Direct Versus Indirect Revascularization for Moyamoya: a Large Multicenter Study.

BACKGROUND: Moyamoya is a chronic occlusive cerebrovascular disease of unknown etiology causing neovascularization of the lenticulostriate collaterals at the base of the brain. Although revascularization surgery is the most effective treatment for moyamoya, there is still no consensus on the best surgical treatment modality as different studies provide different outcomes. OBJECTIVE: In this large case series, we compare the outcomes of direct (DR) and indirect revascularisation (IR) and compare our results to the literature in order to reflect on the best revascularization modality for moyamoya. METHODS: We conducted a multicenter retrospective study in accordance with the Strengthening the Reporting of Observational studies in Epidemiology guidelines of moyamoya affected hemispheres treated with DR and IR surgeries across 13 academic institutions predominantly in North America. All patients who underwent surgical revascularization of their moyamoya-affected hemispheres were included in the study. The primary outcome of the study was the rate of symptomatic strokes. RESULTS: The rates of symptomatic strokes across 515 disease-affected hemispheres were comparable between the two cohorts (11.6% in the DR cohort vs 9.6% in the IR cohort, OR 1.238 (95% CI 0.651 to 2.354), p=0.514). The rate of total perioperative strokes was slightly higher in the DR cohort (6.1% for DR vs 2.0% for IR, OR 3.129 (95% CI 0.991 to 9.875), p=0.052). The rate of total follow-up strokes was slightly higher in the IR cohort (8.1% vs 6.6%, OR 0.799 (95% CI 0.374 to 1.709) p=0.563). CONCLUSION: Since both modalities showed comparable rates of overall total strokes, both modalities of revascularization can be performed depending on the patient's risk assessment.

The impact of hypertension on clinical outcomes in moyamoya disease: a multicenter, propensity score-matched analysis.

BACKGROUND: Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by progressive steno-occlusive changes in the internal carotid arteries, leading to an abnormal vascular network. Hypertension is prevalent among MMD patients, raising concerns about its impact on disease outcomes. This study aims to compare the clinical characteristics and outcomes of MMD patients with and without hypertension. METHODS: We conducted a multicenter, retrospective study involving 598 MMD patients who underwent surgical revascularization across 13 academic institutions in North America. Patients were categorized into hypertensive (n=292) and non-hypertensive (n=306) cohorts. Propensity score matching (PSM) was performed to adjust for baseline differences. RESULTS: The mean age was higher in the hypertension group (46 years vs. 36.8 years, p < 0.001). Hypertensive patients had higher rates of diabetes mellitus (45.2% vs. 10.7%, p < 0.001) and smoking (48.8% vs. 27.1%, p < 0.001). Symptomatic stroke rates were higher in the hypertension group (16% vs. 7.1%; OR: 2.48; 95% CI: 1.39-4.40, p = 0.002) before matching. After PSM, there were no significant differences in symptomatic stroke rates (11.1% vs. 7.7%; OR: 1.5; CI: 0.64-3.47, p = 0.34), perioperative strokes (6.2% vs. 2.1%; OR 3.13; 95% CI: 0.83-11.82, p = 0.09), or good functional outcomes at discharge (93% vs. 92.3%; OR 1.1; 95% CI: 0.45-2.69, p = 0.82). CONCLUSION: No significant differences in symptomatic stroke rates, perioperative strokes, or functional outcomes were observed between hypertensive and non-hypertensive Moyamoya patients. Appropriate management can lead to similar outcomes in both groups. Further prospective studies are required to validate these findings.

International controlled study of revascularization and outcomes following COVID-positive mechanical thrombectomy.

BACKGROUND AND PURPOSE: Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. METHODS: A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. RESULTS: In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). CONCLUSION: COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

Ischemic Stroke Occurs Less Frequently in Patients With COVID-19: A Multicenter Cross-Sectional Study.

BACKGROUND AND PURPOSE: The impact of coronavirus disease 2019 (COVID-19) on the occurrence of ischemic stroke has been the subject of increased speculation but has not been confirmed in large observational studies. We investigated the association between COVID-19 and stroke. METHODS: We performed a cross-sectional study involving patients discharged from a healthcare system in New York State, from January to April 2020. A mixed-effects logistic regression analysis and a propensity score-weighted analysis were used to control for confounders and investigate the association of COVID-19 with ischemic stroke. Similar techniques were used to detect the impact of concurrent COVID-19 infection on unfavorable outcomes for patients with stroke. RESULTS: Among 24 808 discharges, 2513 (10.1%) were diagnosed with COVID-19, and 566 (0.2%) presented with acute ischemic stroke. Patients diagnosed with COVID-19 were at one-quarter the odds of stroke compared with other patients (odds ratio, 0.25 [95% CI, 0.16-0.40]). This association was consistent in all age groups. Our results were robust in sensitivity analyses, including propensity score-weighted regression models. In patients presenting with stroke, concurrent infection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) was associated with higher case-fatality (odds ratio, 10.50 [95% CI, 3.54-31.18]) and a trend towards increased occurrence of discharge to rehabilitation (odds ratio, 2.45 [95% CI, 0.81-1.25]). CONCLUSIONS: Using a comprehensive cross-section of patients from a large NY-based healthcare system, we did not identify a positive association between ischemic stroke and COVID-19. However, patients with stroke with COVID-19 had worse outcomes compared with those without, with over a 9-fold increase in mortality. Although no definitive conclusions can be reached from our observational study, our data do not support the concerns for an epidemic of stroke in young adults with COVID-19.

Reporting of Baseline Characteristics to Accompany Analysis by Instrumental Variables.

A property and criticism of instrumental variable (IV) estimators is that they estimate the exposure effect in the compliers, individuals whose exposure is influenced by the instrument. It is conceivable that the exposure effect is different in individuals whose exposure is not influenced by the instrument. For that reason, it is useful to know who the compliers are. We present methods for reporting averages and other statistics and comparing them between the compliers and noncompliers, which are applicable to scenarios in which the instrument and exposure are fixed in time and dichotomous. The methods are illustrated in a comparison of outcomes between teaching and nonteaching hospitals in patients undergoing brain or spinal surgery.

Correlation of hospital magnet status with the quality of physicians performing neurosurgical procedures in New York State.

PURPOSE: The quality of physicians practicing in hospitals recognized for nursing excellence by the American Nurses Credentialing Center has not been studied before. We investigated whether Magnet hospital recognition is associated with higher quality of physicians performing neurosurgical procedures. MATERIALS AND METHODS: We performed a cohort study of patients undergoing neurosurgical procedures from 2009-2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Propensity score adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial. RESULTS: During the study period, 185,277 patients underwent neurosurgical procedures, and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions. Instrumental variable analysis demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% CI, 13.2% to 14.1%), and a 4.3% higher chance of being treated by a physician with superior performance in terms of length-of-stay (LOS) (95% CI, 3.8% to 4.7%) in comparison to non-Magnet institutions. The same associations were present in propensity score adjusted mixed effects models. CONCLUSIONS: Using a comprehensive all-payer cohort of neurosurgical patients in New York State we identified an association of Magnet hospital recognition with superior physician performance.

Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. METHODS: We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay. RESULTS: Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models. CONCLUSIONS: Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.

Effect of an Immersive Preoperative Virtual Reality Experience on Patient Reported Outcomes: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of exposure to a virtual reality (VR) environment preoperatively on patient-reported outcomes for surgical operations. BACKGROUND: There is a scarcity of well-developed quality improvement initiatives targeting patient satisfaction. METHODS: We performed a randomized controlled trial of patients undergoing cranial and spinal operations in a tertiary referral center. Patients underwent a 1:1 randomization to an immersive preoperative VR experience or standard preoperative experience stratified on type of operation. The primary outcome measures were the Evaluation du Vecu de l'Anesthesie Generale (EVAN-G) score and the Amsterdam Preoperative Anxiety and Information (APAIS) score, as markers of the patient's experience during the surgical encounter. RESULTS: During the study period, a total of 127 patients (mean age 55.3 years, 41.9% females) underwent randomization. The average EVAN-G score was 84.3 (standard deviation, SD, 6.4) after VR, and 64.3 (SD, 11.7) after standard preoperative experience (difference, 20.0; 95% confidence interval, CI, 16.6-23.3). Exposure to an immersive VR experience also led to higher APAIS score (difference, 29.9; 95% CI, 24.5-35.2). In addition, VR led to lower preoperative VAS stress score (difference, -41.7; 95% CI, -33.1 to -50.2), and higher preoperative VAS preparedness (difference, 32.4; 95% CI, 24.9-39.8), and VAS satisfaction (difference, 33.2; 95% CI, 25.4-41.0) scores. No association was identified with VAS stress score (difference, -1.6; 95% CI, -13.4 to 10.2). CONCLUSIONS: In a randomized controlled trial, we demonstrated that patients exposed to preoperative VR had increased satisfaction during the surgical encounter. Harnessing the power of this technology, hospitals can create an immersive environment that minimizes stress, and enhances the perioperative experience.

Does scope of practice correlate with the outcomes of craniotomy for tumor resection in children?

BACKGROUND: The relationship of scope of practice (predominantly adult, versus predominantly pediatric) with the outcomes of brain tumor surgery in children remains uncertain. We investigated the association of practice focus with the outcomes of neurosurgical oncology operations in pediatric patients. METHODS: We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent craniotomies for tumor resections from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning with mixed effects analysis to account for clustering at the hospital level. RESULTS: During the study period, there were 770 pediatric patients who underwent craniotomy for tumor resection and met the inclusion criteria. Of these, 370 (48.1%) underwent treatment by providers with predominantly adult practices and 400 (51.9%) by physicians who operated predominantly on children. Mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.12; 95% CI, 0.48-2.58), and discharge to a facility (OR, 1.25; 95% CI, 0.77-2.03). These associations persisted in propensity-adjusted models. CONCLUSIONS: In a cohort of pediatric patients undergoing craniotomy for tumor resection from a comprehensive all-payer database, we did not demonstrate a difference in mortality, and discharge to a facility between providers with predominantly adult and predominantly pediatric practices.

The relationship of regional hemoglobin A1c testing and amputation rate among patients with diabetes.

Objective The risk of leg amputation among patients with diabetes has declined over the past decade, while use of preventative measures-such as hemoglobin A1c monitoring-has increased. However, the relationship between hemoglobin A1c testing and amputation risk remains unclear. Methods We examined annual rates of hemoglobin A1c testing and major leg amputation among Medicare patients with diabetes from 2003 to 2012 across 306 hospital referral regions. We created linear regression models to study associations between hemoglobin A1c testing and lower extremity amputation. Results From 2003 to 2012, the proportion of patients who received hemoglobin A1c testing increased 10% (74% to 84%), while their rate of lower extremity amputation decreased 50% (430 to 232/100,000 beneficiaries). Regional hemoglobin A1c testing weakly correlated with crude amputation rate in both years (2003 R = -0.20, 2012 R = -0.21), and further weakened with adjustment for age, sex, and disability status (2003 R = -0.11, 2012 R = -0.17). In a multivariable model of 2012 amputation rates, hemoglobin A1c testing was not a significant predictor. Conclusion Lower extremity amputation among patients with diabetes nearly halved over the past decade but only weakly correlated with hemoglobin A1c testing throughout the study period. Better metrics are needed to understand the relationship between preventative care and amputation.

Regional disparities in hospitalization charges for patients undergoing craniotomy for tumor resection in New York State: correlation with outcomes.

There is increasing regulatory pressure for cost containment in neuro-oncology, and rationalization of the observed regional disparities. We investigated the presence of such disparities in New York State and examined the impact of risk adjustment on the magnitude of this variation. We performed a cohort study involving patients with brain tumors (gliomas, metastases, or meningiomas), who underwent craniotomy for resection from 2009 to 2013, and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A linear regression model was utilized for risk-adjustment of inpatient charges using socioeconomic factors and comorbidities. Hospitals with fewer than 20 craniotomies were excluded. 13,535 patients underwent treatment, including 5032 (37.2 %) gliomas, 4858 (35.9 %) metastases, and 3645 (26.9 %) meningiomas. Unadjusted median hospitalization charges ranged from $22,954 to $177,398 at the hospital level, and $30,086 to $159,281 at the county level. Despite extensive risk-adjustment we observed persistent disparities with median hospitalization charges ranging from $40,455 to $124,691 at the hospital level, and $53,999 to $94,844 at the county level. Analysis of variance (ANOVA) demonstrated that these disparities were significant at the facility and the county level (P < 0.0001). Increased charges were not associated with shorter LOS (r = 0.10, P = 0.41), or lower rates of death (r = 0.09, P = 0.46), and unfavorable discharge (r = 0.24, P = 0.06). Using a comprehensive all-payer cohort of patients with brain tumors in New York State we identified wide disparities at the hospital and the county level despite comprehensive risk-adjustment. Increased charges were not associated with shorter LOS, or lower rates of death and unfavorable discharge.

Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients.

BACKGROUND: Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among black, Hispanic, and white patients, and to determine associations between hemoglobin A1c testing and amputation risk. METHODS: We identified 11,942,840 Medicare patients (55% female) with diabetes over the age of 65 years between 2002 and 2012 and followed them for a mean of 6.6 years. Of these, 86% were white, 11.5% were black, and 2.5% were Hispanic. We recorded the occurrence of major amputation and hemoglobin A1c testing during this time period and studied secular changes in amputation rate by race (black, Hispanic, and white). Finally, we examined associations between amputation risk and hemoglobin A1c testing. We measured both the presence of any testing and testing consistency using 3 categories: poor consistency (hemoglobin A1c testing in 0-50% of years), medium consistency (testing in 50-90% of years), and high consistency (testing in >90% of the years in the cohort). RESULTS: Between 2002 and 2012, the average major lower-extremity amputation rate in diabetic Medicare patients was 1.78 per 1,000 per year for black patients, 1.15 per 1,000 per year for Hispanic patients, and 0.56 per 1,000 per year for white patients (P < 0.001). Over the study period, the incidence of major amputation in Medicare patients with diabetes declined by 54%, from 1.15 per 1,000 in 2002 to 0.53 per 1,000 in 2012 (rate ratio = 0.53, 95% CI = 0.51-0.54). The reduction in amputation rate was similar across racial groups: 52% for black patients, 61% for Hispanic patients, and 55% for white patients. In multivariable analysis adjusting for patient characteristics, including race, any use of hemoglobin A1c testing was associated with a 15% decline in amputation risk (hazard ratio, 0.85; 95% CI, 0.83-0.87; P < 0.001). High consistency hemoglobin A1c testing was associated with a 39% decline in amputation (hazard ratio, 0.61; 95% CI, 0.59-0.62; P < 0.0001). CONCLUSIONS: Although more frequent among racial minorities, major lower-extremity amputation rates have declined similarly across black, Hispanic, and white patients over the last decade. Hemoglobin A1c testing, particularly the consistency of testing over time, may be an effective component metric of longitudinal quality measures toward limiting amputation in all races.

Scope of practice and outcomes of cerebrovascular procedures in children.

PURPOSE: The impact of scope of practice of providers (predominantly adult versus predominantly pediatric) on the outcomes of cerebrovascular procedures in children remains an issue of debate. We investigated the association of scope of practice with the outcomes of cerebrovascular interventions. METHODS: We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent cerebrovascular procedures from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning and mixed effects analysis to account for clustering at the hospital level. RESULTS: During the study period, there were 1243 pediatric patients who underwent cerebrovascular procedures and met the inclusion criteria. Of these, 631 (50.7 %) underwent treatment by providers with predominantly adult practices and 612 (49.3 %) by physicians who operated predominantly on children. The mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.20; 95 % CI, 0.61-2.38), discharge to a facility (OR, 1.50; 95 % CI, 0.73-3.09), and length of stay (LOS) (adjusted difference, 0.003; 95 % CI, -0.09 to 0.10). These associations persisted in propensity-adjusted models. CONCLUSIONS: In a cohort of pediatric patients undergoing cerebrovascular procedures from a comprehensive all-payer database, we did not demonstrate a difference in mortality, discharge to a facility, and LOS between providers with predominantly adult and predominantly pediatric practices.

Prehospital helicopter transport and survival of patients with traumatic brain injury.

OBJECTIVE: To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS). BACKGROUND: Helicopter utilization and its effect on the outcomes of TBI remain controversial. METHODS: We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS. RESULTS: During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81-2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74-2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64-2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55-1.94; ARR, 4.69). CONCLUSIONS: Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS.

The Association of Insurance Status and Race With Transfers of Patients With Traumatic Brain Injury Initially Evaluated at Level III and IV Trauma Centers.

OBJECTIVE: To investigate the association of lack of insurance and African American race with the probability of transfer to level I/II trauma centers after evaluation in the emergency department of level III/IV trauma centers for traumatic brain injury (TBI). BACKGROUND: The influence of nonmedical factors on the disposition of TBI patients initially seen in less specialized institutions is debated. METHODS: We conducted a retrospective cohort study involving TBI patients who were registered in the National Trauma Data Bank between 2009 and 2011. Regression methods were used to investigate the association of insurance status and race with the disposition of TBI patients evaluated in less specialized trauma centers. RESULTS: During the study period, there were 26,031 TBI patients who were registered in the National Trauma Data Bank and met inclusion criteria. Of these, 10,572 (35.9%) were transferred to a higher level of care institution. Multivariable logistic regression after coarsened exact matching demonstrated an association of uninsured patients with an increased possibility of transfer (odds ratio [OR] = 1.22; 95% confidence interval [CI], 1.05-1.42). On the contrary, there was no association of African Americans with transfers (OR = 1.27; 95% CI, 0.99-1.62). Those with Glasgow Coma Scale score above 8 (OR = 1.22; 95% CI, 1.08-1.39) or Injury Severity Score below 16 (OR = 1.33; 95% CI, 1.13-1.56) had a higher possibility of transfer. CONCLUSIONS: In TBI patients, lack of insurance was associated with an increased possibility of transfer to higher level of care institutions after evaluation in a level III or IV trauma center emergency department. Regardless of insurance status, this transfer pattern was also observed for African Americans, but only for those with milder injuries.

Variations in the intensive use of head CT for elderly patients with hemorrhagic stroke.

PURPOSE: To investigate the variability in head computed tomographic (CT) scanning in patients with hemorrhagic stroke in U.S. hospitals, its association with mortality, and the number of different physicians consulted. MATERIALS AND METHODS: The study was approved by the Committee for the Protection of Human Subjects at Dartmouth College. A retrospective analysis of the Medicare fee-for-service claims data was performed for elderly patients admitted for hemorrhagic stroke in 2008-2009, with 1-year follow-up through 2010. Risk-adjusted primary outcome measures were mean number of head CT scans performed and high-intensity use of head CT (six or more head CT scans performed in the year after admission). We examined the association of high-intensity use of head CT with the number of different physicians consulted and mortality. RESULTS: A total of 53 272 patients (mean age, 79.6 years; 31 377 women [58.9%]) with hemorrhagic stroke were identified in the study period. The mean number of head CT scans conducted in the year after admission for stroke was 3.4; 8737 patients (16.4%) underwent six or more scans. Among the hospitals with the highest case volume (more than 50 patients with hemorrhagic stroke), risk-adjusted rates ranged from 8.0% to 48.1%. The correlation coefficient between number of physicians consulted and rates of high-intensity use of head CT was 0.522 (P < .01) for all hospitals and 0.50 (P < .01) for the highest-volume hospitals. No improvement in 1-year mortality was found for patients undergoing six or more head CT scans (odds ratio, 0.84; 95% confidence interval: 0.69, 1.02). CONCLUSION: High rates of head CT use for patients with hemorrhagic stroke are frequently observed, without an association with decreased mortality. A higher number of physicians consulted was associated with high-intensity use of head CT.

Drivers of hospitalization cost after craniotomy for tumor resection: creation and validation of a predictive model.

BACKGROUND: The economic sustainability of all areas of medicine is under scrutiny. Limited data exist on the drivers of cost after a craniotomy for tumor resection (CTR). The objective of the present study was to develop and validate a predictive model of hospitalization cost after CTR. METHODS: We performed a retrospective study involving CTR patients who were registered in the Nationwide Inpatient Sample (NIS) database from 2005-2010. This cohort underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model. RESULTS: Of the 36,433 patients undergoing CTR, 14638 (40.2%) underwent craniotomies for primary malignant, 9574 (26.3%) for metastatic, and 11414 (31.3%) for benign tumors. The median hospitalization cost was $24,504 (Interquartile Range (IQR), $4,265-$44,743). Common drivers of cost identified in the multivariate analyses included: length of stay, number of procedures, hospital size and region, and patient income. The models were validated in independent cohorts and demonstrated final R2 very similar to the initial models. The predicted and observed values in the validation cohort demonstrated good correlation. CONCLUSIONS: This national study identified significant drivers of hospitalization cost after CTR. The presented model can be utilized as an adjunct in the cost containment debate and the creation of data-driven policies.

Renaissance of laser interstitial thermal ablation.

Laser interstitial thermal therapy (LITT) is a minimally invasive technique for treating intracranial tumors, originally introduced in 1983. Its use in neurosurgical procedures was historically limited by early technical difficulties related to the monitoring and control of the extent of thermal damage. The development of magnetic resonance thermography and its application to LITT have allowed for real-time thermal imaging and feedback control during laser energy delivery, allowing for precise and accurate provision of tissue hyperthermia. Improvements in laser probe design, surgical stereotactic targeting hardware, and computer monitoring software have accelerated acceptance and clinical utilization of LITT as a neurosurgical treatment alternative. Current commercially available LITT systems have been used for the treatment of neurosurgical soft-tissue lesions, including difficult to access brain tumors, malignant gliomas, and radiosurgery-resistant metastases, as well as for the ablation of such lesions as epileptogenic foci and radiation necrosis. In this review, the authors aim to critically analyze the literature to describe the advent of LITT as a neurosurgical, laser excision tool, including its development, use, indications, and efficacy as it relates to neurosurgical applications.

The present and future of quality measures and public reporting in neurosurgery.

Quality measurement and public reporting are intended to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. However, regulatory implementation has created a complex network of reporting requirements for physicians and medical practices. These include Medicare's Physician Quality Reporting System, Electronic Health Records Meaningful Use, and Value-Based Payment Modifier programs. The common denominator of all these initiatives is that to avoid penalties, physicians must meet "generic" quality standards that, in the case of neurosurgery and many other specialties, are not pertinent to everyday clinical practice and hold specialists accountable for care decisions outside of their direct control. The Centers for Medicare and Medicaid Services has recently authorized alternative quality reporting mechanisms for the Physician Quality Reporting System, which allow registries to become subspecialty-reporting mechanisms under the Qualified Clinical Data Registry (QCDR) program. These programs further give subspecialties latitude to develop measures of health care quality that are relevant to the care provided. As such, these programs amplify the power of clinical registries by allowing more accurate assessment of practice patterns, patient experiences, and overall health care value. Neurosurgery has been at the forefront of these developments, leveraging the experience of the National Neurosurgery Quality and Outcomes Database to create one of the first specialty-specific QCDRs. Recent legislative reform has continued to change this landscape and has fueled optimism that registries (including QCDRs) and other specialty-driven quality measures will be a prominent feature of federal and private sector quality improvement initiatives. These physician- and patient-driven methods will allow neurosurgery to underscore the value of interventions, contribute to the development of sustainable health care solutions, and actively participate in meaningful quality initiatives for the benefit of the patients served.

The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale.

Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N(2)QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N(2)QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N(2)QOD QCDR is further evidence of neurosurgery's commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N(2)QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.