ABSTRACT
Wound closure is an integral part of every spinal procedure. Effective and secure wound closure is paramount in the prevention of infection, wound dehiscence and the preservation of cosmesis. Barbed suture technologies such as STRATAFIX™ Symmetric have been studied and are used in a variety of specialties, including obstetrics and orthopedic surgery, but is underutilized in neurosurgery. This study aims to assess the time and rate of closure using STRATAFIX™ Symmetric technology for fascial closure and compare this method to the more traditionally used method of fascial closure using braided absorbable sutures below the epidermis. 20 patients were recruited for the study. 10 patients underwent fascial approximation with braided absorbable sutures and definitive fascial closure with STRATAFIX™ Symmetric. In the control group, fascial closure was completed entirely with interrupted braided absorbable stitches. Patients assigned to STRATAFIX™ Symmetric group had shorter mean time for fascial closure, faster rate of average fascial closure, and lower number of total sutures used. The use of barbed suture technology such as STRATAFIX™ Symmetric may reduce the time to closure in thoracolumbar spine surgery without increasing the risk of adverse events. This pilot study forms the framework for a larger randomized, controlled trial appropriately powered for such an analysis.
Subject(s)
Fasciotomy , Suture Techniques , Sutures , Humans , Pilot Projects , Female , Male , Middle Aged , Aged , Fasciotomy/methods , Prospective Studies , Adult , Neurosurgical Procedures/methods , Spine/surgery , Treatment OutcomeABSTRACT
OBJECTIVE: To investigate the effects of yearly institutional case volume for carotid endarterectomy (CEA) and stenting (CAS) among symptomatic carotid stenosis patients on the rates of postoperative stroke and inpatient mortality. MATERIALS AND METHODS: Patients with prior stroke ("symptomatic") undergoing CEA or CAS during an inpatient stay were identified from the National Inpatient Sample for years 2012-2015. The primary variable was volume of CEA or CAS performed annually by each institution. The primary outcome was a composite variable for in-hospital death or postoperative stroke. RESULTS: A total of 5,628 patients with symptomatic carotid stenosis underwent CEA, while 245 underwent CAS. In the symptomatic CEA population, 519 (9.2 %) patients experienced postoperative stroke or mortality, and were more likely to be treated at centers with a lower yearly institutional volume (median 10 [IQR 5-15] versus 10 [7-20] cases, p < 0.001). In the symptomatic CAS population, 32 (13.1 %) patients experienced stroke or mortality, and these patients were also more likely to undergo treatment at hospitals with a lower yearly institutional volume (median 5 [IQR 5-7] versus 5 [5-10] cases, p = 0.044). Thresholds for yearly institutional volume found differences in adverse outcome between 0-9, 10-29, and ≥30 cases/year (11.7 % vs 8.4 % vs 6.0 %, p < 0.001) for CEA, and differences in postoperative stroke between 0-9 and ≥10 cases/year for CAS (11.0 % vs 1.4 %, p = 0.028). CONCLUSIONS: Hospitals performing higher volumes of CEA or CAS have fewer postoperative strokes. The threshold reported herein is ≥30 CEA procedures or ≥10 CAS procedures annually for appreciably improved outcomes.
Subject(s)
Carotid Stenosis , Databases, Factual , Endarterectomy, Carotid , Hospital Mortality , Hospitals, High-Volume , Hospitals, Low-Volume , Stents , Stroke , Humans , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/mortality , Carotid Stenosis/mortality , Carotid Stenosis/therapy , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/complications , Carotid Stenosis/surgery , Male , Aged , Female , Treatment Outcome , United States/epidemiology , Time Factors , Risk Factors , Stroke/mortality , Stroke/diagnosis , Stroke/etiology , Middle Aged , Aged, 80 and over , Endovascular Procedures/adverse effects , Endovascular Procedures/mortality , Endovascular Procedures/instrumentation , Risk Assessment , Retrospective Studies , InpatientsABSTRACT
PURPOSE: Owing to their vicinity near the superior sagittal sinus, parasagittal and parafalcine meningiomas are challenging tumors to surgically resect. In this study, we investigate key factors that portend increased risk of recurrence after surgery. METHODS: This is a retrospective study of patients who underwent resection of parasagittal and parafalcine meningiomas at our institution between 2012 and 2018. Relevant clinical, radiographic, and histopathological variables were selected for analysis as predictors of tumor recurrence. RESULTS: A total of 110 consecutive subjects (mean age: 59.4 ± 15.2 years, 67.3% female) with 74 parasagittal and 36 parafalcine meningiomas (92 WHO grade 1, 18 WHO grade 2/3), are included in the study. A total of 37 patients (33.6%) exhibited recurrence with median follow-up of 42 months (IQR: 10-71). In the overall cohort, parasagittal meningiomas exhibited shorter progression-free survival compared to parafalcine meningiomas (Kaplan-Meier log-rank p = 0.045). On univariate analysis, predictors of recurrence include WHO grade 2/3 vs. grade 1 tumors (p < 0.001), higher Ki-67 indices (p < 0.001), partial (p = 0.04) or complete sinus invasion (p < 0.001), and subtotal resection (p < 0.001). Multivariable Cox regression analysis revealed high-grade meningiomas (HR: 3.62, 95% CI: 1.60-8.22; p = 0.002), complete sinus invasion (HR: 3.00, 95% CI: 1.16-7.79; p = 0.024), and subtotal resection (HR: 3.10, 95% CI: 1.38-6.96; p = 0.006) as independent factors that portend shorter time to recurrence. CONCLUSION: This study identifies several pertinent factors that confer increased risk of recurrence after resection of parasagittal and parafalcine meningiomas, which can be used to devise appropriate surgical strategy to achieve improved patient outcomes.
Subject(s)
Meningeal Neoplasms , Meningioma , Humans , Female , Adult , Middle Aged , Aged , Male , Meningioma/diagnostic imaging , Meningioma/surgery , Meningeal Neoplasms/diagnostic imaging , Meningeal Neoplasms/surgery , Retrospective Studies , Neoplasm Recurrence, Local/surgery , Neoplasm Recurrence, Local/pathology , Superior Sagittal Sinus/surgeryABSTRACT
INTRODUCTION: The National Inpatient Sample (NIS) has led to several breakthroughs via large sample size. However, utility of NIS is limited by the lack of admission NIHSS and 90-day modified Rankin score (mRS). This study creates estimates for stroke severity at admission and 90-day mRS using NIS data for acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). METHODS: Three patient cohorts undergoing MT for AIS were utilized: Cohort 1 (Nâ¯=â¯3729) and Cohort 3 (Nâ¯=â¯1642) were derived from NIS data. Cohort 2 (N=293) was derived from a prospectively-maintained clinical registry. Using Cohort 1, Administrative Stroke Outcome Variable (ASOV) was created using disposition and mortality. Factors reflective of stroke severity were entered into a stepwise logistic regression predicting poor ASOV. Odds ratios were used to create the Administrative Data Stroke Scale (ADSS). Performances of ADSS and ASOV were tested using Cohort 2 and compared with admission NIHSS and 90-day mRS, respectively. ADSS performance was compared with All Patient Refined-Diagnosis Related Group (APR-DRG) severity score using Cohort 3. RESULTS: Agreement of ASOV with 90-day mRS > 2 was fair (κâ¯=â¯0.473). Agreement with 90-day mRS > 3 was substantial (κâ¯=â¯0.687). ADSS significantly correlated (p < 0.001) with clinically-significant admission NIHSS > 15. ADSS performed comparably (AUCâ¯=â¯0.749) to admission NIHSS (AUCâ¯=â¯0.697) in predicting 90-day mRS > 2 and mRS > 3 (AUCâ¯=â¯0.767, 0.685, respectively). ADSS outperformed APR-DRG severity score in predicting poor ASOV (AUCâ¯=â¯0.698, 0.682, respectively). CONCLUSION: We developed and validated measures of stroke severity at admission (ADSS) and outcome (ASOV, estimate for 90-day mRS > 3) to increase utility of NIS data in stroke research.
Subject(s)
Administrative Claims, Healthcare , Disability Evaluation , Inpatients , Ischemic Stroke/diagnosis , Aged , Databases, Factual , Female , Humans , Ischemic Stroke/drug therapy , Ischemic Stroke/epidemiology , Male , Middle Aged , Patient Admission , Predictive Value of Tests , Registries , Reproducibility of Results , Severity of Illness Index , Thrombectomy , Time Factors , Treatment Outcome , United States/epidemiologyABSTRACT
OBJECTIVES: Intracranial atherosclerotic disease (ICAD) is responsible for 8-10% of acute ischemic strokes, and resistance to antiplatelet therapy is prevalent. CYP2C19 gene loss-of-function (up to 45% of patients) causes clopidogrel resistance. For patients with asymptomatic ICAD and ICAD characterized by transient ischemic attack (TIA), this study measures the effect of CYP2C19 loss-of-function on ischemic stroke risk during clopidogrel therapy. MATERIALS AND METHODS: From a deidentified database of medical records, patients were selected with ICD-9/10 code for ICAD, availability of CYP2C19 genotype, clopidogrel exposure, and established patient care. Dual-antiplatelet therapy patients were included. Patients with prior ischemic stroke, other neurovascular condition, intracranial angioplasty/stenting, or observation time <1 month were excluded. Time-to-event analysis using Cox regression was conducted to model first-time ischemic stroke events based on CYP2C19 loss-of-function allele and adjusted for age, gender, race, length of aspirin, length of concurrent antiplatelet/anticoagulant treatment, diabetes, coagulopathy, hypertension, heart disease, atrial fibrillation, and lipid disorder. Subset analyses were performed for asymptomatic and post-TIA subtypes of ICAD. RESULTS: A total of 337 patients were included (median age 68, 58% male, 88% Caucasian, 26% CYP2C19 loss-of-function). A total of 161 (47.8%) patients had TIA at time of ICAD diagnosis, while 176 (52.2%) were asymptomatic. First-time ischemic stroke was observed among 20 (12.4%) post-TIA ICAD patients and 17 (9.7%) asymptomatic ICAD patients. Median observation time was 2.82 [IQR 1.13-5.17] years. CYP2C19 loss-of-function allele was associated with ischemic stroke event (HR 2.2, 95% CI 1.1-4.3, p=0.020) after adjustment. Post-TIA ICAD patients had a higher risk of ischemic stroke from CYP2C19 loss-of-function (HR 3.4, 95% CI 1.4-8.2, p=0.006). CONCLUSIONS: CYP2C19 loss-of-function was associated with 3-fold increased risk of first-time ischemic stroke for ICAD patients treated with clopidogrel after TIA. This effect was not observed for asymptomatic ICAD. CYP2C19-guided antiplatelet selection may improve stroke prevention in ICAD after TIA.
Subject(s)
Clopidogrel/adverse effects , Cytochrome P-450 CYP2C19/genetics , Drug Resistance/genetics , Intracranial Arteriosclerosis/drug therapy , Ischemic Attack, Transient/prevention & control , Ischemic Stroke/prevention & control , Pharmacogenomic Variants , Platelet Aggregation Inhibitors/adverse effects , Aged , Clopidogrel/administration & dosage , Databases, Factual , Female , Humans , Intracranial Arteriosclerosis/complications , Intracranial Arteriosclerosis/diagnostic imaging , Ischemic Attack, Transient/diagnostic imaging , Ischemic Attack, Transient/etiology , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/etiology , Male , Middle Aged , Platelet Aggregation Inhibitors/administration & dosage , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND/PURPOSE: Our study aimed to assess the impacts of neighborhood socioeconomic status on mechanical thrombectomy (MT) outcomes for acute ischemic stroke (AIS). METHODS: We conducted a prospective observational study of consecutive adult AIS patients treated with MT at one US comprehensive stroke center from 2012 to 2018. A composite neighborhood socioeconomic score (nSES) was created using patient home address, median household income, percentage of households with interest, dividend, or rental income, median value of housing units, percentage of persons 25 or older with high school degrees, college degrees or holding executive, managerial or professional specialty occupations. Using this score, patients were divided into low, middle and high nSES tertiles. Outcomes included 90-day functional independence, in-hospital mortality, length of hospital stay, discharge location, time to recanalization, successful recanalization, and symptomatic intracranial hemorrhage (sICH). RESULTS: 328 patients were included. Between the three nSES groups, proportion of White patients, time-to-recanalization and admission NIH stroke scale differed significantly (p<0.05). Patients in the high nSES tertile were more likely to be functionally dependent at 90 days (unadjusted OR, 95% CI, 1.91 [1.10, 3.36]) and were less likely to die in the hospital (unadjusted OR, 95% CI, 0.46, [0.20, 0.98]). Further, patients in the high nSES tertile had decreased times to recanalization (median time in minutes, low=335, mid=368, high=297, p=0.04). However, after adjusting for variance in race and severity of stroke, the differences in clinical outcomes were not significant. CONCLUSION: This study highlights how unadjusted neighborhood socioeconomic status is significantly associated with functional outcome, mortality, and time-to-recanalization following MT for AIS. Since adjustment modifies the significant association, the socioeconomic differences may be influenced by differences in pre-hospital factors that drive severity of stroke and time to recanalization. Better understanding of the interplay of these factors may lead to timelier evaluation and improvement in patient outcomes.
Subject(s)
Health Status Disparities , Healthcare Disparities , Ischemic Stroke/epidemiology , Ischemic Stroke/therapy , Residence Characteristics , Social Class , Social Determinants of Health , Thrombectomy , Aged , Educational Status , Female , Functional Status , Hospital Mortality , Humans , Income , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Length of Stay , Male , Middle Aged , Occupations , Prospective Studies , Race Factors , Recovery of Function , Risk Factors , Tennessee/epidemiology , Thrombectomy/adverse effects , Thrombectomy/mortality , Time Factors , Time-to-Treatment , Treatment OutcomeABSTRACT
Recent media articles have stirred controversy over anecdotal reports of medical students practising educational pelvic examinations on women under anaesthesia without explicit consent. The understandable public outrage that followed merits a substantive response from the medical community. As medical students, we offer a unique perspective on consent for trainee involvement informed by the transitional stage we occupy between patient and physician. We start by contextualising the role of educational pelvic examinations under anaesthesia (EUAs) within general clinical skill development in medical education. Then we analyse two main barriers to achieving explicit consent for educational pelvic EUAs: ambiguity within professional guidelines on how to operationalize 'explicit consent' and divergent patient and physician perspectives on harm which prevent physicians from understanding what a reasonable patient would want to know before a procedure. To overcome these barriers, we advocate for more research on patient perspectives to empower the reasonable patient standard. Next, we call for minimum disclosure standards informed by this research and created in conjunction with students, physicians and patients to improve the informed consent process and relieve medical student moral injury caused by performing 'unconsented' educational pelvic exams.
ABSTRACT
Effective treatment of opioid use disorder (OUD) must target both the medical and psychosocial aspects of a patient's condition. This, in turn, requires a collaboration between medical providers and social supports. We would like to illustrate a key difficulty in this collaboration for some patients in our country: many post-discharge recovery houses continue to refuse to allow patients to remain on medication treatment for OUD (M-OUD). This barrier to M-OUD access in recovery houses is a significant obstacle to effective OUD treatment.
Subject(s)
Halfway Houses/trends , Insurance Coverage/trends , Intersectoral Collaboration , Narcotic-Related Disorders/rehabilitation , Patient Discharge/trends , Buprenorphine/therapeutic use , Cost-Benefit Analysis/economics , Cost-Benefit Analysis/trends , Halfway Houses/economics , Health Services Needs and Demand/economics , Health Services Needs and Demand/trends , Ill-Housed Persons/statistics & numerical data , Humans , Insurance Coverage/economics , Narcotic-Related Disorders/economics , Patient Discharge/economics , TennesseeABSTRACT
PURPOSE: Chronic sleep problems can lead to difficulties for both the individual and society at large, making it important to effectively measure sleep. This study assessed the accuracy of an iPhone application (app) that could potentially be used as a simple, inexpensive means to measure sleep over an extended period of time in the home. METHODS: Twenty-five subjects from the ages of 2-14 who were undergoing overnight polysomnography (PSG) were recruited. The phone was placed on the mattress, near their pillow, and recorded data simultaneously with the PSG. The data were then downloaded and certain parameters were compared between the app and PSG, including total sleep time, sleep latency, and time spent in various defined "stages." RESULTS: Although there seemed to be a visual relationship between the graphs generated by the app and PSG, this was not confirmed on numerical analysis. There was no correlation between total sleep time or sleep latency between the app and PSG. Sleep latency from the PSG and latency to "deep sleep" from the app had a significant relationship (p = 0.03). No combination of PSG sleep stages corresponded with app "stages" in a meaningful way. CONCLUSIONS: The Sleep Cycle App may have value in increasing the user's awareness of sleep issues, but it is not yet accurate enough to be used as a clinical tool.
Subject(s)
Mobile Applications , Monitoring, Ambulatory/instrumentation , Polysomnography/instrumentation , Sleep Wake Disorders/diagnosis , Smartphone , Adolescent , Child , Child, Preschool , Female , Humans , Male , Reproducibility of Results , Statistics as TopicABSTRACT
BACKGROUND: Although not a technically difficult operation, cranioplasty is associated with high rates of complications. The optimal timing of cranioplasty to mitigate complications remains the subject of debate. OBJECTIVE: To report outcomes between patients undergoing cranioplasty at ultra-early (0-6 weeks), intermediate (6 weeks to 6 months), and late (>6 months) time frames. We report a novel craniectomy contour classification (CCC) as a radiographic parameter to assess readiness for cranioplasty. METHODS: A single-institution retrospective analysis of patients undergoing cranioplasty was performed. Patients were stratified into ultra-early (within 6 weeks of index craniectomy), intermediate (6 weeks to 6 months), and late (>6 months) cranioplasty cohorts. We have devised CCC scores, A, B, and C, based on radiographic criteria, where A represents those with a sunken brain/flap, B with a normal parenchymal contour, and C with "full" parenchyma. RESULTS: A total of 119 patients were included. There was no significant difference in postcranioplasty complications, including return to operating room ( P = .212), seizures ( P = .556), infection ( P = .140), need for shunting ( P = .204), and deep venous thrombosis ( P = .066), between the cohorts. Univariate logistic regression revealed that ultra-early cranioplasty was significantly associated with higher rate of functional independence at >6 months (odds ratio 4.32, 95% CI 1.39-15.13, P = .015) although this did not persist when adjusting for patient selection features (odds ratio 2.90, 95% CI 0.53-19.03, P = .234). CONCLUSION: In appropriately selected patients, ultra-early cranioplasty is not associated with increased rate of postoperative complications and is a viable option. The CCC may help guide decision-making on timing of cranioplasty.
Subject(s)
Decompressive Craniectomy , Plastic Surgery Procedures , Humans , Retrospective Studies , Patient Selection , Decompressive Craniectomy/adverse effects , Surgical FlapsABSTRACT
OBJECTIVE: Low socioeconomic status is a determinant of pediatric traumatic brain injury (TBI) incidence and severity. In this study, the authors used National (Nationwide) Inpatient Sample (NIS) data to evaluate socioeconomic and health disparities among children hospitalized after TBI. METHODS: This retrospective study identified pediatric patients aged 0 to 19 years with ICD-9 codes for TBI in the NIS database from 2012 to 2015. Socioeconomic variables included race, sex, age, census region, and median income of the patient residential zip code. Outcomes included mechanism of injury, hospital length of stay (LOS), cost, disposition at discharge, death, and inpatient complications. Multivariate linear regressions in log scale were built for LOS and cost. Logistic regressions were built for death, disposition, and inpatient complications. RESULTS: African American, Hispanic, and Native American patients experienced longer LOSs (ß 0.06, p < 0.001; ß 0.03, p = 0.03; ß 0.13, p = 0.02, respectively) and increased inpatient costs (ß 0.13, p < 0.001; ß 0.09, p < 0.001; ß 0.14, p = 0.03, respectively). Females showed increased rates of medical complications (OR 1.57, p < 0.001), LOS (ß 0.025, p = 0.02), and inpatient costs (p = 0.04). Children aged 15 to 19 years were less likely to be discharged home (OR 3.99, p < 0.001), had increased mortality (OR 1.32, p = 0.03) and medical complications (OR 1.84, p < 0.001), and generated increased costs (p < 0.001). CONCLUSIONS: The study results have demonstrated that racial minorities, females, older children, and children in lower socioeconomic groups were at increased risk of poor outcomes following TBI, including increased LOS, medical complications, mortality, inpatient costs, and worse hospital disposition. Public education and targeted funding for these groups will ensure that all children have equal opportunity for optimal clinical outcomes following TBI.
ABSTRACT
This study measures effect of CYP2C19 genotype on ischemic stroke risk during clopidogrel therapy for asymptomatic, extracranial carotid stenosis patients. Using deidentified electronic health records, patients were selected for retrospective cohort using administrative code for carotid stenosis, availability of CYP2C19 genotype result, clopidogrel exposure, and established patient care. Patients with intracranial atherosclerosis, aneurysm, arteriovenous malformation, prior ischemic stroke, or observation time <1 month were excluded. Dual antiplatelet therapy patients were included. Patients with carotid endarterectomy or stenting were analyzed in a separate subgroup. Time-to-event analysis using Cox regression was conducted to model ischemic stroke events based on CYP2C19 loss-of-function allele and adjusted with the most predictive covariates from univariate analysis. Covariates included age, gender, race, length of aspirin, length of concurrent antiplatelet/anticoagulant treatment, diabetes, coagulopathy, hypertension, heart disease, atrial fibrillation, and lipid disorder. A total of 1110 patients met selection criteria for medical therapy cohort (median age 68 [interquartile range (IQR) 60-75] years, 64.9% male, 91.9% Caucasian). Median study period was 2.8 [0.8-5.3] years. A total of 47 patients (4.2%) had an ischemic stroke event during study period. CYP2C19 loss-of-function allele was strongly associated with ischemic stroke events (one allele: HR 2.3, 95% CI 1.1-4.7, p=0.020; two alleles: HR 10.2, 95% CI 2.8-36.8, p<0.001) after adjustment. For asymptomatic carotid stenosis patients receiving clopidogrel to prevent ischemic stroke, CYP2C19 loss-of-function allele is associated with 2- to 10-fold increased risk of ischemic stroke. CYP2C19 genotype may be considered when selecting antiplatelet therapy for stroke prophylaxis in non-procedural, asymptomatic carotid stenosis.
Subject(s)
Carotid Stenosis , Ischemic Attack, Transient , Ischemic Stroke , Stroke , Aged , Carotid Stenosis/diagnostic imaging , Carotid Stenosis/genetics , Clopidogrel/adverse effects , Cytochrome P-450 CYP2C19/genetics , Cytochrome P-450 CYP2C19/therapeutic use , Female , Humans , Ischemic Attack, Transient/drug therapy , Male , Middle Aged , Platelet Aggregation Inhibitors/adverse effects , Retrospective Studies , Stroke/complications , Stroke/genetics , Treatment OutcomeABSTRACT
OBJECTIVE: Cerebral arteriovenous malformations (AVMs) are complex vascular lesions at perpetual risk for rupture, which can lead to significant morbidity and mortality. This study sought to evaluate the dynamic relationship between comorbidities and post-procedure complications to quantify the risk of poor discharge outcomes to create a predictive outcomes model. METHODS: The National Inpatient Sample (NIS) data from 2012 to 2015 was queried for AVM treatment using International Classification of Diseases, Ninth Revision codes. The Neurovascular Comorbidities Index (NCI) quantified patient comorbidity burden. In-hospital complications included surgical and medical complications or seizures. The primary outcome was the NIS Subarachnoid Hemorrhage Outcome Measure (NIS-SOM). RESULTS: A total of 1363 patients were included. A total of 1330 patients (98%) underwent embolization, 28 (2%) underwent resection, and 9 (0.7%) underwent radiosurgery. A higher NCI was associated with the occurrence of any complication (odds ratio [OR], 1.30 if NCI = 2; P < 0.001). Higher NCI was also significantly associated with a poor NIS-SOM outcome (OR, 2.45 if NCI = 2 and no complications; P < 0.001). A ruptured AVM with intracranial hemorrhage (ICH) increased the risk of in-hospital complications (OR, 2.16; P = 0.007) and a poor NIS-SOM outcome (OR, 3.18; P < 0.001). Various hypothetical patient scenarios and the predicted outcomes are also presented. CONCLUSION: Neurovascular comorbidities have a significant impact on poor functional outcomes at discharge in patients with and without complications following procedural management of AVMs. At the time of initial patient assessment, risk stratification strategies should take into account neurovascular comorbidities and potential complications. Such an approach would ultimately optimize patient outcomes and increase the value of care provided.
Subject(s)
Embolization, Therapeutic , Intracranial Arteriovenous Malformations , Radiosurgery , Subarachnoid Hemorrhage , Comorbidity , Humans , Intracranial Arteriovenous Malformations/complications , Intracranial Arteriovenous Malformations/surgery , Retrospective Studies , Subarachnoid Hemorrhage/surgery , Treatment OutcomeABSTRACT
BACKGROUND: Identifying drivers of nationwide variation in healthcare costs could help reduce overall cost. Endovascular treatment for unruptured cerebral aneurysms (ETUCR) is an elective neurointerventional procedure that allows for detailed analysis of cost variation. This study aimed to investigate the role of insurance type in cost variation of ETUCR. METHODS: A retrospective analysis of patients undergoing ETUCR was done. Demographic and hospital data were obtained from the National Inpatient Sample 2012-2015. Multivariate analysis was done using a generalized linear model. Oaxaca-Blinder decomposition was performed to identify factors driving cost variation. RESULTS: There was a significant difference in median cost ($25 331.82 vs $25 825.25, respectively, P<0.001) as well as length of stay (P<0.001) and complications (P<0.001) between patients with private insurance and Medicare. In multivariate analysis, insurance type was not predictive of increased cost. Among patients aged 65-75 years there was a higher median cost with private insurance compared to Medicare ($28 373.85 vs $25 558.25, respectively, P<0.001) but no difference in complications or length of stay. Oaxaca-Blinder decomposition showed higher marginal costs associated with private insurance patients at hospitals with greater endovascular operative volume (P=0.015). CONCLUSIONS: In patients aged 65-75 years, private insurance is associated with higher costs compared to Medicare; however, insurance type is not predictive of increased cost in multivariate analysis. Differential treatment of private insurance and Medicare patients at hospitals with greater operative volume seems to influence this difference, likely due to differential reimbursement schemes that lead to weaker cost controls.
Subject(s)
Endovascular Procedures/economics , Health Care Costs , Insurance, Health/economics , Intracranial Aneurysm/economics , Intracranial Aneurysm/surgery , Medicare/economics , Adult , Aged , Aged, 80 and over , Female , Humans , Insurance Coverage/economics , Intracranial Aneurysm/epidemiology , Length of Stay/economics , Male , Middle Aged , Retrospective Studies , Treatment Outcome , United States/epidemiologyABSTRACT
OBJECTIVE: Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children. METHODS: This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients. RESULTS: A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients. CONCLUSIONS: Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.
ABSTRACT
OBJECTIVE: We aim to define the dynamic interplay between neurovascular-specific comorbidities and in-hospital complications on outcomes (functional outcome and mortality), length of stay (LOS), and cost of hospital stay. METHODS: The 2012-2015 National Inpatient Sample (NIS) was queried for intracranial aneurysm treatment after subarachnoid hemorrhage using International Classification of Diseases, Ninth Revision codes. Neurovascular comorbidity index (NCI) was aggregated. NIS-Subarachnoid Hemorrhage Severity Score (NIS-SSS) was used as a Hunt-Hess grade proxy. In-hospital complications were medical complications, surgical complications, seizures, and cerebral vasospasm. Outcomes were functional outcome (modified Rankin Scale [mRS]-equivalent measure), in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost. RESULTS: A total of 5353 patients were included. The median NCI was 4.00 (interquartile range [IQR], 0.00-7.00) and 2882 patients (54%) had in-hospital complication. Higher NCI (odds ratio [OR], 1.13 if NCI = 1; OR, 2.05 if NCI = 7; P < 0.001) was associated with any complication, seizure (OR, 1.11, NCI = 1; OR, 1.60, NCI = 7; P < 0.001), medical complication (OR, 1.18, NCI = 1; OR, 2.50, NCI = 7; P < 0.001), surgical complication (OR, 1.13, NCI = 1; OR, 1.91, NCI = 7; P < 0.001), and cerebral vasospasm (OR, 1.09, NCI = 1; OR, 1.49, NCI = 7; P < 0.001). Patients with higher NCI (OR, 1.06, NCI = 1; OR, 1.95, NCI = 7; P < 0.001) or with in-hospital complication (P < 0.001) had poorer mRS equivalent outcome. Similar trends were observed for other outcomes including in-hospital mortality, LOS, and cost. CONCLUSIONS: Neurovascular comorbidities are the primary driver of poor mRS equivalent outcome, in-hospital mortality, higher LOS, and higher cost after ruptured intracranial aneurysm procedural treatment. The conditional event of complication influences patients with moderate comorbidities more so than those with low or high comorbidities.
Subject(s)
Aneurysm, Ruptured/epidemiology , Aneurysm, Ruptured/surgery , Disease Management , Intracranial Aneurysm/epidemiology , Intracranial Aneurysm/surgery , Postoperative Complications/epidemiology , Comorbidity , Databases, Factual/trends , Female , Hospital Mortality/trends , Humans , Length of Stay/trends , Male , Middle Aged , Nervous System Diseases/epidemiology , Nervous System Diseases/surgery , Risk Factors , Treatment OutcomeABSTRACT
OBJECTIVE: This study investigates the relationship between neurovascular comorbidities and in-hospital complications in determining functional outcome, mortality, length of stay (LOS), and cost of stay. METHODS: Patients were identified from the 2012-2015 National Inpatient Sample (NIS) using International Classification of Diseases, Ninth Revision codes for unruptured intracranial aneurysm (UIA) treatment in patients without subarachnoid hemorrhage. In-hospital complications were divided into medical complications, surgical complications, and seizures. Primary outcomes were functional outcome measured by modified Rankin Scale (mRS)-equivalent measure, in-hospital mortality, LOS, and cost. Multivariable logistic regression models were built for mRS-equivalent and in-hospital mortality. Multivariable linear regression models in log scale were built for LOS and cost. RESULTS: A total of 7398 procedurally managed patients with UIA were included (median age, 58 years; 75% female; 66% white; 43% private insurance). Higher Neurovascular Comorbidities Index (NCI) was associated with seizure (odds ratio [OR], 1.11 if NCI = 1; OR, 2.49 if NCI = 7; P < 0.001), medical complication (OR, 1.21, NCI = 1; OR, 3.46, NCI = 7; P < 0.001), and surgical complication (OR, 1.25, NCI = 1; OR, 3.47, NCI = 7; P < 0.001). NCI remained significantly predictive of poor mRS-equivalent outcome (OR, 1.20, NCI = 1; OR, 5.79, NCI = 7; P < 0.001), in-hospital mortality (OR, 1.98, NCI = 1; OR, 10.9, NCI = 7; P < 0.001), LOS (coefficient dependent on multiple variables, P < 0.001), and cost (coefficient dependent on multiple variables, P < 0.001) after adjustment. CONCLUSIONS: Neurovascular comorbidities are the primary driver of poor mRS-equivalent outcome, in-hospital mortality, higher LOS, and higher cost after procedural treatment of UIA. The conditional event of complication influences patients with fewer comorbidities more so than those with no comorbidities or high comorbidities. It is imperative to precisely account for these factors to optimize targeted resource allocation and increase the value of care for patients with UIA.
Subject(s)
Disease Management , Intracranial Aneurysm/epidemiology , Intracranial Aneurysm/surgery , Nervous System Diseases/epidemiology , Nervous System Diseases/surgery , Postoperative Complications/epidemiology , Aged , Cerebrovascular Disorders/epidemiology , Cerebrovascular Disorders/surgery , Comorbidity , Databases, Factual/trends , Female , Hospital Mortality/trends , Humans , Male , Middle Aged , Risk Factors , Treatment OutcomeABSTRACT
OBJECTIVE: Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. METHODS: Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. RESULTS: A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. CONCLUSIONS: The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.
ABSTRACT
OBJECTIVE: Several scores estimate the prognosis for gunshot wounds to the head (GSWH) at the point of hospital admission. However, prognosis may change over the course of the hospital stay. This study measures the accuracy of the Baylor score among patients who have already survived the acute phase of hospitalization and generates conditional outcome curves for the duration of hospital stay for patients with GSWH. METHODS: Patients in whom GSWH with dural penetration occurred between January 2009 and June 2019 were identified from a trauma registry at a level I trauma center in the southeastern US. The Baylor score was calculated using component variables. Conditional overall survival and good functional outcome (Glasgow Outcome Scale score of 4 or 5) curves were generated. The accuracy of the Baylor score in predicting mortality and functional outcome among acute-phase survivors (survival > 48 hours) was assessed using receiver operating characteristic curves and the area under the curve (AUC). RESULTS: A total of 297 patients were included (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male), and 129 patients survived the initial 48 hours of admission. These acute-phase survivors had a decreased mortality rate of 32.6% (n = 42) compared to 68.4% (n = 203) for all patients, and an increased rate of good functional outcome (48.1%; n = 62) compared to the rate for all patients (23.2%; n = 69). Among acute-phase survivors, the Baylor score accurately predicted mortality (AUC = 0.807) and functional outcome (AUC = 0.837). However, the Baylor score generally overestimated true mortality rates and underestimated good functional outcome. Additionally, hospital day 18 represented an inflection point of decreasing probability of good functional outcome. CONCLUSIONS: During admission for GSWH, surviving beyond the acute phase of 48 hours doubles the rates of survival and good functional outcome. The Baylor score maintains reasonable accuracy in predicting these outcomes for acute-phase survivors, but generally overestimates mortality and underestimates good functional outcome. Future prognostic models should incorporate conditional survival to improve the accuracy of prognostication after the acute phase.
ABSTRACT
OBJECTIVE: In the present study, we quantified the effect of the coronavirus disease 2019 (COVID-19) on the volume of adult and pediatric neurosurgical procedures, inpatient consultations, and clinic visits at an academic medical center. METHODS: Neurosurgical procedures, inpatient consultations, and outpatient appointments at Vanderbilt University Medical Center were identified from March 23, 2020 through May 8, 2020 (during COVID-19) and March 25, 2019 through May 10, 2019 (before COVID-19). The neurosurgical volume was compared between the 2 periods. RESULTS: A 40% reduction in weekly procedural volume was demonstrated during COVID-19 (median before, 75; interquartile range [IQR], 72-80; median during, 45; IQR, 43-47; P < 0.001). A 42% reduction occurred in weekly adult procedures (median before, 62; IQR, 54-70; median during, 36; IQR, 34-39; P < 0.001), and a 31% reduction occurred in weekly pediatric procedures (median before, 13; IQR, 12-14; median during, 9; IQR, 8-10; P = 0.004). Among adult procedures, the most significant decreases were seen for spine (P < 0.001) and endovascular (P < 0.001) procedures and cranioplasty (P < 0.001). A significant change was not found in the adult open vascular (P = 0.291), functional (P = 0.263), cranial tumor (P = 0.143), or hydrocephalus (P = 0.173) procedural volume. Weekly inpatient consultations to neurosurgery decreased by 24% (median before, 99; IQR, 94-114; median during, 75; IQR, 68-84; P = 0.008) for adults. Weekly in-person adult and pediatric outpatient clinic visits witnessed a 91% decrease (median before, 329; IQR, 326-374; median during, 29; IQR, 26-39; P < 0.001). In contrast, weekly telehealth encounters increased from a median of 0 (IQR, 0-0) before to a median of 151 (IQR, 126-156) during COVID-19 (P < 0.001). CONCLUSIONS: Significant reductions occurred in neurosurgical operations, clinic visits, and inpatient consultations during COVID-19. Telehealth was increasingly used for assessments. The long-term effects of the reduced neurosurgical volume and increased telehealth usage on patient outcomes should be explored.