ACDF was 84 minutes; the average presurgical time for deformity was 68 minutes. This highlights the critical analysis for further examination of optimal scheduling, on-time first start, turnover periods, and the orchestration of all members of the providing team to optimize the cutting time for safe and consistent implementation of overlapping spine surgery.
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Discotomia , Laminectomia , Fusão Vertebral , Centros de Atenção Terciária , Humanos , Laminectomia/métodos , Discotomia/métodos , Fusão Vertebral/métodos , Duração da Cirurgia , Coluna Vertebral/cirurgia , Feminino , Procedimentos Neurocirúrgicos/métodos , Masculino , Vértebras Cervicais/cirurgia , Salas Cirúrgicas , Doenças da Coluna Vertebral/cirurgiaRESUMO
Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 h of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24 h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants age ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; one additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared with without (median: 630.6 pg/mL, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p = 0.049), and were associated with axonal injury (no: median 226.7 pg/mL [109.6-435.1], yes: 828.6 pg/mL [204.0-1194.3], p = 0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our small sample size and await validation from larger studies.
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Lesões Encefálicas Traumáticas , Imageamento por Ressonância Magnética , Hemorragia Subaracnoídea Traumática , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Hemorragia Subaracnoídea Traumática/diagnóstico por imagem , Adulto , Tomografia Computadorizada por Raios X/métodos , Estudos Prospectivos , Lesões Encefálicas Traumáticas/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Idoso , Escala de Coma de GlasgowRESUMO
OBJECTIVE: The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients. METHODS: The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic). RESULTS: Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome. CONCLUSIONS: The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.
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Lesões Encefálicas Traumáticas , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Lesões Encefálicas Traumáticas/mortalidade , Lesões Encefálicas Traumáticas/terapia , Pessoa de Meia-Idade , Feminino , Prognóstico , Masculino , Adulto , Estudos Prospectivos , Idoso , Estudos de Coortes , Adulto Jovem , AdolescenteRESUMO
BACKGROUND AND OBJECTIVES: Hospital length of stay (HLOS) is a metric of injury severity, resource utilization, and healthcare access. Recent evidence has shown an association between Medicaid insurance and increased HLOS after traumatic brain injury (TBI). This study aims to validate the association between Medicaid and prolonged HLOS after TBI using the National Trauma Data Bank. METHODS: National Trauma Data Bank Trauma Quality Programs Participant Use Files (2003-2021) were queried for adult patients with TBI using traumatic intracranial injury ICD-9/ICD-10 codes. Patients with complete HLOS, age, sex, race, insurance payor, Glasgow Coma Scale, Injury Severity Score, and discharge disposition data were included (N = 552 949). Analyses were stratified by TBI severity using Glasgow Coma Scale. HLOS was coded into Tiers according to percentiles within TBI severity categories (Tier 1: 1-74th; 2: 75-84th; 3: 85-94th; 4: 95-99th). Multivariable logistic regressions evaluated associations between insurance payor and prolonged (Tier 4) HLOS, controlling for sociodemographic, Injury Severity Score, cranial surgery, and discharge disposition variables. Adjusted odds ratios (aOR) and 95% CI were reported. RESULTS: HLOS Tiers consisted of 0-19, 20-27, 28-46, and ≥47 days (Tiers 1-4, respectively) in severe TBI (N = 103 081); 0-15, 16-21, 22-37, and ≥38 days in moderate TBI (N = 39 904); and 0-7, 8-10, 11-19, and ≥20 days in mild TBI (N = 409 964). Proportion of Medicaid patients increased with Tier ([Tier 1 vs Tier 4] severe: 16.0% vs 36.1%; moderate: 14.1% vs 31.6%; mild TBI: 10.2% vs 17.4%; all P < .001). On multivariable analyses, Medicaid was associated with prolonged HLOS (severe TBI: aOR = 2.35 [2.19-2.52]; moderate TBI: aOR = 2.30 [2.04-2.61]; mild TBI: aOR = 1.75 [1.67-1.83]; reference category: private/commercial). CONCLUSION: This study supports Medicaid as an independent predictor of prolonged HLOS across TBI severity strata. Reasons may include different efficacies in care delivery and reimbursement, which require further investigation. Our findings support the development of discharge coordination pathways and policies for Medicaid patients with TBI.
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BACKGROUND AND OBJECTIVES: Intraoperative ultrasound (IOUS) during anterior cervical surgery is hindered by large transducer size and small operative corridor. We hypothesized that a linear (minimally invasive) transducer designed for transsphenoidal surgery can visualize the spinal cord, nerve roots, and surrounding structures during anterior cervical approaches, facilitating intraoperative assessment of central and foraminal decompression. METHODS: IOUS was used to evaluate 26 levels in 17 patients (15 anterior cervical discectomy and fusion, 1 corpectomy, 1 arthroplasty) with a linear probe (7 × 6-mm end-fire transducer, 150-mm length, 12-15 MHz). After pin-based distraction, discectomy, and posterior longitudinal ligament resection, IOUS assessed adequacy of cord decompression and, following proximal foraminotomy or uncinectomy, nerve root decompression. If indicated, additional decompression was completed. Criteria for adequate central and foraminal decompression were visualization of subarachnoid space around the cord and cerebrospinal fluid pulsatility along the root sleeve/absence of nerve root compression distal to the root sleeve, respectively. RESULTS: IOUS successfully visualized the cord, nerve roots, and surrounding structures in all 26 levels and influenced management in 11 levels (42.3%). IOUS indicated persistent cord and nerve root compression in 2 and 7 levels, respectively. Planned uncinectomy was aborted in 2 levels after IOUS demonstrated adequate nerve root decompression with intervertebral distraction/proximal foraminotomy alone. IOUS identified persistent nerve root compression after initial proximal foraminotomy in 4 levels and uncinectomy in 2 levels. An unplanned uncinectomy was performed in 1 level after IOUS showed persistent nerve root compression after multiple iterations of proximal foraminotomy. At follow-up (mean 3.1 months), the mean improvement in Numeric Rating Scale neck and arm pain, Neck Disability Index, and modified Japanese Orthopedic Association was 4.0%, 3.2%, 3.7%, and 0.7%, respectively. CONCLUSION: The neural elements and their relationships to surrounding bone/soft tissue can be visualized using a minimally invasive IOUS transducer during anterior cervical surgery without having to remove pin-based distraction. This allows surgeons to intraoperatively verify the extent of central and foraminal decompression.
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Vértebras Cervicais , Descompressão Cirúrgica , Humanos , Feminino , Pessoa de Meia-Idade , Vértebras Cervicais/cirurgia , Vértebras Cervicais/diagnóstico por imagem , Masculino , Adulto , Descompressão Cirúrgica/métodos , Descompressão Cirúrgica/instrumentação , Idoso , Fusão Vertebral/métodos , Fusão Vertebral/instrumentação , Transdutores , Discotomia/métodos , Discotomia/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Monitorização Intraoperatória/métodos , Ultrassonografia de Intervenção/métodosRESUMO
BACKGROUND AND OBJECTIVES: Under the Merit-Based Incentive Payment System (MIPS), Medicare evaluates provider performance to determine payment adjustments. Studies examining the first year of MIPS (2017) showed that safety-net providers had lower MIPS scores, but the performance of safety-net physicians over time has not been studied. This study aimed to examine the performance of safety-net vs non-safety-net neurosurgeons in MIPS from 2017 to 2020. METHODS: Safety-net neurosurgeons were defined as being in the top quartile according to proportion of dual-eligible beneficiaries and non-safety-net in the bottom quartile. Outcomes were total MIPS scores and dual-eligible proportion over time. In this descriptive study, we evaluated ordinary least squares regression models with SEs clustered at the physician level. Covariates of interest included safety-net status, year, and average Hierarchical Condition Category risk score of beneficiaries. RESULTS: There were 2796-3322 physicians included each year between 2017 and 2020. Mean total MIPS scores were not significantly different for safety-net than non-safety-net physicians in 2017 but were greater for safety-net in 2018 (90.7 vs 84.5, P < .01), 2019 (86.4 vs 81.5, P < .01), and 2020 (90.9 vs 86.7, P < .01). Safety-net status (coefficient -9.11; 95% CI [-13.15, -5.07]; P < .01) and participation in MIPS as an individual (-9.89; [-12.66, -7.13]; P < .01) were associated with lower scores while year, the interaction between safety-net status and year, and participation in MIPS as a physician group or alternative payment model were associated with higher scores. Average Hierarchical Condition Category risk score of beneficiaries (-.011; [-.015, -.006]; P < .01) was associated with decreasing dual-eligible case mix, whereas average age of beneficiaries (.002; [.002, .003]; P < .01) was associated with increasing dual-eligible case mix. CONCLUSION: Being a safety-net physician was associated with lower MIPS scores, but safety-net neurosurgeons demonstrated greater improvement in MIPS scores than non-safety-net neurosurgeons over time. Providers with higher-risk patients were more likely to decrease their dual-eligible case mix over time.
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OBJECTIVE: Venous thromboembolism (VTE) following traumatic spinal cord injury (SCI) is a significant clinical concern. This study sought to determine the incidence of VTE and hemorrhagic complications among patients with SCI who received low-molecular-weight heparin (LMWH) within 24 hours of injury or surgery and identify variables that predict VTE using the prospective Transforming Research and Clinical Knowledge in SCI (TRACK-SCI) database. METHODS: The TRACK-SCI database was queried for individuals with traumatic SCI from 2015 to 2022. Primary outcomes of interest included rates of VTE (including deep vein thrombosis [DVT] and pulmonary embolism [PE]) and in-hospital hemorrhagic complications that occurred after LWMH administration. Secondary outcomes included intensive care unit and hospital length of stay, discharge location type, and in-hospital mortality. RESULTS: The study cohort consisted of 162 patients with SCI. Fifteen of the 162 patients withdrew from the study, leading to loss of data for certain variables for these patients. One hundred thirty patients (87.8%) underwent decompression and/or fusion surgery for SCI. DVT occurred in 11 (7.4%) of 148 patients, PE in 9 (6.1%) of 148, and any VTE in 18 (12.2%) of 148 patients. The analysis showed that admission lower-extremity motor score (p = 0.0408), injury at the thoracic level (p = 0.0086), admission American Spinal Injury Association grade (p = 0.0070), and younger age (p = 0.0372) were significantly associated with VTE. There were 3 instances of postoperative spine surgery-related bleeding (2.4%) in the 127 patients who had spine surgery with bleeding complication data available, with one requiring return to surgery (0.8%). Thirteen (8.8%) of 147 patients had a bleeding complication not related to spine surgery. There were 2 gastrointestinal bleeds associated with nasogastric tube placement, 3 cases of postoperative non-spine-related surgery bleeding, and 8 cases of other bleeding complications (5.4%) not related to any surgery. CONCLUSIONS: Initiation of LMWH within 24 hours was associated with a low rate of spine surgery-related bleeding. Bleeding complications unrelated to SCI surgery still occur with LMWH administration. Because neurosurgical intervention is typically the limiting factor in initializing chemical DVT prophylaxis, many of these bleeding complications would have likely occurred regardless of the protocol.
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Embolia Pulmonar , Traumatismos da Medula Espinal , Traumatismos da Coluna Vertebral , Tromboembolia Venosa , Humanos , Heparina de Baixo Peso Molecular/efeitos adversos , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/epidemiologia , Estudos Prospectivos , Anticoagulantes/efeitos adversos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/tratamento farmacológico , Traumatismos da Medula Espinal/cirurgia , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/prevenção & controle , Hemorragia Pós-Operatória/epidemiologia , Sistema de Registros , HeparinaRESUMO
Lumbar interbody fusion (LIF) is a well-established approach in treating spinal deformity and degenerative conditions of the spine. Since its inception in the 20th century, LIF has continued to evolve, allowing for minimally invasive approaches, high fusion rates, and improving disability scores with favorable complication rates. The anterior to the psoas (ATP) approach utilizes a retroperitoneal pathway medial to the psoas muscle to access the L1-S1intervertebral disc spaces. In contrast to the transpsoas arppoach, its primary advantage is avoiding transgressing the psoas muscle and the contained lumbar plexus, which potentially decreases the risk of injury to the lumbar plexus. Avoiding transgression of the psoas may minimize the risk of transient or permanent neurological deficits secondary to lumbar plexus injury. Indications for ATP approaches may expand as it is shown to be a safe and effective method of achieving spinal arthrodesis.
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Vértebras Lombares , Fusão Vertebral , Humanos , Vértebras Lombares/cirurgia , Região Lombossacral , Trifosfato de AdenosinaRESUMO
Importance: One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited. Objective: To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years. Design, Setting, and Participants: This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023. Exposures: Postindex TBI(s). Main Outcomes and Measures: Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs. Results: Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains. Conclusions and Relevance: In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.
Assuntos
Lesões Encefálicas Traumáticas , Lesões Encefálicas , Humanos , Masculino , Adulto , Feminino , Estudos de Coortes , Estudos Prospectivos , Qualidade de Vida , Lesões Encefálicas Traumáticas/epidemiologiaRESUMO
This Viewpoint explores a critical source of administrative burden and physician frustrationthe explosive growth of health care quality metricsand how improving these metrics could combat clinician burnout.
Assuntos
Esgotamento Profissional , Médicos , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde , Humanos , Esgotamento Profissional/prevenção & controle , Esgotamento Psicológico/prevenção & controle , Médicos/psicologiaRESUMO
BACKGROUND: Hospital length of stay (HLOS) after traumatic brain injury (TBI) is a metric of injury severity, resource utilization, and access to services. This study aimed to evaluate socioeconomic and clinical factors associated with prolonged HLOS after TBI. METHODS: Retrospective data from adult hospitalized patients diagnosed with acute TBI at a US Level 1 trauma center between August 1, 2019 - April 1, 2022 were extracted from the electronic health record. HLOS was stratified by Tier (1: 1-74th percentile; 2: 75-84th; 3: 85-94th; 4: 95-99th). Demographic, socioeconomic, injury severity, and level-of-care factors were compared by HLOS. Multivariable logistic regressions evaluated associations between socioeconomic and clinical variables and prolonged HLOS, using multivariable odds ratios (mOR) and [95% confidence intervals]. Estimated daily charges were calculated for a subset of medically-stable inpatients awaiting placement. Statistical significance was assessed at p < 0.05. RESULTS: In 1443 patients, median HLOS was 4 days (interquartile range 2-8; range 0-145). HLOS Tiers were 0-7, 8-13, 14-27, and ≥28 days (Tiers 1-4, respectively). Patients with Tier 4 HLOS differed significantly from others, with increased Medicaid insurance (53.4% vs. 30.3-33.1%, p = 0.003), severe TBI (Glasgow Coma Scale 3-8: 38.4% vs. 8.7-18.2%, p < 0.001), younger age (mean 52.3-years vs. 61.1-63.7-years, p = 0.003), low socioeconomic status (53.4% vs. 32.0-33.9%, p = 0.003), and need for post-acute care (60.3% vs. 11.2-39.7%, p < 0.001). Independent factors associated with prolonged (Tier 4) HLOS were Medicaid (mOR = 1.99 [1.08-3.68], vs. Medicare/commercial), moderate and severe TBI (mOR = 3.48 [1.61-7.56]; mOR = 4.43 [2.18-8.99], respectively, vs. mild TBI), and need for post-acute placement (mOR = 10.68 [5.74-19.89], while age was protective (per-year mOR = 0.98 [0.97-0.99]). Estimated daily charges for a medically-stable inpatient was $17126. CONCLUSIONS: Medicaid insurance, moderate/severe TBI, and need for post-acute care were independently associated with prolonged HLOS ≥28 days. Medically-stable inpatients awaiting placement accrue immense daily healthcare costs. At-risk patients should be identified early, receive care transitions resources, and be prioritized for discharge coordination pathways.
Assuntos
Lesões Encefálicas Traumáticas , Medicare , Adulto , Humanos , Idoso , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Tempo de Internação , Estudos Retrospectivos , Lesões Encefálicas Traumáticas/terapia , Escala de Coma de Glasgow , Hospitais , Fatores SocioeconômicosRESUMO
INTRODUCTION: Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. METHODS: Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. RESULTS: In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]). CONCLUSIONS: Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.
RESUMO
BACKGROUND: The electronic health record (EHR) is central to clinical workflow, yet few studies to date have explored EHR usage patterns among neurosurgery trainees. OBJECTIVE: To describe the amount of EHR time spent by postgraduate year (PGY)-2 and PGY-3 neurosurgery residents during on-call days and the distribution of EHR activities in which they engage. METHODS: This cohort study used the EHR audit logs, time-stamped records of user activities, to review EHR usage of PGY-2 and PGY-3 neurosurgery residents scheduled for 1 or more on-call days across 2 calendar years at the University of California San Francisco. We focused on the PGY-2 and PGY-3, which, in our training program, represent the primary participants in the in-house on-call pool. RESULTS: Over 723 call days, 12 different residents took at least one on-call shift. The median (IQR) number of minutes that residents spent per on-call shift actively using the EHR was 536.8 (203.5), while interacting with an average (SD) of 68.1 (14.7) patient charts. There was no significant difference between Active EHR Time between residents as PGY-2 and PGY-3 on paired t -tests. Residents spent the most time on the following EHR activities: patient reports, notes, order management, patient list, and chart review. CONCLUSION: Residents spent, on average, 9 hours of their on-call shift actively using the EHR, and there was no improved efficiency as residents gained experience. We noted several areas of administrative EHR burden, which could be reduced.