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BACKGROUND: Transcarotid artery revascularization (TCAR) is an increasingly popular technique for the management of extracranial carotid stenosis. Its off-label use in the treatment of intracranial neurovascular disease is poorly described. Our objective is to describe the use of a dedicated open transcarotid access system for the treatment of neurovascular pathologies other than extracranial carotid stenosis. METHODS: We conducted a retrospective review of a prospectively maintained database of consecutive patients who underwent treatment of neurovascular disease at a single academic center using the ENROUTE Transcarotid Arterial Sheath. Demographics, procedural characteristics, and patient outcomes were reported. RESULTS: Twenty patients were included in the study between September 2017 and March 2023. The following pathologies were treated: intracranial atherosclerotic disease (ICAD, nine patients), complex cervico-petrous carotid disease (five patients), intracranial aneurysms (three patients), and large vessel occlusion-acute ischemic stroke (three patients). Eighteen of the 20 cases were performed with active carotid flow reversal. All cases were successfully completed. There were no access-related complications. One periprocedural complication was incurred: a microguidewire perforation during an exchange maneuver for the treatment of ICAD. CONCLUSION: An open transcarotid approach using a dedicated transcarotid system may offer a safe alternative access strategy for the endovascular treatment of complex neurovascular pathologies when a traditional transfemoral or transradial approach is contraindicated or failed.
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INTRODUCTION: Several studies have demonstrated the benefits of enhanced recovery after surgery (ERAS) protocols for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumented fusion (PSIF). However, there are relatively few studies investigating the effect of regular multidisciplinary team meetings on level selection, surgical performance parameters, and patient outcomes after PSIF for AIS. The aim of this study was to assess changes in intra- and postoperative outcomes following multidisciplinary team meeting implementation for patients undergoing PSIF for AIS. METHODS: The medical records of 96 adolescents (10 to 18 years old) diagnosed with AIS and undergoing PSIF at a major academic institution from 2017 to 2022 were retrospectively reviewed. A quality improvement (QI) initiative was implemented in February 2020, including institution of monthly multidisciplinary conferences focusing on preoperative indications, level selection, postoperative review of surgical performance parameters for previous cases, and discussion and optimization of postoperative ambulation and pain control protocols. Patients were placed into "Pre-QI" (treated pre-February 2020) and "Post-QI" (treated post-February 2020) cohorts. Patient demographics, comorbidities, deformity characteristics, intraoperative variables, ambulation status, postoperative complications, length of stay (LOS), and unplanned readmission rates were assessed. RESULTS: Of the 96 study patients, 44 (45.8%) were in the Pre-QI cohort, and 52 (54.2%) were in the Post-QI cohort. Mean major curve was not significantly different between the two cohorts (Pre-QI: 58.0 ± 7.3° vs Post-QI: 57.9 ± 14.5°, p = 0.169). The Pre-QI cohort had a greater mean minor curve degree (Pre-QI: 42.7 ± 11.8° vs Post-QI: 36.8 ± 12.4, p = 0.008). The Pre-QI cohort had significantly greater mean spinal levels fused (Pre-QI: 11.7 ± 1.7 vs Post-QI: 10.4 ± 2.6, p = 0.009), significantly greater mean estimated blood loss (Pre-QI: 1063.6 ± 631.5 ml vs. Post-QI: 415.8 ± 189.9 ml, p < 0.001), significantly greater mean operative time normalized to levels fused (Pre-QI: 0.6 ± 0.1 h/level fused vs Post-QI: 0.4 ± 0.1 h/level fused, p < 0.001), and a significantly greater proportion of patients with intraoperative drain placement (Pre-QI: 93.2% vs Post-QI: 5.8%, p < 0.001). The Post-QI cohort had significantly shorter time to postoperative ambulation (Pre-QI: 2.1 ± 0.9 days vs Post-QI: 1.3 ± 0.5 days, p < 0.001). A significantly greater proportion of patients in the Pre-QI cohort developed any postoperative complication (Pre-QI: 72.7% vs Post-QI: 34.6%, p < 0.001), and mean LOS was significantly greater among Pre-QI patients (Pre-QI: 4.5 ± 1.1 days vs Post-QI: 3.2 ± 0.8 days, p < 0.001). Discharge disposition (p = 0.758) and 30-day unplanned readmissions (p = 0.207) were similar between the cohorts. CONCLUSIONS: Our findings suggest that monthly multidisciplinary pediatric spine team meetings may improve patient care. Further studies exploring the incorporation of QI implementation with frequent multidisciplinary team meetings into existing ERAS protocols are merited.
Subject(s)
Quality Improvement , Scoliosis , Spinal Fusion , Humans , Scoliosis/surgery , Spinal Fusion/methods , Adolescent , Female , Male , Retrospective Studies , Child , Treatment Outcome , Length of Stay , Patient Care Team/organization & administration , Postoperative Complications/epidemiology , Enhanced Recovery After SurgeryABSTRACT
BACKGROUND AND OBJECTIVES: First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT). METHODS: A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation. RESULTS: A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable. CONCLUSION: FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.
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Background: Malnutrition is a common condition that may exacerbate many medical and surgical pathologies. However, few have studied the impact of malnutrition on surgical outcomes for patients undergoing surgery for metastatic disease of the spine. This study aims to evaluate the impact of malnutrition on perioperative complications and healthcare resource utilization following surgical treatment of spinal metastases. Methods: We conducted a retrospective cohort study using the 2011-2019 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients with spinal metastases who underwent laminectomy, corpectomy, or posterior fusion for extradural spinal metastases were identified using the CPT, ICD-9-CM, and ICD-10-CM codes. The study population was divided into two cohorts: Nourished (preoperative serum albumin values ≥ 3.5 g/dL) and Malnourished (preoperative serum albumin values < 3.5 g/dL). We assessed patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), hospital LOS, discharge disposition, readmission, and reoperation. Multivariate logistic regression analyses were performed to identify the factors associated with a prolonged length of stay (LOS), AEs, non-routine discharge (NRD), and unplanned readmission. Results: Of the 1613 patients identified, 26.0% were Malnourished. Compared to Nourished patients, Malnourished patients were significantly more likely to be African American and have a lower BMI, but the age and sex were similar between the cohorts. The baseline comorbidity burden was significantly higher in the Malnourished cohort compared to the Nourished cohort. Compared to Nourished patients, Malnourished patients experienced significantly higher rates of one or more AEs (Nourished: 19.8% vs. Malnourished: 27.6%, p = 0.004) and serious AEs (Nourished: 15.2% vs. Malnourished: 22.6%, p < 0.001). Upon multivariate regression analysis, malnutrition was found to be an independent and associated with an extended LOS [aRR: 3.49, CI (1.97, 5.02), p < 0.001], NRD [saturated aOR: 1.76, CI (1.34, 2.32), p < 0.001], and unplanned readmission [saturated aOR: 1.42, CI (1.04, 1.95), p = 0.028]. Conclusions: Our study suggests that malnutrition increases the risk of postoperative complication, prolonged hospitalizations, non-routine discharges, and unplanned hospital readmissions. Further studies are necessary to identify the protocols that pre- and postoperatively optimize malnourished patients undergoing spinal surgery for metastatic spinal disease.
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Importance: Intracerebral hemorrhage (ICH) is a serious complication of brain arteriovenous malformation (AVM). Apolipoprotein E (APOE) ε4 is a well-known genetic risk factor for ICH among persons without AVM, and cerebral amyloid angiopathy is a vasculopathy frequently observed in APOE ε4 carriers that may increase the risk of ICH. Objective: To assess whether APOE ε4 is associated with a higher risk of ICH in patients with a known AVM. Design, Setting, and Participants: This cross-sectional study including 412 participants was conducted in 2 stages (discovery and replication) using individual-level data from the UK Biobank (released March 2012 and last updated October 2023) and the All of Us Research Program (commenced on May 6, 2018, with its latest update provided in October 2023). The occurrence of AVM and ICH was ascertained at the time of enrollment using validated International Classification of Diseases, Ninth Revision and Tenth Revision, codes. Genotypic data on the APOE variants rs429358 and rs7412 were used to ascertain the ε status. Main Outcomes and Measures: For each study, the association between APOE ε4 variants and ICH risk was assessed among patients with a known AVM by using multivariable logistic regression. Results: The discovery phase included 253 UK Biobank participants with known AVM (mean [SD] age, 56.6 [8.0] years, 119 [47.0%] female), of whom 63 (24.9%) sustained an ICH. In the multivariable analysis of 240 participants of European ancestry, APOE ε4 was associated with a higher risk of ICH (odds ratio, 4.58; 95% CI, 2.13-10.34; P < .001). The replication phase included 159 participants with known AVM enrolled in All of Us (mean [SD] age, 57.1 [15.9] years; 106 [66.7%] female), of whom 29 (18.2%) sustained an ICH. In multivariable analysis of 101 participants of European ancestry, APOE ε4 was associated with higher risk of ICH (odds ratio, 4.52; 95% CI, 1.18-19.38; P = .03). Conclusions and Relevance: The results of this cross-sectional study of patients from the UK Biobank and All of Us suggest that information on APOE ε4 status may help identify patients with brain AVM who are at particularly high risk of ICH and that cerebral amyloid angiopathy should be evaluated as a possible mediating mechanism of the observed association.
Subject(s)
Apolipoprotein E4 , Cerebral Hemorrhage , Intracranial Arteriovenous Malformations , Female , Humans , Male , Middle Aged , Apolipoprotein E4/genetics , Brain/blood supply , Cerebral Amyloid Angiopathy/complications , Cerebral Hemorrhage/etiology , Cerebral Hemorrhage/genetics , Cross-Sectional Studies , Intracranial Arteriovenous Malformations/complicationsABSTRACT
INTRODUCTION: Affective disorders (AD) have been shown to influence patient outcomes and healthcare resource utilization across several pathologies, though this relationship has not been described in patients with Chiari I malformations (CM-I). The aim of this study was to determine the impact of comorbid AD on postoperative events and healthcare resource utilization in adults following suboccipital decompression for CM-I. METHODS: A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults who underwent suboccipital decompression for CM-I were identified using ICD-10-CM codes. Patients were stratified into two cohorts, those with AD and those without (No AD). Patient demographics, comorbidities, operative characteristics, perioperative adverse events (AEs), and healthcare resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of prolonged length of stay (LOS), exorbitant admission costs, and non-routine discharge (NRD). RESULTS: A total of 3985 patients were identified, of which 2780 (69.8%) were in the No AD cohort and 1205 (30.2%) were in the AD cohort. Patient demographics were similar, except for a greater proportion of Female patients than the No AD cohort (p = 0.004). Prevalence of some comorbidities varied between cohorts, including obesity (p = 0.030), ADHD (p < 0.001), GERD (p < 0.001), smoking (p < 0.001), and chronic pulmonary disease (p < 0.001). The AD cohort had a greater proportion of patients with 1-2 (p < 0.001) or ≥ 3 comorbidities (p < 0.001) compared to the No AD cohort. A greater proportion of patients in the AD cohort presented with headache compared to the No AD cohort (p = 0.003). Incidence of syringomyelia was greater in the No AD cohort (p = 0.002). A greater proportion of patients in the No AD cohort underwent duraplasty only (without cervical laminectomy) compared to the AD cohort (p = 0.021). Healthcare resource utilization was similar between cohorts, with no significant differences in mean LOS (No AD: 3.78 ± 3.51 days vs. 3.68 ± 2.71 days, p = 0.659), NRD (No AD: 3.8% vs. AD: 5.4%, p = 0.260), or mean admission costs (No AD: $20,254 ± 14,023 vs. AD: $29,897 ± 22,586, p = 0.284). On multivariate analysis, AD was not independently associated with extended LOS [OR (95%CI): 1.09 (0.72-1.65), p = 0.669], increased hospital costs [OR (95%CI): 0.98 (0.63-1.52), p = 0.930], or NRD [OR (95%CI): 1.39 (0.65-2.96), p = 0.302]. CONCLUSION: Our study suggests that the presence of an AD may not have as much of an impact on postoperative events and healthcare resource utilization in adult patients undergoing Chiari decompression. Additional studies may be warranted to identify other potential implications that AD may have in other aspects of healthcare in this patient population.
Subject(s)
Arnold-Chiari Malformation , Decompression, Surgical , Adult , Humans , Female , Decompression, Surgical/adverse effects , Retrospective Studies , Treatment Outcome , Hospital Costs , Arnold-Chiari Malformation/epidemiology , Arnold-Chiari Malformation/surgery , Arnold-Chiari Malformation/complications , Postoperative Complications/etiologyABSTRACT
Importance: Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. Objective: To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. Design, Setting, and Participants: This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Exposures: Cardiac intervention during admission. Main Outcomes and Measures: The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Results: Among 634â¯407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318â¯363 patients (50.2%) were male, and 316â¯044 (49.8%) were female. A total of 12â¯093 had a cardiac intervention. An NIHSS score was reported in 218â¯576 admissions, 216â¯035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23â¯660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). Conclusions and Relevance: In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.
Subject(s)
Brain Ischemia , Endovascular Procedures , Ischemic Stroke , Stroke , Adult , Humans , Male , Female , United States/epidemiology , Adolescent , Aged , Ischemic Stroke/surgery , Brain Ischemia/surgery , Retrospective Studies , Cohort Studies , Stroke/epidemiology , Stroke/surgery , Thrombectomy/methods , Treatment Outcome , Endovascular Procedures/methodsABSTRACT
INTRODUCTION: The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM). METHODS: Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs. RESULTS: A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052). CONCLUSIONS: Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.
Subject(s)
Spinal Cord Diseases , Spinal Fusion , Spinal Osteophytosis , Spondylosis , Adult , Humans , Spondylosis/complications , Diskectomy , Spinal Cord Diseases/surgery , Decompression, Surgical , Cervical Vertebrae/surgery , Spinal Fusion/adverse effects , Spinal Osteophytosis/surgery , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Frailty is a prevalent state associated with several aging-related traits and conditions. The relationship between frailty and stroke remains understudied. Here we aim to investigate whether the hospital frailty risk score (HFRS) is associated with the risk of stroke and determine whether a significant association between genetically determined frailty and stroke exists. DESIGN: Observational study using data from All of Us research program and Mendelian Randomization analyses. METHODS: Participants from All of Us with available electronic health records were selected for analysis. All of Us began national enrollment in 2018 and is expected to continue for at least 10 years. All of Us is recruiting members of groups that have traditionally been underrepresented in research. All participants provided informed consent at the time of enrollment, and the date of consent was recorded for each participant. Incident stroke was defined as stroke event happening on or after the date of consent to the All of Us study HFRS was measured with a 3-year look-back period before the date of consent for stroke risk. The HFRS was stratified into 4 categories: no-frailty (HFRS=0), low (HFRS ≥1 and <5), intermediate (≥5 and <15), and high (HFRS ≥15). Last, we implemented Mendelian Randomization analyses to evaluate whether genetically determined frailty is associated with stroke risk. RESULTS: Two hundred fifty-three thousand two hundred twenty-six participants were at risk of stroke. In multivariable analyses, frailty status was significantly associated with risk of any (ischemic or hemorrhagic) stroke following a dose-response way: not-frail versus low HFRS (HR, 4.9 [CI, 3.5-6.8]; P<0.001), not-frail versus intermediate HFRS (HR, 11.4 [CI, 8.3-15.7]; P<0.001) and not-frail versus high HFRS (HR, 42.8 [CI, 31.2-58.6]; P<0.001). We found similar associations when evaluating ischemic and hemorrhagic stroke separately (P value for all comparisons <0.05). Mendelian Randomization confirmed this association by indicating that genetically determined frailty was independently associated with risk of any stroke (OR, 1.45 [95% CI, 1.15-1.84]; P=0.002). CONCLUSIONS: Frailty, based on the HFRS was associated with higher risk of any stroke. Mendelian Randomization analyses confirmed this association providing evidence to support a causal relationship.
Subject(s)
Hemorrhagic Stroke , Population Health , Stroke , Humans , Stroke/epidemiology , Stroke/genetics , Risk Factors , Hospitals , Retrospective StudiesABSTRACT
OBJECTIVE: Mobilizing out of bed and ambulation are key components of recovery following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). However, there remains a paucity of studies identifying risk factors associated with delayed ambulation and its impact on postoperative outcomes. The aim of this study was to investigate patient- and surgical-level risk factors associated with delayed ambulation and the ramifications of delayed ambulation on healthcare utilization for patients undergoing PSF for AIS. METHODS: The medical records of 129 adolescent (10-18 years) patients diagnosed with AIS undergoing posterior spinal fusion at a major academic institution between 2013 and 2020 were reviewed. Patients were categorized based on days from surgery to ambulation: early (≤ 1 day), intermediate (2 days), or late (≥ 3 days). Patient demographics, comorbidities, spinal deformity characteristics, intraoperative variables, postoperative complications, LOS, and unplanned readmissions were assessed. The odds ratios for risk-adjusted delayed ambulation and extended LOS were determined via multivariate stepwise logistic regressions. RESULTS: One Hundred and Twenty Nine patients were included in this study, of which 10.8% (n = 14) were classified as Early ambulators, 41.9% (n = 54) Intermediate ambulators, and 47.3% (n = 61) were Late ambulators. Late ambulators were significantly younger than early and intermediate ambulators (Early: 15.7 ± 1.9 years vs. Intermediate: 14.8 ± 1.7 years vs. Late: 14.1 ± 1.9 years, p = 0.010). The primary and secondary spinal curves were significantly worse among Late ambulators (p < 0.001 and p = 0.002 respectively). Fusion levels (p < 0.01), EBL (p = 0.014), and the rate of RBC transfusions (p < 0.001) increased as time to ambulation increased. Transition time from IV to oral pain medications (Early: 1.6 ± 0.8 days vs. Intermediate: 2.2 ± 0.6 days vs. Late: 2.4 ± 0.6 days, p < 0.001) and total hospital length of stay (Early: 3.9 ± 1.4 days vs. Intermediate: 4.7 ± 0.9 days vs. Late: 5.1 ± 1.2 days, p < 0.001) were longer in Late ambulators. On multivariate analysis, significant predictors of delayed ambulation included primary curve degree ≥ 70° [aOR: 5.67 (1.29â31.97), p = 0.030] and procedure time [aOR: 1.66 (1.1â2.59), p = 0.019]. CONCLUSIONS: Our study suggests that there may be patient- and surgical-level factors that are independently associated with late ambulation following PSF for AIS, including extent of major curve and length of operative time. Additionally, delayed ambulation has implications to length of hospital stay and postoperative complications.
Subject(s)
Kyphosis , Scoliosis , Spinal Fusion , Thoracic Surgical Procedures , Humans , Adolescent , Scoliosis/epidemiology , Spinal Fusion/adverse effects , Spinal Fusion/methods , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Comorbidity , Kyphosis/etiology , Pain/etiologyABSTRACT
BACKGROUND: Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS. METHODS: The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS. RESULTS: Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062). CONCLUSIONS: Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS.
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OBJECTIVE: Insurance disparities have been suggested to influence the medical and surgical outcomes of adult patients with spinal cord injury (SCI), with a paucity of studies demonstrating their impact on the outcomes of pediatric and adolescent SCI patients. The aim of this study was to assess the impact of insurance status on healthcare utilization and outcomes in adolescent patients presenting with SCI. METHODS: An administrative database study was performed using the 2017 admission year from 753 facilities using the National Trauma Data Bank. Adolescent patients (11-17 years old) with cervical/thoracic SCIs were identified using International Classification of Diseases, Tenth Revision, Clinical Modification coding. Patients were categorized by governmental insurance versus private insurance/self-pay. Patient demographics, comorbidities, imaging, procedures, hospital adverse events (AEs), and length of stay (LOS) data were collected. Multivariate regression analyses were used to determine the effect of insurance status on LOS, any imaging or procedure, or any AE. RESULTS: Of the 488 patients identified, 220 (45.1%) held governmental insurance while 268 (54.9%) were privately insured. Age was similar between the cohorts (p = 0.616), with the governmental insurance cohort (GI cohort) having a significantly lower proportion of non-Hispanic White patients than the private insurance cohort (PI cohort) (GI: 43.2% vs PI: 72.4%, p < 0.001). While transportation accident was the most common mechanism of injury for both cohorts, assault was significantly greater in the GI cohort (GI: 21.8% vs PI: 3.0%, p < 0.001). A significantly greater proportion of patients in the PI cohort received any imaging (GI: 65.9% vs PI: 75.0%, p = 0.028), while there were no significant differences in procedures performed (p = 0.069) or hospital AEs (p = 0.386) between the cohorts. The median (IQR) LOS (p = 0.186) and discharge disposition (p = 0.302) were similar between the cohorts. On multivariate analysis, with respect to governmental insurance, private insurance was not independently associated with obtaining any imaging (OR 1.38, p = 0.139), undergoing any procedure (OR 1.09, p = 0.721), hospital AEs (OR 1.11, p = 0.709), or LOS (adjusted risk ratio -2.56, p = 0.203). CONCLUSIONS: This study suggests that insurance status may not independently influence healthcare resource utilization and outcomes in adolescent patients presenting with SCIs. Further studies are needed to corroborate these findings.
Subject(s)
Spinal Cord Injuries , Adult , Humans , Adolescent , Child , Spinal Cord Injuries/diagnostic imaging , Spinal Cord Injuries/epidemiology , Spinal Cord Injuries/therapy , Hospitalization , Length of Stay , Insurance Coverage , Patient Acceptance of Health Care , Retrospective StudiesABSTRACT
STUDY DESIGN: Observational cohort study. OBJECTIVE: The aim of this study was to investigate the association between safety-net hospital (SNH) status and hospital length of stay (LOS), cost, and discharge disposition in patients undergoing surgery for metastatic spinal column tumors. SUMMARY OF BACKGROUND DATA: SNHs serve a high proportion of Medicaid and uninsured patients. However, few studies have assessed the effects of SNH status on outcomes after surgery for metastatic spinal column tumors. PATIENTS AND METHODS: This study was performed using the 2016-2019 Nationwide Inpatient Sample database. All adult patients undergoing metastatic spinal column tumor surgeries, identified using ICD-10-CM coding, were stratified by SNH status, defined as hospitals in the top quartile of Medicaid/uninsured coverage burden. Hospital characteristics, demographics, comorbidities, intraoperative variables, postoperative complications, and outcomes were assessed. Multivariable analyses identified independent predictors of prolonged LOS (>75th percentile of cohort), nonroutine discharge, and increased cost (>75th percentile of cohort). RESULTS: Of the 11,505 study patients, 24.0% (n = 2760) were treated at an SNH. Patients treated at SNHs were more likely to be Black-identifying, male, and lower income quartile. A significantly greater proportion of patients in the non-SNH (N-SNH) cohort experienced any postoperative complication [SNH: 965 (35.0%) vs . N-SNH: 3535 (40.4%), P = 0.021]. SNH patients had significantly longer LOS (SNH: 12.3 ± 11.3 d vs . N-SNH: 10.1 ± 9.5 d, P < 0.001), yet mean total costs (SNH: $58,804 ± 39,088 vs . N-SNH: $54,569 ± 36,781, P = 0.055) and nonroutine discharge rates [SNH: 1330 (48.2%) vs . N-SNH: 4230 (48.4%), P = 0.715) were similar. On multivariable analysis, SNH status was significantly associated with extended LOS [odds ratio (OR): 1.41, P = 0.009], but not nonroutine discharge disposition (OR: 0.97, P = 0.773) or increased cost (OR: 0.93, P = 0.655). CONCLUSIONS: Our study suggests that SNHs and N-SNHs provide largely similar care for patients undergoing metastatic spinal tumor surgeries. Patients treated at SNHs may have an increased risk of prolonged hospitalizations, but comorbidities and complications likely contribute greater to adverse outcomes than SNH status alone. LEVEL OF EVIDENCE: 3.
Subject(s)
Safety-net Providers , Spinal Cord Neoplasms , Adult , United States/epidemiology , Humans , Male , Hospitals , Length of Stay , Postoperative Complications/epidemiology , Spine , Retrospective StudiesABSTRACT
PURPOSE: The Hospital Frailty Risk Score (HFRS) is a frailty-identifying metric developed using ICD-10-CM codes. While other studies have examined frailty in adult spinal deformity (ASD), the HFRS has not been assessed in this population. The aim of this study was to utilize the HFRS to investigate the impact of frailty on outcomes in ASD patients undergoing posterior spinal fusion (PSF). METHODS: A retrospective study was performed using the 2016-2019 National Inpatient Sample database. Adults with ASD undergoing elective PSF were identified using ICD-10-CM codes. Patients were categorized into HFRS-based frailty cohorts: Low (HFRS < 5) and Intermediate-High (HFRS ≥ 5). Patient demographics, comorbidities, intraoperative variables, and outcomes were assessed. Multivariate regression analyses were used to determine whether HFRS independently predicted extended length of stay (LOS), non-routine discharge, and increased cost. RESULTS: Of the 7500 patients identified, 4000 (53.3%) were in the Low HFRS cohort and 3500 (46.7%) were in the Intermediate-High HFRS cohort. On average, age increased progressively with increasing HFRS scores (p < 0.001). The frail cohort experienced more postoperative adverse events (p < 0.001), greater LOS (p < 0.001), accrued greater admission costs (p < 0.001), and had a higher rate of non-routine discharge (p < 0.001). On multivariate analysis, Intermediate-High HFRS was independently associated with extended LOS (OR: 2.58, p < 0.001) and non-routine discharge (OR: 1.63, p < 0.001), though not increased admission cost (OR: 1.01, p = 0.929). CONCLUSION: Our study identified HFRS to be significantly associated with prolonged hospitalizations and non-routine discharge. Other factors that were found to be associated with increased healthcare resource utilization include age, Hispanic race, West hospital region, large hospital size, and increasing number of AEs.
ABSTRACT
OBJECTIVE: Frailty has been shown to affect patient outcomes after medical and surgical interventions. The Hospital Frailty Risk Score (HFRS) is a growing metric used to assess patient frailty using International Classification of Diseases, Tenth Revision codes. The goal of this study was to investigate the impact of frailty, assessed by HFRS, on health care resource utilization and outcomes in patients undergoing surgery for spinal meningiomas. METHODS: A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. Adult patients with benign or malignant spinal meningiomas, identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes, were stratified by HFRS: low frailty (HFRS <5) and intermediate-high frailty (HFRS ≥5). Patient demographics, hospital characteristics, comorbidities, procedural variables, adverse events, length of stay (LOS), discharge disposition, and cost of admission were assessed. Multivariate regression analysis was used to identify predictors of increased LOS, discharge disposition, and cost. RESULTS: Of the 3345 patients, 530 (15.8%) had intermediate-high frailty. The intermediate-high cohort was significantly older (P < 0.001). More patients in the intermediate-high cohort had ≥3 comorbidities (P < 0.001). In addition, a greater proportion of patients in the intermediate-high cohort experienced ≥1 perioperative adverse events (P < 0.001). Intermediate-high patients experienced greater mean LOS (P < 0.001) and accrued greater costs (P < 0.001). A greater proportion of intermediate-high patients had nonroutine discharges (P < 0.001). On multivariate analysis, increased HFRS (≥5) was independently associated with extended LOS (adjusted odds ratio [aOR], 3.04; P < 0.001), nonroutine discharge (aOR, 1.98; P = 0.006), and increased costs (aOR, 2.39; P = 0.004). CONCLUSIONS: Frailty may be associated with increased health care resource utilization in patients undergoing surgery for spinal meningiomas.
Subject(s)
Frailty , Meningeal Neoplasms , Meningioma , Adult , Humans , Retrospective Studies , Meningioma/epidemiology , Meningioma/surgery , Frailty/epidemiology , Prevalence , Length of Stay , Hospitals , Risk Factors , Postoperative Complications/epidemiologyABSTRACT
BACKGROUND: Andexanet alfa (AA), a factor Xa-inhibitor (FXi) reversal agent, is given as a bolus followed by a 2-hour infusion. This long administration time can delay EVD placement in intracerebral hemorrhage (ICH) patients. We sought to evaluate the safety of EVD placement immediately post-AA bolus compared to post-AA infusion. METHODS: We conducted a retrospective study that included adult patients admitted with FXi-associated ICH who received AA and underwent EVD placement The primary outcome was the occurrence of a new hemorrhage (tract, extra-axial, or intraventricular hemorrhage). Secondary outcomes included mortality, intensive care unit and hospital length of stay, and discharge modified Rankin Score. The primary safety outcome was documented thrombotic events. RESULTS: Twelve patients with FXi related ICH were included (EVD placement post-AA bolus, N = 8; EVD placement post-AA infusion, N = 4). Each arm included one patient with bilateral EVD placed. There was no difference in the incidence of new hemorrhages, with one post-AA bolus patient had small, focal, nonoperative extra-axial hemorrhage. Morbidity and mortality were higher in post-AA infusion patients (mRS, post-AA bolus, 4 [4-6] vs. post-AA infusion 6 [5,6], p = 0.24 and post-AA bolus, 3 (37.5 %) vs. post-AA infusion, 3 (75 %), p = 0.54, respectively). One patient in the post-AA bolus group had thrombotic event. There was no difference in hospital LOS (post-AA bolus, 19 days [12-26] vs. post-AA infusion, 14 days [9-22], p = 0.55) and ICU LOS (post-AA bolus, 10 days [6-13] vs. post-AA infusion, 11 days [5-21], p = 0.86). CONCLUSION: We report no differences in the incidence of tract hemorrhage, extra-axial hemorrhage, or intraventricular hemorrhage post-AA bolus versus post-AA infusion. Larger prospective studies to validate these results are warranted.
Subject(s)
Factor Xa , Thrombosis , Adult , Humans , Factor Xa Inhibitors , Retrospective Studies , Prospective Studies , Cerebral Hemorrhage/surgery , Fibrinolytic Agents , Drainage/methods , Recombinant ProteinsABSTRACT
PURPOSE: To provide an up-to-date review of the epidemiology, histopathology, molecular biology, and etiology of spinal meningiomas, as well as discuss the clinical presentation, clinical evaluation, and most recent treatment recommendations for these lesions. METHODS: PubMed and Google Scholar search was performed for studies related to meningiomas of the spine. The terms "meningioma," "spinal meningioma," "spine meningioma," "meningioma of the spine," "benign spinal tumors," and "benign spine tumors," were used to identify relevant studies. All studies, including primary data papers, meta-analyses, systematic reviews, general reviews, case reports, and clinical trials were considered for review. RESULTS: Eighty-four studies were identified in the review. There were 22 studies discussing adverse postoperative outcomes, 21 studies discussing tumor genetics, 19 studies discussing epidemiology and current literature, 9 studies discussing radiation modalities and impact on subsequent tumor development, 5 studies on characteristic imaging findings, 5 studies discussing hormone use/receptor status on tumor development, 2 discussing operative techniques and 1 discussing tumor identification. CONCLUSION: Investigations into spinal meningiomas generally lag behind that of intracranial meningiomas. Recent advancements in the molecular profiling of spinal meningiomas has expanded our understanding of these tumors, increasing our appreciation for their heterogeneity. Continued investigation into the defining characteristics of different spinal meningiomas will aid in treatment planning and prognostication.
Subject(s)
Meningeal Neoplasms , Meningioma , Spinal Cord Neoplasms , Spinal Neoplasms , Humans , Meningioma/diagnosis , Meningioma/epidemiology , Meningioma/genetics , Meningeal Neoplasms/diagnosis , Meningeal Neoplasms/epidemiology , Meningeal Neoplasms/genetics , Spine/pathology , Spinal Cord Neoplasms/diagnosis , Spinal Cord Neoplasms/epidemiology , Spinal Cord Neoplasms/therapy , Spinal Neoplasms/diagnosis , Spinal Neoplasms/epidemiology , Spinal Neoplasms/geneticsSubject(s)
Frailty , Hydrocephalus, Normal Pressure , Hydrocephalus , Humans , Hydrocephalus, Normal Pressure/surgery , Hydrocephalus, Normal Pressure/etiology , Ventriculoperitoneal Shunt/adverse effects , Patient Readmission , Frailty/surgery , Hydrocephalus/surgery , Hydrocephalus/etiology , Risk FactorsABSTRACT
AIM: To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs). METHODS: A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge. RESULTS: Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001). CONCLUSIONS: Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.