Predictors of Prolonged Length of Stay After Pituitary Adenoma Resection: A Large Cohort Analysis Using the National Inpatient Sample (2016-2019).

OBJECTIVE: In this nationwide retrospective study, the authors aimed to identify demographic, clinical, and baseline health risk factors predictive of a prolonged length of stay (PLOS) for patients with pituitary adenomas (PAs). METHODS: The National Inpatient Sample dataset from 2016 to 2019 was utilized to identify all included hospitalizations for PA resection as identified by the appropriate diagnosis-related group code. Comorbidities were classified based on the Charlson Comorbidity Index mapping of ICD-10 codes, and PLOS was identified as any stay longer than 3 days. Univariable and multivariable logistic regression models, accounting for the sample design, were built to determine factors associated with PLOS and emergent surgery. RESULTS: Overall, 30 945 patients were included in this study with 10 535 patients having PLOS. Female patients experienced an increased odds of PLOS (odds ratio [OR]: 1.29; P < .001). Black patients (OR: 1.49; P < .001) and Hispanic patients (OR: 1.30; P = .003) had 1.49 times and 1.30 times the odds of PLOS compared to White patients, respectively. Compared to patients insured by Medicare, patients insured by Medicaid had an increased odds of PLOS (OR: 1.36; P = .007) as well as emergent surgery (OR: 5.40; P < .001). When stratified by emergent surgeries, Black patients (OR: 1.89; P < .001), Hispanic patients, (OR: 2.14; P < .001), and patients on Medicaid insurance (OR: 1.71; P < .001) were at an increased risk of emergent procedures. However, female sex (OR: 0.65; P < .001), upper third quartile (OR: 0.73; P = .017), and fourth quartile (OR: 0.69; P = .014) of patients categorized by zip code income were at decreased odds of an emergent procedure. CONCLUSIONS: Black and Hispanic patients, patients with Medicaid insurance, and patients of low socioeconomic status patients are at significantly higher risk of emergent PA resection and PLOS. Efforts to prevent emergent surgeries and shorten hospitalization after pituitary surgery may need to primarily focus on patient groups with select sociodemographic characteristics.

Influence of Insurance Status and Demographic Factors on Outcomes Following Tracheostomy.

OBJECTIVES/HYPOTHESIS: Little data exists regarding the relationship between socioeconomic and demographic factors and tracheostomy outcomes. The goal of this study was to determine associations between socioeconomic status (SES), demographic factors, and insurance status with hospital length of stay (LOS), intensive care unit (ICU) LOS, and mortality following tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis of all patients who underwent tracheostomy at an urban tertiary-care academic hospital from 2016 to 2017 was performed. Patients were aggregated into low-, middle-, and high-income brackets. Other variables included age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index (CCI). Outcomes included hospital and ICU LOS, in-hospital mortality, and 30-day mortality following tracheostomy. Outcomes were compared using Kruskal-Wallis tests for continuous variables and χ2 or Fisher exact tests for categorical variables. The α level was set to .05. RESULTS: In total, 523 patients were included in the study. Patients from high-income areas were more likely to be male (P < .01), white (P < .01), and had lower body mass index (P = .04). On multiple regression analysis, Hispanic or Latino ethnicity was associated with an increased odds of 30-day mortality (odds ratio [OR]: 4.43, P = .020). CCI was also associated with increased odds of 30-day mortality (OR: 1.12, P = .039). CONCLUSIONS: Lower SES was not associated with increased morbidity or mortality after tracheostomy. Although Hispanic patients tended to have a lower CCI score, they had increased 30-day mortality, suggesting there are factors specific to this population that may influence outcomes, and future targeted studies are warranted to study these relationships. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1463-1467, 2021.

Hospital Charge Variability across New York State: Sociodemographic Factors in Pituitary Surgery.

Introduction Significant charge disparities exist across New York State (NYS). Race and income are associated with increased charges. To determine risk factor, we correlate hospital charges for pituitary surgery with socioeconomic factors. Additionally, we identify patients at risk for increased hospital charges and provide insight into cost-effective practices. Methods Retrospective cohort study of the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health was conducted. The SPARCS database was reviewed. Patients who underwent transsphenoidal pituitary surgery from 1995 to 2015 were identified. Income and urban status were referenced from U.S. census data. Linear regression was performed to analyze the effect of sociodemographic factors, comorbidities, and complications on hospital charges while controlling for length of stay. Results A total of 9,373 patients were identified. Black (10.8%, p < 0.001) and Asian (14.5%, p < 0.001) had higher hospital charges. Patients from nonurban cities (13.4%, p < 0.001), Medicaid (13.8%, p < 0.001), and those from the 0 to 25th (9.1%, p < 0.001) and 25 to 50th (11.7%, p < 0.001) income quartile had lower hospital charges. Patients with postoperative cerebrospinal fluid leak (24.0%, p < 0.001), diabetes insipidus (22.1%, p < 0.001), smoking history (11.8%, p < 0.001), hypertension (7.4%, p < 0.001), and hypothyroidism (6.9%, p < 0.001) had higher hospital charges. Conclusion Patients incurring higher chargers were more likely to have a smoking history, hypertension, hypothyroidism, and comorbidities. The determinants of this analysis may provide insight into barriers to patient access and cost improvement strategies. In addition, this emphasizes the need for future studies to create a risk stratification model, similar to those in other fields.

Costs in Pituitary Surgery: Racial, Socioeconomic, and Hospital Factors.

Objective To investigate the influence of patient demographic factors and hospital factors on cost and length of stay in patients undergoing pituitary surgery. Design/Setting A retrospective cross-sectional study of the 2008 to 2012 Nationwide/National Inpatient Sample. Participants Patient demographics and hospital characteristics for patients undergoing pituitary surgery were compared between white, black, and Hispanic patients. Main Outcome Measures Variables associated with increased cost and increased length of hospital stay were ascertained and compared against each racial and ethnic group via multiple linear regression analysis. Results Of 8,812 patients who underwent pituitary surgery, 5,924 (67.2%) patients were white, 1,590 (18.0%) were black, and 1,296 (14.7%) were Hispanic. Patient variables found to be significantly different between racial groups via univariate analysis were age, chronic conditions, gender, income, and primary payer. Hospital variables found to be significantly different were location/teaching status, region, and ownership. Hospitalization cost was significantly lower for whites (-$3,082, 95% confidence interval [CI] -$3,961 to -$2,202) and significantly higher for both blacks ($1,889, 95% CI $842-$2,937) and Hispanics ($2,997, 95% CI $1,842-$4,152). Length of hospital stay was also significantly lower in whites (-1.01, 95% CI -1.31 to -0.72) and significantly higher for both blacks (0.65, 95% CI 0.30 to 1.00) and Hispanics (0.96, 95% CI 0.57-1.35). Conclusions Racial and ethnic factors contribute to differences in hospital utilization and cost for patients undergoing pituitary surgery. Further investigations are necessary to uncover the sources of these disparities in an effort to provide safer and more affordable care to all patients.

Percutaneous versus surgical tracheostomy: timing, outcomes, and charges.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to compare timing of procedure, patient characteristics, outcomes, and charges for patients who underwent percutaneous versus surgical tracheostomy. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective analysis was performed for all patients who underwent tracheostomy in 2015 to 2016 in New York State. Patients were identified using International Classification of Diseases, 10th Revision, Clinical Modification codes and stratified to the type of tracheostomy performed. The primary outcome of interest was mortality at index stay. Secondary outcomes of interest included length of stay and total hospitalization charges. RESULTS: Of the 8,682 patients, 2,488 (28.7%) underwent percutaneous and 6,194 (71.3%) underwent surgical tracheostomy. At hospitals where both procedures were performed, percutaneous tracheostomy patients were older, had more comorbidities, and had lower income (P < .05). Timing of the tracheostomy relative to admission did not affect the type of tracheostomy performed. While controlling for patient characteristics and complications during the visit, percutaneous tracheostomy was associated with increased mortality (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.03-1.33, P = .0153) and increased hospital charges (OR: + 7.76%, 95% CI: 5.4-10.11, P < .0001). Length of stay was not affected by procedure type. CONCLUSIONS: Surgical tracheostomies are more commonly performed than percutaneous tracheostomies across New York State. Older, lower-income, and sicker patients have a higher chance of receiving percutaneous tracheostomies. Percutaneous approaches were associated with statistically significant increased mortality and higher charges despite no difference in length of stay. Further studies are needed to determine if these differences in outcomes are clinically significant. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2844-2851, 2018.

Intracranial Meningioma Surgery: Value-Based Care Determinants in New York State, 1995-2015.

OBJECTIVE: Intracranial meningiomas are the most commonly diagnosed brain tumor in the United States. With increasing incidence, efficient allocation of limited health care resources is a critical component of emerging value-based models of care. The purpose of this study was to evaluate the effect of patient and hospital variables on metrics of value-based care. METHODS: The Statewide Planning and Research Cooperative System database was queried for records of patients undergoing intracranial meningioma surgery in New York State from 1995 to 2015. Multivariate logistic regression was used to investigate the effect of hospital volume and patient demographics on 30-day readmissions, 30-day mortality, prolonged length of stay (pLOS), and excess hospital charges. RESULTS: Among the 14,239 patients included, 10,252 (72%) cases were performed at high-volume centers (HVC) (>75th percentile). HVC were associated with lower rates of readmissions, mortality, and pLOS, but higher hospital charges. In the multivariate analysis, HVC had reduced odds of pLOS (odds ratio, 0.56; P < 0.0001) and 30-day mortality (odds ratio, 0.39; P < 0.0001). Patient variables associated with adverse outcomes in the multivariate model included advanced age, male gender, higher Charlson Comorbidity Index, lower socioeconomic status (low income, Medicaid, and Medicare insurance), black race, and Hispanic ethnicity. These populations were more likely to undergo treatment at lower-volume centers. CONCLUSIONS: This statewide population analysis of readmissions, mortality, length of stay, and hospital charges after intracranial meningioma surgery identified patient predictors of adverse outcomes. These determinants may be used by hospitals to develop improved systems of care in at-risk populations.

The socioeconomic determinants for transsphenoidal pituitary surgery: a review of New York State from 1995 to 2015.

BACKGROUND: Prolonged length of stay (pLOS), disease-related complications, and 30-day readmissions are important quality metrics under the Affordable Care Act. The purpose of our study was to investigate the effect of patient-level and hospital-level factors on these outcomes for patients admitted for transsphenoidal pituitary surgery. METHODS: The Statewide Planning and Research Cooperative System (SPARCS) database was queried to investigate 30-day readmissions and pLOS for transsphenoidal pituitary surgery in New York from 1995 to 2015. Multivariate logistic regression, adjusting for patient and hospital characteristics, was performed to assess the effect of these variables on the outcomes of interest. RESULTS: A total of 9950 patients underwent transsphenoidal pituitary surgery; 7122 (72%), 2394 (24%), and 434 (4%) patients were treated at high-volume, medium-volume, and low-volume centers, respectively. Patient factors associated with treatment at high-volume centers (HVCs) included: top income quartile, private insurance, urban residence, and white or Asian race (p < 0.05). Patient variables associated with treatment at low-volume centers (LVCs) included: age >65 years, elevated Charlson comorbidity index (CCI) scores, bottom income quartile, Medicaid and Medicare insurance, rural residence, black race, and Hispanic ethnicity (p < 0.05). Variables predictive of prolonged hospitalizations in our multivariable model included black race, Hispanic ethnicity, Medicaid insurance, low income, female gender, LVC, and comorbidities (panhypopituitarism, hypothyroidism, diabetes insipidus [DI], visual disturbances, CCI) while predictors of readmissions included Asian race, female gender, and comorbidities (Cushing syndrome, DI, CCI). CONCLUSION: Patients undergoing transsphenoidal pituitary surgery at HVCs have shorter hospitalizations, fewer postoperative electrolyte abnormalities, and lower charges; however, socioeconomic factors may influence access to quality care.

The price of free tissue transfer after tongue reconstruction: quantifying the risks.

OBJECTIVES/HYPOTHESIS: To evaluate the preoperative variables, mean operative time, morbidity, and mortality associated with reconstruction of partial glossectomy defects. STUDY DESIGN: Retrospective data analysis. METHODS: The National Surgical Quality Improvement Program database was queried for patients having undergone glossectomy procedures. The study sample was split into two groups based on the lack or presence of a flap reconstruction. A total of 1,012 glossectomy patients were identified, with 805 undergoing nonflap reconstruction and 207 undergoing free flap reconstruction. Variables evaluated included wound complications, major and minor morbidity, return to the operating room, mortality, and mean operative time. RESULTS: Patients undergoing free flap reconstruction experienced significantly longer mean operative times (482.1 vs. 183.0 minutes, P < .001), were more likely to return to the operating room (odds ratio [OR] = 2.39, 95% confidence interval [CI] = 1.33-4.29, P = .003), and had higher likelihood of wound complications (OR = 5.78, 95% CI = 2.72-12.26, P < .001), major morbidity (OR = 12.39, 95% CI = 7.02-21.85, P < .001), and minor morbidity (OR = 4.20, 95% CI = 2.12-8.33, P < .001). There was no difference in mortality between groups (OR = 8.62, 95% CI = 0.53-141.7, P = .131). CONCLUSIONS: Free flap reconstruction of glossectomy defects involving up to half of the tongue is associated with increased morbidity and operative time when compared with nonflap reconstruction. Currently available functional outcomes data for tongue reconstruction are poor. Possible functional impairment must be weighed against the associated morbidity when deciding which defects require reconstruction, and the decision to reconstruct should not be taken lightly. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1551-1557, 2017.

Cost of management in epistaxis admission: Impact of patient and hospital characteristics.

OBJECTIVES/HYPOTHESIS: To investigate patient and hospital characteristics associated with increased cost and length of stay in the inpatient management of epistaxis. STUDY DESIGN: Retrospective cross-sectional study of the 2008 to 2012 National (Nationwide) Inpatient Sample. METHODS: Patient and hospital characteristics of epistaxis admissions were analyzed. Multiple linear regression analysis was used to ascertain variables associated with increased cost and length of hospital stay. Variables significantly associated with high cost were further analyzed to determine the contribution of operative intervention and total procedures to cost. RESULTS: A total of 16,828 patients with an admitting diagnosis of epistaxis were identified. The average age was 67.5; 52.3% of the patients were male; 73.3% of the patients were Caucasian; and 70.7% of the hospital stays were government funded. The average length of stay was 3.24 days, and average hospitalization cost was $6,925. Longer length of stay was associated with black race, alcohol abuse, sinonasal disease, renal disease, Medicaid, and care at a northeastern U.S. hospital. Increased hospitalization costs of > $1,000 were associated with Asian/Pacific Islander race; sinonasal disease; renal disease; top income quartile; and care at urban teaching, northeastern, and western hospitals in the United States. High costs were predicted by procedural intervention in patients with comorbid alcohol abuse, sinonasal disease, renal disease, patients with private insurance, and patients managed at large hospitals. CONCLUSION: Although hospitalization costs are complex and multifactorial, we were able to identify patient and hospital characteristics associated with high costs in the management of epistaxis. Early identification and intervention, combined with implementation of targeted hospital management protocols, may improve outcomes and reduce financial burden. LEVEL OF EVIDENCE: 2C.