The influence of race on outcomes following pituitary tumor resection.

OBJECTIVE: To assess the influence of race on short-term patient outcomes in a pituitary tumor surgery population. PATIENTS AND METHODS: Coarsened exact matching was used to retrospectively analyze consecutive patients (n = 567) undergoing pituitary tumor resection over a six-year period (June 07, 2013 to April 29, 2019) at a single, multi-hospital academic medical center. Black/African American and white patients were exact matched based on twenty-nine (29) patient, procedure, and hospital characteristics. Matching characteristics included surgical costs, American Society of Anesthesiologists grade, duration of surgery, and Charlson Comorbidity Index, amongst others. Outcomes studied included unplanned 90-day readmission, emergency room (ER) evaluation, and unplanned reoperation. RESULTS: Ninety-two (n = 92) patients were exact matched and analyzed. There was no significant difference in 90-day readmission (p = 0.267, OR (black/AA vs white) = 0.500, 95% CI = 0.131-1.653) or ER evaluation within 90 days (p = 0.092, OR = 3.000, 95% CI = 0.848-13.737) between the two cohorts. Furthermore, there was no significant difference in the rate of unplanned reoperation throughout the duration of the follow up period between matched black/African American and white patients (p = 0.607, OR = 0.750, 95% CI = 0.243-2.211). CONCLUSION: This study suggests that the effect of race on post-operative outcomes is largely mitigated when equal access is attained, and when race is effectively isolated from socioeconomic factors and comorbidities in a population undergoing pituitary tumor resection.

Association of overlapping cardiac surgery with short-term patient outcomes.

OBJECTIVE: This study seeks to assess the safety of overlap in cardiac surgery. METHODS: Coarsened exact matching was used to assess the impact of overlap on outcomes among cardiac surgical interventions (n = 4463) over 2 years (2014-2016). Overlap was categorized as any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables, including Charlson comorbidity score, surgical costs, body mass index, length of postoperative hospitalization, and race, among others. Serious unanticipated events were studied, including readmission, unplanned return to the operating room, and mortality. RESULTS: A total of 984 patients had any overlap and were matched to similar patients without overlap (n = 1501). For beginning/end overlap, separate matched groups were created (n = 462, n = 329 patients, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap did not predict increased readmission, reoperation, or emergency department visits at 30 or 90 days. Overlap did not predict higher rates of death over follow-up. Beginning/end overlap had results similar to any overlap. CONCLUSIONS: Nonconcurrent, overlapping surgery is not associated with an increase in adverse outcomes in a large, matched cardiac surgery population.

Composite Score for Outcome Prediction in Gynecologic Surgery Patients.

BACKGROUND: The LACE+ index is a well-studied metric that compacts patient data in an effort to assess readmission risk. PURPOSE: Assess the capacity of LACE+ scores for predicting short-term undesirable outcomes in an entire single-center population of patients undergoing gynecologic surgery. IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY: Proactive identification of high-risk patients, with tools such as the LACE+ index, may serve as the first step toward appropriately engaging resources for reducing readmissions. METHODS: This study was a retrospective analysis that used coarsened exact matching. All gynecologic surgery cases over 2 years within a single health system (n = 12,225) were included for analysis. Outcomes of interest were unplanned readmission, emergency room (ER) evaluation, and return to surgery. Composite LACE+ scores were separated into quartiles and matched. For outcome comparison, matched patients were assessed by LACE+ quartile, using Q4 as the reference group. RESULTS: Increasing LACE+ score reflected a higher rate of readmission (p = .003, p = .001) and visits to the ER at 30 postoperative days (p < .001). CONCLUSION: The data presented here suggest that LACE+ index is a viable metric for patient outcome prediction following gynecologic surgery.

Prediction of Adverse Outcomes Within 90 Days of Surgery in a Heterogeneous Orthopedic Surgery Population.

INTRODUCTION: The LACE+ index has been shown to predict readmissions; however, LACE+ has not been validated for extended postoperative outcomes in an orthopedic surgery population. The purpose of this study is to examine whether LACE+ scores predict unplanned readmissions and adverse outcomes following orthopedic surgery. Use of the LACE1 index to proactively identify at-risk patients may enable actions to reduce preventable readmissions. METHODS: LACE+ scores were retrospectively calculated at the time of discharge for all consecutive orthopedic surgery patients (n = 18,893) at a multicenter health system over 3 years (2016-2018). Coarsened exact matching was used to match patients based on characteristics not assessed in the LACE+ index. Outcome differences between matched patients in different LACE quartiles (i.e. Q4 vs. Q3, Q2, and Q1) were analyzed. RESULTS: Higher LACE+ scores significantly predicted readmission and emergency department visits within 90 days of discharge and for 30-90 days after discharge for all studied quartiles. Higher LACE+ scores also significantly predicted reoperations, but only between Q4 and Q3 quartiles. CONCLUSIONS: The results suggest that the LACE+ risk-prediction tool may accurately predict patients with a high likelihood of adverse outcomes after a broad array of orthopedic procedures.

Role of Race in Short-Term Outcomes for 1700 Consecutive Patients Undergoing Brain Tumor Resection.

BACKGROUND: Access to medical care seems to be impacted by race. However, the effect of race on outcomes, once care has been established, is poorly understood. PURPOSE: This study seeks to assess the influence of race on patient outcomes in a brain tumor surgery population. IMPORTANCE AND RELEVANCE TO HEALTHCARE QUALITY: This study offers insights to if or how quality is impacted based on patient race, after care has been established. Knowledge of disparities may serve as a valuable first step toward risk factor mitigation. METHODS: Patients differing in race, but matched on other outcomes affecting characteristics, were assessed for differences in outcomes subsequent to brain tumor resection. Coarsened exact matching was used to match 1700 supratentorial brain tumor procedures performed over a 6-year period at a single, multihospital academic medical center. Patient outcomes assessed included unplanned readmission, mortality, emergency department (ED) visits, and unanticipated return to surgery. RESULTS: There was no significant difference in readmissions, mortality, ED visits, return to surgery after index admission, or return to surgery within 30 days between the two races. CONCLUSION: This study suggests that race does not independently influence postsurgical outcomes but may instead serve as a proxy for other closely related demographics.

Predictive index for 90-day postoperative outcomes following gynecologic surgery.

OBJECTIVES: Assessment of the potential of LACE+ index scores in patients undergoing gynecologic surgery to predict short-term undesirable outcomes. STUDY DESIGN: Retrospective study over a 2-year time period (2016-2018). METHODS: Coarsened exact matching was used to assess the predictive capacity of the LACE+ index among all gynecologic surgery cases over a 2-year period (2016-2018) at 1 health system (N = 12,225). Study subjects were matched on characteristics not assessed by LACE+, including race and duration of surgery. For comparison of outcomes, LACE+ score was divided into quartiles and otherwise matched populations were compared in reference to LACE+ quartile (Q): Q4 vs Q1, Q4 vs Q2, Q4 vs Q3. RESULTS: A total of 1715 patients were matched for Q1 to Q4, 1951 patients were matched for Q2 to Q4, and 1822 patients were matched for Q3 to Q4. Escalating LACE+ score significantly predicted increased readmission, reoperation, and emergency department (ED) visits from 30 to 90 postoperative days as well as readmission, reoperation, and ED visits from 0 to 90 postoperative days. CONCLUSIONS: The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a gynecologic surgery population.

Assessing the Role of Patient Race in Disparity of 90-Day Brain Tumor Resection Outcomes.

BACKGROUND: This study assesses the influence of race on patient outcomes in a brain tumor surgery population. METHODS: Coarsened exact matching was used to retrospectively analyze 1700 supratentorial brain tumor procedures over a 6-year period (June 7, 2013 to April 29, 2019) at a single, multihospital academic medical center. Outcome measures included readmission, mortality, emergency room visits, and reoperation. RESULTS: McNemar test (mid-P) showed no significant difference in 90-day mortality between the 2 races (P = 0.3018). However, there was a significant difference in 90-day readmissions between the 2 races (P = 0.0237). There was no significant difference in 90-day emergency room visits (P = 0.0579), 90-day return to surgery after index admission (P = 0.6015), or return to surgery within 90 days (P = 0.6776) between the 2 races. There was also no significant difference in return to surgery for the duration of the follow-up period (P = 0.8728). CONCLUSIONS: This study suggests that race alone does not result in disparate outcomes; however, there was an associated difference in 90-day postsurgical readmissions. Despite coarsened exact matching, persistent differences in median household income may play a role in the disparate outcome noted.

The LACE+ Index as a Predictor of 30-Day Patient Outcomes in a Plastic Surgery Population: A Coarsened Exact Match Study.

BACKGROUND: This study used coarsened exact matching to investigate the effectiveness of the LACE+ index (i.e., length of stay, acuity of admission, Charlson Comorbidity Index, and emergency department visits in the past 6 months) predictive tool in patients undergoing plastic surgery. METHODS: Coarsened exact matching was used to assess the predictive ability of the LACE+ index among plastic surgery patients over a 2-year period (2016 to 2018) at one health system (n = 5744). Subjects were matched on factors not included in the LACE+ index such as duration of surgery, body mass index, and race, among others. Outcomes studied included emergency room visits, hospital readmission, and unplanned return to the operating room. RESULTS: Three hundred sixty-six patients were matched and compared for quarter 1 to quarter 4 (n = 732, a 28.2 percent match rate); 504 patients were matched for quarter 2 to quarter 4 (n = 1008, a 36.7 percent match rate); 615 patients were matched for quarter 3 to quarter 4 (n = 1230, a 44.8 percent match rate). Increased LACE+ score significantly predicted readmission within 30 days for quarter 1 versus quarter 4 (1.09 percent versus 4.37 percent; p = 0.019), quarter 2 versus quarter 4 (3.57 percent versus 7.34 percent; p = 0.008), and quarter 3 versus quarter 4 (5.04 percent versus 8.13 percent; p = 0.028). Higher LACE+ score also significantly predicted 30-day reoperation for quarter 3 versus quarter 4 (1.30 percent versus 3.90 percent; p = 0.003) and emergency room visits within 30 days for quarter 2 versus quarter 4 (3.17 percent versus 6.75 percent; p = 0.008). CONCLUSION: The results of this study demonstrate that the LACE+ index may be suitable as a prediction model for patient outcomes in a plastic surgery population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

LACE+ index as a predictor of 90-day plastic surgery outcomes.

OBJECTIVES: This study used coarsened exact matching to assess the ability of the LACE+ index to predict adverse outcomes after plastic surgery. STUDY DESIGN: Two-year retrospective study (2016-2018). METHODS: LACE+ scores were retrospectively calculated for all patients undergoing plastic surgery at a multicenter health system (N = 5744). Coarsened exact matching was performed to sort patient data before analysis. Outcomes including unplanned hospital readmission, emergency department visits, and reoperation were compared for patients in different LACE+ score quartiles (Q1, Q2, Q3, Q4). RESULTS: A total of 2970 patient procedures were matched during coarsened exact matching. Increased LACE+ score significantly predicted readmission within 90 days of discharge for Q4 versus Q1 (6.28% vs 1.91%; P = .003), Q4 versus Q2 (12.30% vs 5.56%; P <.001), and Q4 versus Q3 (13.84% vs 7.33%; P <.001). Increased LACE+ score also significantly predicted emergency department visits within 90 days for Q4 versus Q1 (9.29% vs 3.01%; P <.001), Q4 versus Q2 (11.31% vs 3.57%; P <.001), and Q4 versus Q3 (13.70% vs 8.48%; P = .003). Higher LACE+ score also significantly predicted secondary reoperation within 90 days for Q4 versus Q1 (3.83% vs 1.37%; P = .035), Q4 versus Q2 (5.95% vs 3.37%; P = .042), and Q4 versus Q3 (7.50% vs 3.26%; P <.001). CONCLUSIONS: The results of this study demonstrate that the LACE+ index may be suitable as a prediction model for patient outcomes in a plastic surgery population.

Composite score for prediction of 30-day orthopedic surgery outcomes.

The LACE+ (Length of stay, Acuity of admission, Charlson Comorbidity Index score, and Emergency department visits in the past 6 months) risk-prediction tool has never been tested in an orthopedic surgery population. LACE+ may help physicians more effectively identify and support high-risk orthopedics patients after hospital discharge. LACE+ scores were retrospectively calculated for all consecutive orthopedic surgery patients (n = 18 893) at a multi-center health system over 3 years (2016-2018). Coarsened exact matching was employed to create "matched" study groups with different LACE+ score quartiles (Q1, Q2, Q3, Q4). Outcomes were compared between quartiles. In all, 1444 patients were matched between Q1 and Q4 (n = 2888); 2079 patients between Q2 and Q4 (n = 4158); 3032 patients between Q3 and Q4 (n = 6064). Higher LACE+ scores significantly predicted 30D readmission risk for Q4 vs Q1 and Q4 vs Q3 (P < .001). Larger LACE+ scores also significantly predicted 30D risk of ED visits for Q4 vs Q1, Q4 vs Q2, and Q4 vs Q3 (P < .001). Increased LACE+ score also significantly predicted 30D risk of reoperation for Q4 vs Q1 (P = .018), Q4 vs Q2 (P < .001), and Q4 vs Q3 (P < .001).

The Effect of Race on Short-Term Pituitary Tumor Outcomes.

BACKGROUND: The relationship between race and neurosurgical outcomes is poorly characterized despite its importance. The influence of race on short-term patient outcomes in a pituitary tumor surgery population was assessed. METHODS: Coarsened exact matching was used to retrospectively analyze 567 consecutive pituitary tumor cases from a 6-year period (June 7, 2013, to April 29, 2019) at a single, multihospital academic medical center. Outcomes studied included 30-day readmission, mortality, and reoperation. RESULTS: There were 92 exact-matched cases suitable for analysis. There was a significant difference in 30-day emergency department visits between the 2 races (black/African American vs. white odds ratio = 4.5, 95% confidence interval = 1.072-30.559, P = 0.0386). There was no observed mortality over the 30-day postoperative period. There was no significant difference in 30-day readmission between the 2 race cohorts (P = 0.3877), in return to surgery after index admission within 30 days (P = 1.000), or in return to surgery within 30 days (P = 0.3750). CONCLUSIONS: This study suggests that the effect of race on outcomes is partly mitigated for individuals who can attain access, and when socioeconomic factors and comorbidities are controlled for. The noted significant difference in emergency department visits could be indicative of confounding variables that were not well controlled for and requires further exploration.

Assessment of Short-Term Patient Outcomes Following Overlapping Orthopaedic Surgery at a Large Academic Medical Center.

BACKGROUND: Overlapping surgery is a long-standing practice that has not been well studied. The aim of this study was to assess whether overlapping surgery is associated with untoward outcomes for orthopaedic patients. METHODS: Coarsened exact matching was used to assess the impact of overlap on outcomes among elective orthopaedic surgical interventions (n = 18,316) over 2 years (2014 and 2015) at 1 health-care system. Overlap was categorized as any overlap, and subcategories of exclusively beginning overlap and exclusively end overlap. Study subjects were matched on the Charlson comorbidity index score, duration of surgery, surgical costs, body mass index, length of stay, payer, and race, among others. Serious unanticipated events were studied. RESULTS: A total of 3,395 patients had any overlap and were matched (a match rate of 90.8% of 3,738). For beginning and end overlap, matched groups were created, with a match rate of 95.2% of 1043 and 94.7% of 863, respectively. Among matched patients, any overlap did not predict an unanticipated return to surgery at 30 days (8.2% for any overlap and 8.3% for no overlap; p = 0.922) or 90 days (14.1% and 14.1%, respectively; p = 1.000). Patients who had surgery with any overlap demonstrated no difference compared with controls with respect to reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (a reoperation rate of 3.1% and 3.2%, respectively [p = 0.884] at 30 days and 4.2% and 3.5% [p = 0.173] at 90 days; a readmission rate of 10.3% and 11.0% [p = 0.352] at 30 days and 5.5% and 5.2% [p = 0.570] at 90 days; and an ER visit rate of 5.2% and 4.6% [p = 0.276] at 30 days and 4.8% and 4.3% [p = 0.304] at 90 days). Patients with surgical overlap showed reduced mortality compared with controls during follow-up (1.8% and 2.6%, respectively; p = 0.029). Patients with beginning and/or end overlap had a similar lack of association with serious unanticipated events; however, patients with end overlap showed an increased unexpected rate of return to the operating room after reoperation at 90 days (13.3% versus 9.7%; p = 0.015). CONCLUSIONS: Nonconcurrent overlapping surgery was not associated with adverse outcomes in a large, matched orthopaedic surgery population across 1 academic health system. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The LACE + index as a predictor of 90-day urologic surgery outcomes.

PURPOSE: This study assessed the ability of the LACE + [Length of stay, Acuity of admission, Charlson Comorbidity Index (CCI) score, and Emergency department visits in the past 6 months] index to predict adverse outcomes after urologic surgery. METHODS: LACE + scores were retrospectively calculated for all consecutive patients (n = 9824) who received urologic surgery at one multi-center health system over 2 years (2016-2018). Coarsened exact matching was employed to sort patient data before analysis; matching criteria included duration of surgery, BMI, and race among others. Outcomes including unplanned hospital readmission, emergency room visits, and reoperation were compared for patients with different LACE + quartiles. RESULTS: 722 patients were matched between Q1 and Q4; 1120 patients were matched between Q2 and Q4; 2550 patients were matched between Q3 and Q4. Higher LACE + score significantly predicted readmission within 90 days (90D) of discharge for Q1 vs Q4 and Q2 vs Q4. Increased LACE + score also significantly predicted 90D emergency room visits for Q1 vs Q4, Q2 vs Q4, and Q3 vs Q4. LACE + score was also significantly predictive of 90D reoperation for Q1 vs Q4. LACE + score did not predict 90D reoperation for Q2 vs Q4 or Q3 vs Q4 or 90D readmission for Q3 vs. Q4. CONCLUSION: These results suggest that LACE + may be a suitable prediction model for important patient outcomes after urologic surgery.

Evaluation of Short-term Outcomes Following Overlapping Urologic Surgery at a Large Academic Medical Center.

OBJECTIVE: To explore the effect of overlapping surgery on the risk of adverse outcomes in urologic surgery. METHODS: Coarsened exact matching was used to assess the impact of overlap on outcomes among urologic surgical interventions (n = 4853) over 2 years (2013-2015) at 1 health system. Overlap was categorized as any overlap, beginning overlap or end overlap. Study subjects were matched 1:1 on 11 clinically relevant variables. Serious unanticipated events were studied. RESULTS: Four hundred and thirty-four patients had any overlap and were matched (n = 575, a 75.47% match rate). For beginning/end overlap, matched groups were created (n = 108/83 patients, match rate was 83.07/75.45%, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap predicted neither reoperation, readmission, or ER visits at 30 or 90 days. Overlap patients showed no difference in mortality during follow-up. Beginning/end overlap had a similar lack of association with serious unanticipated events. CONCLUSION: Nonconcurrent overlapping surgery is not associated with adverse outcomes in a large, matched urologic surgery population across 1 academic health system.

Undiagnosed Obstructive Sleep Apnea as Predictor of 90-Day Readmission for Brain Tumor Patients.

BACKGROUND: Previously undiagnosed obstructive sleep apnea (OSA) is a known contributor to negative postoperative outcomes. The STOP-Bang questionnaire is a screening tool for OSA that has been validated in both medical and surgical populations. The authors have previously studied this screening tool in a brain tumor population at 30 days. The present study seeks to investigate the effectiveness of this questionnaire, for predicting 90-day readmissions in a population of brain tumor patients with previously undiagnosed OSA. METHODS: Included for analysis were all patients undergoing craniotomy for supratentorial neoplasm at a multihospital, single academic medical center. Data were collected from supratentorial craniotomy cases for which the patient was alive at 90 days after surgery (n = 238). Simple logistic regression analyses were used to assess the ability of the STOP-Bang questionnaire and subsequent single variables to accurately predict patient outcomes at 90 days. RESULTS: The sample included 238 brain tumor admissions, of which 50% were female (n = 119). The average STOP-Bang score was 1.95 ± 1.24 (range 0-7). A 1-unit higher increase in STOP-Bang score accurately predicted 90-day readmissions (odds ratio [OR] = 1.65, P = 0.001), 30- to 90-day emergency department visits (OR = 1.85, P < 0.001), and 30- to 90-day reoperation (OR = 2.32, P < 0.001) with fair accuracy as confirmed by the receiver operating characteristic (C-statistic = 0.65-0.76). However, the STOP-Bang questionnaire did not correlate with home discharge (P = 0.315). CONCLUSIONS: The results of this study suggest that undiagnosed OSA, as evaluated by the STOP-Bang questionnaire, is an effective predictor of readmission risk and health system utilization in a brain tumor craniotomy population with previously undiagnosed OSA.

Evaluation of the LACE+ Index for Short-term Cardiac Surgery Outcomes: A Coarsened Exact Match Study.

BACKGROUND: The potential of length of stay, acuity of admission, Charlson Comorbidity Index score, and emergency department visits in the past 6 months (LACE+) scores in patients undergoing cardiac surgery to predict short-term undesirable outcomes was examined. METHODS: Coarsened exact matching was used to assess the predictive capacity of the LACE+ index among all cardiac surgery cases over a 2-year period (2016-2018) at 1 health system (n = 4001). Study subjects were matched according to characteristics not assessed by LACE+, including duration of surgery, wound class, body mass index, insurance type, median household income, and race. For a comparison of outcomes, LACE score was divided into quartiles and otherwise matched populations were compared in reference to LACE quartile (Q): Q4 versus Q1, Q4 versus Q2, and Q4 versus Q3. RESULTS: Escalating LACE+ score significantly predicted increased readmission (6.99% versus 25.92% for Q1 versus Q4, 12.79% versus 26.74% for Q2 versus Q4, and 20.52% versus 27.66% for Q3 versus Q4, respectively; P < .001, P < .001, and P = .003), reoperation (2.39% versus 7.73% for Q1 versus Q4, and 4.33% versus 7.67% for Q2 versus Q4, respectively; P < .001 and P = .015, respectively), and emergency room visits at 30 days after surgery (6.64% versus 13.65% for Q1 versus Q4, and 11.20% versus 14.84% for Q2 versus Q4, respectively; P < .001 and P = .041, respectively) as well as readmission, reoperation, and emergency room visits from 30 to 90 days and 0 to 90 days after surgery. Increasing LACE score predicted higher rates of death during follow-up within 30 and 90 postoperative days (P < .001). CONCLUSIONS: The LACE+ index may be suitable as a prediction model for important patient outcomes in a cardiac surgery population.

The LACE+ Index as a Predictor of 30-Day Patient Outcomes in a Urologic Surgery Population: A Coarsened Exact Match Study.

OBJECTIVE: To examine the potential of LACE+ scores, in patients undergoing urologic surgery, to predict short-term undesirable outcomes. METHODS: Coarsened exact matching was used to assess the predictive value of the LACE+ index among all urologic surgery cases over a 2-year period (2016-2018) at 1 health system (n = 9824). Study subjects were matched on characteristics not assessed by LACE+, including duration of surgery and race, among others. For comparison of outcomes, matched populations were compared by LACE+ quartile with Q4 as the referent group: Q4 vs Q1, Q4 vs Q2, Q4 vs Q3. RESULTS: Seven hundred and twenty-two patients were matched for Q1-Q4; 1120 patients were matched for Q2-Q4; 2550 patients were matched for Q3-Q4. Escalating LACE+ score significantly predicted increased readmission (2.86% vs 4.91% for Q2 vs Q4; P = .012) and Emergency Room (ER) visits at 30 days postop (5.69% vs 11.37% for Q1 vs Q4, 4.11% vs 11.45% for Q2 vs Q4, 8.29% vs 13.32% for Q3 vs Q4; P <.001 for all). Increasing LACE score did not predict reoperation within 30 days or rate of death over follow-up within 30 postoperative days. CONCLUSION: The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a urologic surgery population including unanticipated readmission and ER evaluation.

Association of Overlapping Neurosurgery With Patient Outcomes at a Large Academic Medical Center.

BACKGROUND: Limited data exist on the safety of overlapping surgery, a practice that has recently received widespread attention. OBJECTIVE: To examine the association of overlapping neurosurgery with patient outcomes. METHODS: A total of 3038 routinely scheduled, elective neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. Procedures were categorized into any overlap or no overlap and further subcategorized into beginning overlap (first 50% of procedure only), end overlap (last 50% of procedure only), and middle overlap (overlap at the midpoint). RESULTS: A total of 1030 (33.9%) procedures had any overlap, whereas 278 (9.2%) had beginning overlap, 190 (6.3%) had end overlap, and 476 (15.7%) had middle overlap. Compared with no overlap patients, patients with any overlap had lower American Society of Anesthesiologists scores (P = .0018), less prior surgery (P < .0001), and less prior neurosurgery (P < .0001), though they tended to be older (P < .0001) and more likely in-patients (P = .0038). Any-overlap patients had decreased overall mortality (2.8% vs 4.5%; P = .025), 30- to 90-d readmission rate (3.1% vs 5.5%; P = .0034), 30- to 90-d reoperation rate (1.0% vs 2.0%; P = .03), 30- to 90-d emergency room (ER) visit rate (2.1% vs 3.7%; P = .018), and future surgery on index admission (2.8% vs 7.3%; P < .0001). Multiple regression analysis validated noninferior outcomes for overlapping surgery, except for the association of increased future surgery on index admission with middle overlap (odds ratio 3.99; 95% confidence interval [1.91, 8.33]). CONCLUSION: Overlapping neurosurgery is associated with noninferior patient outcomes that may be driven by surgeon selection of healthier patients, regardless of specific overlap timing.

Undiagnosed obstructive sleep apnea as a predictor of 30-day readmission for brain tumor patients.

OBJECTIVE: Obstructive sleep apnea (OSA) is known to be associated with negative outcomes and is underdiagnosed. The STOP-Bang questionnaire is a screening tool for OSA that has been validated in both medical and surgical populations. Given that readmission after surgical intervention is an undesirable event, the authors sought to investigate, among patients not previously diagnosed with OSA, the capacity of the STOP-Bang questionnaire to predict 30-day readmissions following craniotomy for a supratentorial neoplasm. METHODS: For patients undergoing craniotomy for treatment of a supratentorial neoplasm within a multiple-hospital academic medical center, data were captured in a prospective manner via the Neurosurgery Quality Improvement Initiative (NQII) EpiLog tool. Data were collected over a 1-year period for all supratentorial craniotomy cases. An additional criterion for study inclusion was that the patient was alive at 30 postoperative days. Statistical analysis consisted of simple logistic regression, which assessed the ability of the STOP-Bang questionnaire and additional variables to effectively predict outcomes such as 30-day readmission, 30-day emergency department (ED) visit, and 30-day reoperation. The C-statistic was used to represent the receiver operating characteristic (ROC) curve, which analyzes the discrimination of a variable or model. RESULTS: Included in the sample were all admissions for supratentorial neoplasms treated with craniotomy (352 patients), 49.72% (n = 175) of which were female. The average STOP-Bang score was 1.91 ± 1.22 (range 0-7). A 1-unit higher STOP-Bang score accurately predicted 30-day readmissions (OR 1.31, p = 0.017) and 30-day ED visits (OR 1.36, p = 0.016) with fair accuracy as confirmed by the ROC curve (C-statistic 0.60-0.61). The STOP-Bang questionnaire did not correlate with 30-day reoperation (p = 0.805) or home discharge (p = 0.315). CONCLUSIONS: The results of this study suggest that undiagnosed OSA, as assessed via the STOP-Bang questionnaire, is a significant predictor of patient health status and readmission risk in the brain tumor craniotomy population. Further investigations should be undertaken to apply this prediction tool in order to enhance postoperative patient care to reduce the need for unplanned readmissions.

Association of Overlapping, Nonconcurrent, Surgery With Patient Outcomes at a Large Academic Medical Center: A Coarsened Exact Matching Study.

OBJECTIVE: Assess the safety of overlapping surgery before implementation of new recommendations and regulations. BACKGROUND: Overlapping surgery is a longstanding practice that has not been well studied. There remains a need to analyze data across institutions and specialties to draw well-informed conclusions regarding appropriate application of this practice. METHODS: Coarsened exact matching was used to assess the impact of overlap on outcomes amongst all surgical interventions (n = 61,524) over 1 year (2014) at 1 health system. Overlap was categorized as: any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables. Serious unanticipated events were studied including unplanned return to operating room, readmission, and mortality. RESULTS: In all, 8391 patients (13.6%) had any overlap and underwent coarsened exact matching. For beginning/end overlap, matched groups were created (total matched population N = 4534/3616 patients, respectively). Any overlap did not predict unanticipated return to surgery (9.8% any overlap vs 10.1% no overlap; P = 0.45). Further, any overlap did not predict an increase in reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (30D reoperation 3.6% vs 3.7%; P = 0.83, 90D reoperation 3.8% vs 3.9%; P = 0.84) (30D readmission 9.9% vs 10.2%; P = 0.45, 90D readmissions 6.9% vs 7.0%; P = 0.90) (30D ER 5.4% vs 5.6%; P = 0.60, 90D ER 4.8% vs 4.7%; P = 0.71). In addition, any overlap was not associated with mortality over the surgical follow-up period (90D mortality 1.7% vs 2.1%; P = 0.06). Beginning/end overlap had results similar to any overlap. CONCLUSION: Overlapping, nonconcurrent surgery is not associated with an increase in reoperation, readmission, ER visits, or unanticipated return to surgery.