Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Preoperative Imaging Assessment of Patients With Suspected Nonfunctioning Pituitary Adenomas.

BACKGROUND: The authors reviewed published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas (NFPAs) and formulated recommendations. OBJECTIVE: To provide an exhaustive review of published articles pertaining to the preoperative imaging evaluation of nonfunctioning pituitary adenomas. METHODS: The MEDLINE database was queried for studies investigating imaging for the preoperative evaluation of pituitary adenomas. RESULTS: From an initial search of 5598 articles, 122 articles were evaluated in detail and included in this article. Based on analysis of these articles, the recommendations are as follows: (1) High-resolution magnetic resonance imaging (level II) is recommended as the standard for preoperative assessment of nonfunctioning pituitary adenomas, but may be supplemented with CT (level III) and fluoroscopy (level III). (2) Although there are promising results suggesting the utility of magnetic resonance spectroscopy, magnetic resonance perfusion, positron emission tomography, and single-photon emission computed tomography, there is insufficient evidence to make formal recommendations pertaining to their clinical applications. CONCLUSION: The authors identified 122 articles that form the basis of recommendations for preoperative imaging evaluation of nonfunctioning pituitary adenomas. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_2. ABBREVIATIONS: CT, computed tomographyDWI, diffusion-weighted imagingMRI, magnetic resonance imagingNFPA, nonfunctioning pituitary adenoma.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas.

BACKGROUND: Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is challenging. OBJECTIVE: To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way. METHODS: An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification. RESULTS: Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment. CONCLUSION: Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≥3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8. ABBREVIATION: NFPA, nonfunctioning pituitary adenoma.

Emergency room resource utilization by patients with low-back pain.

OBJECTIVE The objective of this study was to determine factors associated with admission to the hospital through the emergency room (ER) for patients with a primary diagnosis of low-back pain (LBP). The authors further evaluated the impact of ER admission and patient characteristics on mortality, discharge disposition, and hospital length of stay. METHODS The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. Univariate comparisons of patient characteristics according to the type of admission (ER versus non-ER) were conducted. Multivariate analysis evaluated factors associated with an ER admission, risk of mortality, and nonroutine discharge. RESULTS According to the NIS, approximately 183,151 patients with a primary diagnosis of LBP were discharged from US hospitals between 1998 and 2007. During this period, an average of 65% of these patients were admitted through the ER, with a significant increase from 1998 (54%) to 2005 (71%). Multivariate analysis revealed that uninsured patients (OR 2.1, 95% CI 1.7-2.6, p < 0.0001) and African American patients (OR 1.5, 95% CI 1.2-1.7, p < 0.0001) were significantly more likely to be admitted through the ER than private insurance patients or Caucasian patients, respectively. Additionally, a moderate but statistically significant increase in the likelihood of ER admission was noted for patients with more preexisting comorbidities (OR 1.1, 95% CI 1.0-1.2, p < 0.001). An 11% incremental increase in the odds of admission through the ER was observed with each year increment (OR 1.1, 95% CI 1.0-1.2, p < 0.001). Highest income patients ($45,000+) were more likely to be admitted through the ER (OR 1.3, 95% CI 1.1-1.6, p = 0.007) than the lowest income cohort. While ER admission did not impact the risk of mortality (OR 0.95, 95% CI 0.60-1.51, p = 0.84), it increased the odds of a nonroutine discharge (OR 1.39, 95% CI 1.26-1.53, p < 0.0001). CONCLUSIONS A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.

Effect of insurance and racial disparities on outcomes in traumatic brain injury.

INTRODUCTION: We evaluated outcome and resource utilization disparities between commercially insured, Medicaid, and Medicare patients. We further analyzed racial disparities in a subset cohort. METHODS: We reviewed the MarketScan database (2000-2009) for adult traumatic brain injury (TBI) patients. Analyses were performed to evaluate outcome differences by insurance type and race. Outpatient service utilization disparities by insurance and race were also evaluated. RESULTS: Our study included 92,159 TBI patients, 44,108 (47.9%) of whom utilized commercial insurance, 19,743 (21.4%) utilized Medicaid, and 28,308 (30.7%) utilized Medicare. In-hospital mortality was lowest for commercially insured (5.0%) versus 7.6% and 8.5% for Medicaid and Medicare patients, respectively (p < 0.0001). Medicaid patients had a longer hospitalization than commercially insured (12 days versus 6 days; p < 0.0001). Medicaid patients were 1.29 and 1.78 times more likely to die and experience complications than the commercially insured. Females had a lower mortality risk (odds ratio [OR]: 0.80, p < 0.0001) and less complications (OR: 0.67; p < 0.0001) than males. Higher comorbidities increased mortality risk (OR: 2.71; p < 0.0001) and complications (OR: 2.96, p < 0.0001). Mild injury patients had lower mortality (OR: 0.01; p < 0.0001) and less complications (OR: 0.07; p < 0.0001). Medicare (OR: 1.33; p < 0.0001) and higher comorbidity (OR: 1.26; p < 0.0001) patients utilized outpatient rehabilitation services more frequently. Medicare patients had twice the emergency department visits as the commercially insured (p < 0.0001). Medicare (16.6%) patients utilized more rehabilitation than commercially insured (13.4%) and Medicaid (9.1%) patients. Racial disparities were analyzed in a subset of 12,847 white and 4,780 African American (AA) patients. Multivariate analysis showed that AAs were more likely to experience a complication than white patients (OR: 1.13; p = 0.0024) and less likely to utilize outpatient rehabilitation services (OR: 0.83; p = 0.0025) than whites. CONCLUSIONS: Insurance and racial disparities continue to exist for TBI patients. Insurance status appears to have an impact on short- and long-term outcomes to a greater degree than patient race.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform: Clinical article.

OBJECT: The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery. METHODS: The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000-2002) and postreform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. Results A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre-duty-hour restriction era (8.7% vs. 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs. 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs. 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre- and post-duty-hour eras (0.39% vs. 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs. 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs. 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs. 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs. 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post-duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55). CONCLUSIONS: The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions.

OBJECT: On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures. METHODS: The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method. RESULTS: A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17). CONCLUSIONS: The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

Utilization of spinal cord stimulation in patients with failed back surgery syndrome.

STUDY DESIGN: Retrospective analysis of a population-based insurance claims data set. OBJECTIVE: To evaluate the use of spinal cord stimulation (SCS) and lumbar reoperation for the treatment of failed back surgery syndrome (FBSS), and examine their associated complications and health care costs. SUMMARY OF BACKGROUND DATA: FBSS is a major source of chronic neuropathic pain and affects up to 40% of patients who undergo lumbosacral spine surgery for back pain. Thus far, few economic analyses have been performed comparing the various treatments for FBSS, with these studies involving small sample sizes. In addition, the nationwide practices in the use of SCS for FBSS are unknown. METHODS: The MarketScan data set was used to analyze patients with FBSS who underwent SCS or spinal reoperation between 2000 and 2009. Propensity score methods were used to match patients who underwent SCS with those who underwent lumbar reoperation to examine health care resource utilization. Postoperative complications were analyzed with multivariate logistic regression. Health care use was analyzed using negative binomial and general linear models. RESULTS: The study cohort included 16,455 patients with FBSS, with 395 undergoing SCS implantation (2.4%). Complication rates at 90 days were significantly lower for SCS than spinal reoperation (P < 0.0001). Also in the matched cohort, hospital stay (P < 0.0001) and associated charges (P = 0.016) were lower for patients with SCS. However outpatient, emergency room, and medication charges were similar between the 2 groups. Overall cost totaling $82,586 at 2 years was slightly higher in the lumbar reoperation group than in the SCS group with total cost of $80,669 (P = 0.88). CONCLUSION: Although previous studies have demonstrated superior efficacy for the treatment of FBSS, SCS remains underused. Despite no significant decreases in overall health care cost with SCS implantation, because it is associated with decreased complications and improved outcomes, this technology warrants closer consideration for the management of chronic pain in patients with FBSS.

Surgery for spinal stenosis: long-term reoperation rates, health care cost, and impact of instrumentation.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To examine the complications, reoperation rates, and resource use after each of the surgical approaches for the treatment of spinal stenosis. SUMMARY OF BACKGROUND DATA: There are no uniform guidelines for which procedure (decompression, decompression with instrumentation, or decompression with noninstrumented fusion) to perform for the treatment of spinal stenosis. With no clear evidence for increased efficacy, the rate of instrumented fusions is rising. METHODS: We performed a retrospective cohort analysis of patients who underwent spinal stenosis surgery between 2002 and 2009 in the United States. Patients included (n = 12,657) were diagnosed with spinal stenosis without concurrent spondylolisthesis and had at least 2 years of preoperative enrollment. A total of 2385 patients with decompression only and 620 patients with fusion had follow-up data for 5 years or more. RESULTS: Complication rates during the initial procedure hospitalization and at 90 days were significantly higher for those who underwent laminectomy with fusion than for those who underwent laminectomy alone, with reoperation rates not differing significantly between these groups. Long-term (≥5 yr) reoperation rates were similar for those undergoing decompression alone versus decompression with fusion (17.3% vs. 16.0%, P = 0.44). Those with instrumented fusions had a slightly higher rate of reoperation than patients with noninstrumented fusions (17.4% vs. 12.2%, P = 0.11) at more than 5 years. The total cost including initial procedure and hospital, outpatient, emergency department, and medication charges at 5 years was similar for those who received decompression alone and fusion. The long-term costs for instrumented and noninstrumented fusions were also similar, totaling $107,056 and $100,471, respectively. CONCLUSION: For patients with spinal stenosis, if fusion is warranted, use of arthrodesis without instrumentation is associated with decreased costs with similar long-term complication and reoperation rates.

Interspinous device versus laminectomy for lumbar spinal stenosis: a comparative effectiveness study.

BACKGROUND CONTEXT: Currently no studies directly compare effectiveness between interspinous devices (IDs) and laminectomy in lumbar spinal stenosis (LSS) patients. PURPOSE: To compare reoperations, complications, and costs between LSS patients undergoing ID placement versus laminectomy. STUDY DESIGN: Retrospective comparative study. PATIENT SAMPLE: The MarketScan database (2007-2009) was queried for adults with LSS undergoing ID placement as a primary inpatient procedure. OUTCOME MEASURES: Reoperation rates, complication rates, and costs. METHODS: Each ID patient was matched with a laminectomy patient using propensity score matching. Reoperations, complications, and costs were analyzed in patients with at least 18 months postoperative follow-up. The authors did not receive funding from any external sources for this study. RESULTS: Among 498 inpatients that underwent ID placement between 2007 and 2009; the average age was 73 years. The cumulative reoperation rates after ID at 12 and 18 months were 21% and 23%, respectively. The average inpatient hospitalization lasted 1.6 days with an associated cost of $17,432. Two propensity-matched cohorts of 174 patients that had undergone ID versus laminectomy were analyzed. Longer length of stay was observed in the laminectomy cohort (2.5 days vs. 1.6 days, p<.0001), whereas ID patients accrued higher costs at index hospitalization ($17,674 vs. $12,670, p=.0001). Index hospitalization (7.5% vs. 3.5%, p=.099) and 90-day (9.2% vs. 3.5%, p=.028) complications were higher in the laminectomy cohort compared with the ID cohort. The ID patients had significantly higher reoperation rates than laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p=.026) and incurred higher cumulative costs than laminectomy patients at 12 months follow-up ($39,173 vs. $34,324, p=.289). CONCLUSIONS: Twelve-month reoperation rates and index hospitalization costs were significantly higher among patients who underwent ID compared with laminectomy for LSS.

Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis.

BACKGROUND: Surgery remains the mainstay for management of lumbar spondylolisthesis and is considered an effective therapeutic modality following unsuccessful nonoperative treatment. Surgical procedures include decompression, decompression with instrumented arthrodesis, and decompression with noninstrumented arthrodesis. The purpose of this study was to examine the complications, reoperation rates, and health-care costs associated with each of these procedures. METHODS: The MarketScan database was utilized to identify 16,556 patients with a primary diagnosis of lumbar spondylolisthesis who underwent surgical treatment from 2000 to 2009. Outcomes were evaluated in propensity score-matched cohorts, with complication rates analyzed with the chi-square test, reoperation rates analyzed using the Mantel-Haenszel test, and health-care resource use analyzed using the Wilcoxon signed-rank test. RESULTS: Complication rates were significantly higher in patients who underwent arthrodesis compared with those who had decompression alone during the initial hospitalization (8.3% versus 4.8%; p < 0.0001) and at the time of the ninety-day follow-up (9.6% versus 5.5%; p < 0.0001). Complication rates were similar for those who received instrumented and noninstrumented arthrodesis. Patients who underwent decompression alone had higher reoperation rates at two years or more than those who received arthrodesis (15.7% versus 11.9%; p = 0.034). Patients with instrumented arthrodesis trended to have higher reoperation rates than those without instrumentation at five years or more (18.4% versus 10.6%; p = 0.063). Initial hospital costs and two-year and five-year overall costs (in 2009 U.S. dollars) were higher for patients managed with arthrodesis than for those who had decompression only ($102,906 versus $89,337; p = 0.0018). Also, patients who received instrumentation had higher hospitalization costs than those without instrumentation ($39,997 versus $27,309; p = 0.023) and higher overall costs at two years ($73,482 versus $60,394; p < 0.0001), although the difference was not significant at five years (p = 0.29). CONCLUSIONS: Patients with lumbar spondylolisthesis who underwent decompressive laminectomy and spinal arthrodesis had lower reoperation rates but higher overall costs than patients treated with laminectomy alone. Noninstrumented arthrodesis was also associated with lower long-term reoperation rates and health-care costs compared with instrumented arthrodesis. The long-term outcomes and costs of these procedures should be evaluated in conjunction with clinical efficacy to ensure the most cost-effective treatment is utilized. LEVEL OF EVIDENCE: Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of percutaneous and paddle lead implantation for spinal cord stimulation: a comparative analysis of complications, reoperation rates, and health-care costs.

OBJECTIVES: Spinal cord stimulation (SCS) is a well-established modality for the treatment of chronic pain, and can utilize percutaneous or paddle leads. While percutaneous leads are less invasive, they have been shown to have higher lead migration rates. In this study, we compared the long-term outcomes and health-care costs associated with paddle and percutaneous lead implantation. MATERIALS AND METHODS: We utilized the MarketScan data base to examine patients who underwent percutaneous or paddle lead SCS system implantation from 2000 to 2009. Outcomes including complications, reoperation rates, and health-care costs were evaluated in propensity score matched cohorts using univariate and multivariate analyses. RESULTS: The study cohort was comprised of 13,774 patients. At 90 days following the initial procedure, patients in the SCS paddle group were more likely to develop a postoperative complication than patients receiving percutaneous systems (3.4% vs. 2.2%, p = 0.0005). Two-year (6.3% vs. 3.5%, p = 0.0056) and long-term (five+ years) (22.9% vs. 8.5%, p < 0.0008) reoperation rates were significantly higher in those with percutaneous lead systems. However, long-term health-care costs were similar for those receiving paddle and percutaneous leads ($169,768 vs. $186,139, p = 0.30). CONCLUSIONS: While the implantation of paddle leads is associated with slightly higher initial postoperative complications, these leads are associated with significantly lower long-term reoperation rates. Nonetheless, long-term health-care costs are similar between paddle and percutaneous leads. Additional improvements in SCS technologies that address the shortcomings of current systems are needed to reduce the risk of reoperation due to hardware failure. Further study is required to evaluate the efficacy of newer percutaneous and paddle SCS systems and examine their comparative outcomes.

Long-term economic impact of coiling vs clipping for unruptured intracranial aneurysms.

BACKGROUND: : Treatment of unruptured intracranial aneurysms (UIAs) involves endovascular coiling or aneurysm clipping. While many studies have compared these treatment modalities with respect to various clinical outcomes, few studies have investigated the economic costs associated with each procedure. OBJECTIVE: : To determine the reoperation rate, postoperative complications, and inpatient and outpatient costs associated with surgical or endovascular treatment of patients with UIAs in the United States. METHODS: : We utilized the MarketScan database to examine patients who underwent surgical clipping or endovascular coiling procedures for UIAs from 2000 to 2009, comparing reoperation rates, complications, and angiogram and healthcare resource use. Propensity score matching techniques were used to match patients. RESULTS: : We identified 4,504 patients with surgically treated UIAs, with propensity score matching of 3,436 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1- (P < .001), 2- (P < .001), and 5 years (P < .001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1, 2, and 5 years were significantly higher in the coiling group. CONCLUSION: : Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, overall costs at 2 and 5 years were similar to endovascular coiling due to the significantly higher number of follow-up angiograms and outpatient costs in these patients. ABBREVIATIONS: : SAH, subarachnoid hemorrhageUIAs, unruptured intracranial aneurysms.

Disparities in the outcomes of lumbar spinal stenosis surgery based on insurance status.

STUDY DESIGN: Retrospective cohort study using Thomson Reuter's MarketScan database. OBJECTIVE: To evaluate the extent to which Medicaid versus commercial insurance status affects outcomes after lumbar stenosis surgery. SUMMARY OF BACKGROUND DATA: The Affordable Care Act aims to expand health insurance and to help narrow existing health care disparities. Medicaid patients have previously been noted to be at an increased risk for impaired access to health care. Conversely, those with commercial insurance may be subject to overtreatment. We examine the surgical treatment of low back pain as an example that has raised significant public health concerns. METHODS: A total of 28,462 patients, ages 18 and older, were identified who had undergone laminectomy or fusion for spinal stenosis between 2000 and 2009. Patients were characterized by baseline demographic information, comorbidity burden, and type of insurance (Medicaid vs. commercial insurance). Multivariate analysis was performed comparing the relative effect of insurance status on reoperation rates, timing and type of reoperations, postoperative complications, and total postoperative health resource use. RESULTS: Medicaid patients had similar reoperation rates to commercially insured patients at 1 year (4.60% vs. 5.42%, P = .38); but had significantly lower reoperation rates at 2 (7.22% vs. 10.30%; adjusted odds ratio [aOR] = 0.661; 95% confidence interval [CI], 0.533-0.820; P = .0002) and more than 2 years (13.92% vs. 16.89%; aOR = 0.722; 95% CI, 0.612-0.851; P <.0001). Medicaid patients were particularly less likely to undergo fusion as a reoperation (aOR = 0.478; 95% CI, 0.377-0.606; P < 0001). Medicaid patients had greater health care resource utilization as measured by hospital days, outpatient services and medications prescribed; however, commercially insured patients had significantly higher overall health utilization costs at 1 and 2 years. CONCLUSION: There are insurance disparities that affect important surgical outcomes after initial surgery for spinal stenosis. Efforts for national health care reform should include explicit efforts to identify such system factors that will reduce current inequities in care. LEVEL OF EVIDENCE: 2.

Trends in surgical use and associated patient outcomes in the treatment of acoustic neuroma.

OBJECTIVE: To investigate recent trends in surgical volume and associated patient outcomes in the treatment of acoustic neuromas. METHODS: A retrospective analysis was performed using the Nationwide Inpatient Sample database from 2000-2007; cases from 2005 were excluded because of coding inconsistencies. Univariate and multivariate analyses were used to describe surgical trends and analyze inpatient outcomes. RESULTS: Among 14,928 patients studied, 87.1% were treated at large (based on number of beds) hospitals. Cases at these hospitals declined progressively from 2054 to 1467 cases (a 28.6% decrease) from 2000-2007; a 40.8% (178 cases per year, R(2) = 0.73) reduction in surgeries was observed from 2001-2007. Although mortality remained steady at 0.3%, nonroutine discharge (increase from 10.9% to 19.1%) and complication rates (increase from 21.5% to 23.3%) increased in recent years. Patients without private insurance had an increased risk of nonroutine discharge (odds ratio [OR] 1.7, P = 0.0033; OR 1.5, P = 0.0382), and patients with more comorbidities had an increased risk of complications (OR 1.8, P < 0.0001; OR 1.5, P < 0.0001). High surgical caseload reduced nonroutine discharge by 30% (OR 0.7, P < 0.0001) and complications by 10% (OR 0.9, P < 0.0281). CONCLUSIONS: A 41%, or 178 cases per year, reduction in surgical excision of acoustic neuroma cases was observed during the period 2001-2007. A possible explanation for this trend includes increased use of stereotactic radiosurgery. Nonroutine discharge and complications after surgical excision have increased perhaps because of surgery being used for larger tumors.

Racial disparities in Medicaid patients after brain tumor surgery.

The presence of healthcare-related disparities is an ongoing, widespread, and well-documented societal and health policy issue. We investigated the presence of racial disparities among post-operative patients either with meningioma or malignant, benign, or metastatic brain tumors. We used the Medicaid component of the Thomson Reuter's MarketScan database from 2000 to 2009. Univariate and multivariate analysis assessed death, 30-day post-operative risk of complications, length of stay, and total charges. We identified 2321 patients, 73.7% were Caucasian, 57.8% were women; with Charlson comorbidity scores of <3 (56.2%) and treated at low-volume centers (73.4%). Among all, 26.3% of patients were of African-American ethnicity and 22.1% had meningiomas. Mortality was 2.0%, mean length of stay (LOS) was 9 days, mean total charges were US$42,422, an adverse discharge occurred in 22.5% of patients, and overall 30-day complication rate was 23.4%. In a multivariate analysis, African-American patients with meningiomas had higher odds of developing a 30-day complication (p=0.05) and were significantly more likely to have longer LOS (p<0.001) and greater total charges (p<0.001) relative to Caucasian counterparts. The presence of one post-operative complication doubled LOS and nearly doubled total charges, while the presence of two post-operative complications tripled these outcomes. Patients of African-American ethnicity had significantly higher post-operative complications than those of Caucasian ethnicity. This higher rate of complications seems to have driven greater healthcare utilization, including greater LOS and total charges, among African-American patients. Interventions aimed at reducing complications among African-American patients with brain tumor may help reduce post-operative disparities.

Racial disparities in outcomes of spinal surgery for lumbar stenosis.

STUDY DESIGN: A retrospective, cross-sectional study. OBJECTIVE: To evaluate racial disparities in outcomes of lumbar stenosis surgery. SUMMARY OF BACKGROUND DATA: Racial inequalities have been described in the outcomes of cardiovascular and orthopedic procedures. There have been minimal investigation of racial disparities in complications and costs of lumbar laminectomies and fusions. METHODS: We analyzed the Medicaid data set of Thomson Reuter's MarketScan database. African-American and non-Hispanic white patients who underwent laminectomy or fusion for lumbar stenosis with at least 2 years postoperative data were included. We examined the effect of race on the rate of reoperations, complications, and the cost associated with surgery. RESULTS: African-American patients in the Medicaid database were at no higher risk for reoperation in the 2 years after an operation for lumbar stenosis than white patients (7.14% vs. 7.89%, P = 0.7895). However, we did find that African-American patients were more likely to experience postoperative complications of any kind, even after adjusting for length of hospital stay, comorbidities, sex, and age (adjusted odds ratio = 1.819, P = 0.0123 for immediate complication; adjusted odds ratio = 1.746, P = 0.0141 for 30-d complication; and adjusted odds ratio = 1.611, P = 0.0410 for 90-d complication). White patients had a significantly shorter length of stay (3 vs. 5 d, P < 0.007) and accrued fewer hospital-related costs ($16,148 vs. $24,267, P < 0.0007). African-American patients, despite having more comorbidities in our sample, were prescribed significantly fewer medications in the 2 years after index procedures (91 vs. 138 prescriptions, P < 0.0007) and had fewer medication costs during the 2 years after surgery ($5297 vs. $8450, P < 0.0007). CONCLUSION: At the national level, there are several racial disparities in the rate of complications, length of stay, and costs after surgery for lumbar spinal stenosis. LEVEL OF EVIDENCE: 3.

The effect of transfer and hospital volume in subarachnoid hemorrhage patients.

INTRODUCTION: Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the "transfer effect" in a large sample of aneurysmal SAH patients undergoing treatment. METHODS: Using Nationwide Inpatient Sample 2002-2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, length of stay (LOS), and total charges. RESULTS: Of 47,114 patients, 31,711 (67.3 %) were direct-admits and 15,403 (32.7 %) were transfers. More transfer patients were coiled than direct-admits (45.3 vs. 33.7 %, p < 0.0001) and fewer underwent ventriculostomy (26.6 vs. 31.5 %, p = 0.003). Older age (OR 1.2, p < 0.0001), higher disease severity (OR 1.4, p < 0.0001), lower volume (OR 1.5, p < 0.0001), and ventriculostomy (OR 2.1, p < 0.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p = 0.13) and complications (OR 0.9, p = 0.22) as direct-admits, but incurred higher non-routine discharge (OR 1.3, p = 0.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher ($401,386 vs. $242,774, p = 0.03). CONCLUSION: Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.

Epidemiology and the global burden of stroke.

OBJECTIVE: Stroke remains one of the most devastating of all neurological diseases, often causing death or gross physical impairment or disability. As numerous countries throughout the world undergo the epidemiological transition of diseases, trends in the prevalence of stroke have dramatically changed. METHODS: All major international epidemiological articles published during the past 20 years addressing the global burden of stroke were reviewed. A focus was placed upon better defining current and future trends in surveillance, incidence, burden of disease, mortality, and costs associated with stroke internationally. RESULTS: Despite the fact that various surveillance systems are used to identify stroke and its sequela around the world, it is clear that stroke remains one of the top causes of mortality and disability-adjusted life-years (DALYs) lost globally. Concerning trends include the increase of stroke mortality and lost DALYs in low- and middle-income countries. The global economic impact of stroke may be dire if effective preventive measures are not implemented to help decrease the burden of this disease. CONCLUSION: The global burden of stroke is high, inclusive of increasing incidence, mortality, DALYs, and economic impact, particularly in low- and middle-income countries. The implementation of better surveillance systems and prevention programs are needed to help track current trends as well as to curb the projected exponential increase in stroke worldwide.

National trends in spinal arteriovenous malformations.

OBJECT: Spinal arteriovenous malformations (AVMs) are rare and understudied vascular lesions that cause neurological insult by mass effect, venous obstruction, and vascular steal. These lesions are challenging entities to treat because of their complicated anatomy and physiology. Current management options include open microsurgery, endovascular embolization, and stereotactic radiosurgery. METHODS: Our study used the National Inpatient Sample database to analyze outcome data for spinal AVMs treated nationwide over an 11-year period from 1995 through 2006. Trends in procedural management, hospital course, and epidemiology of spinal AVMs are investigated. RESULTS: Annually, an average of 300 patients presented with spinal AVMs requiring hospital treatment. The average length of hospital stay for this treatment has declined from more than 9 days in 1995 to 6 days in 2006. However, the average cost of a hospital stay has increased from < $30,000 to nearly $70,000. Whereas one-half of spinal AVMs were treated operatively in 1995, one-third were managed operatively in 2006. CONCLUSIONS: Spinal AVMs are being increasingly treated by endovascular, radiosurgical, or combined means. A discussion of modern strategies to treat these disorders is presented.

National trends in vertebral augmentation procedures for the treatment of vertebral compression fractures.

BACKGROUND: Vertebral compression fractures represent a serious health care problem. Vertebroplasty and kyphoplasty have been gaining popularity in the treatment of symptomatic compression fractures that are often secondary to osteoporosis or neoplasia. METHODS: We use the NIS database from 1993 through 2004 to examine trends in VCFs. Patients with VCFs were identified using primary diagnostic codes (ICD-9-pathologic vertebral fracture, 733.13) and cross-referenced with ICD-9 procedure codes (ICD-9-VAPs, 78.49; kyphoplasty, 81.66; and vertebroplasty, 81.65). RESULTS: In 2004, more than 23 000 VAPs were performed nationwide on an inpatient basis for VCFs. This represented a 12 900% increase in the number of procedures performed since 1993. Approximately 60% of patients were female and aged 65 to 84 years. Nearly 60% of vertebroplasties and 25% of kyphoplasties were on patients admitted from the ED. Large-sized hospitals and those hospitals located in the southern United States accounted for most of the cases. The mean LOS was 3.7 days for kyphoplasty and 7.3 days for vertebroplasty. The final discharge disposition, home vs institution (nursing home, rehabilitation), was 50:50 for vertebroplasty and 77:23 for kyphoplasty. The mean hospital charges for both procedures were comparable, and the total "national bill" was approximately $672 million in 2004. CONCLUSIONS: With the continued aging of the population, VCFs represent an increasingly important health care issue. The staggering increase in the number of minimally invasive VAPs performed illustrates the continued adoption of these innovative technologies and early trends in their applications.