The impact of social determinants of health on early outcomes after adult Chiari surgery.

We sought to identify social determinants of health (SDoH) for adult patients undergoing Chiari decompression surgery and to analyze their association with postoperative outcomes, including length of stay (LOS), return to the system within 30 days, and the Chicago Chiari Outcomes Score (CCOS). This is a retrospective study of adult patients who underwent Chiari decompression surgery between June 2021 and January 2023. Data was gathered through electronic medical record review and telephone surveys. Descriptive statistics were used to evaluate demographics of all patients meeting inclusion criteria. Fisher's exact tests and logistic regression were used for data analysis. A total of 37 patients underwent Chiari decompression (23 CCOS/SDoH survey respondents): 48% bony decompression only, 30% bony decompression plus intradural exploration, and 22% occipitocervical fusion. Seven patients (30%) had a LOS > 2 days, 1 patient (4%) required inpatient rehabilitation postoperatively, 4 patients (17%) returned to the system within 30 days, 10 patients (43%) had an extremely favorable CCOS (15-16), and 11 patients (48%) reported interaction with a Chiari support group. Mean follow-up was 9.5 months. Patients with occipitocervical fusion were more likely to have a LOS > 2 days (p = 0.03), patients who exercised ≥ 3 days per week were more likely to have a favorable CCOS (p = 0.04), and patients who participated in a Chiari support group were less likely to have a favorable CCOS (p = 0.03). Chiari decompression plus occipitocervical fusion may be associated with increased LOS. While more frequent exercise may be associated with better post-surgical outcomes, participation in a Chiari support group may be correlated with worse outcomes.

Pediatric neurosurgery through the lens of time-driven activity-based costing: a pilot study.

OBJECTIVE: Time-driven activity-based costing (TDABC) is a method used in cost accounting that has gained traction in health economics to identify value optimization initiatives. It measures time, assigns value to time increments spent on a patient, and integrates the cost of material and human resources utilized in each episode of care. In this study, the authors report the first use of TDABC to evaluate costs in a pediatric neurosurgical practice. METHODS: A clinical pathway was developed with a multifunction team. A time survey among each care team member, including surgeons, medical assistants (MAs), and patient service representatives (PSRs), was carried out prospectively over a 10-week period at a pediatric neurosurgery clinic. Consecutive patient encounters for Chiari malformation (CM), hydrocephalus, or tethered cord syndrome (TCS) were included. Encounters were categorized as new or established. Relative annual personnel costs, using the salary of a PSR as a reference (i.e., 1.0-unit cost), were calculated for all members using departmental financial data after adjustments. The relative capacity cost rates (minute-1) for each personnel, a representation of per capita cost per minute, were then derived, and the relative costs per visit were calculated. RESULTS: A total of 110 visits (24 new, 86 established) were captured, including 40% CM, 41% hydrocephalus, and 19% TCS encounters. Surgeons had the highest relative capacity cost rate (118.4 × 10-6), more than 10-fold higher than that of an MA or PSR (10.65 × 10-6 and 9.259 × 10-6, respectively). Surgeons also logged more time with patients compared with the rest of the care team in nearly all visits (p ≤ 0.002); consequently, the total visit costs were primarily driven by the surgeon cost (p < 0.0001). Overall, surgeon cost constituted the vast majority of the total visit cost (92%-93%), regardless of whether the visits were new or established. Visit costs did not differ by diagnosis. On average, new visits took longer than established visits (p < 0.001). This difference was largely driven by new CM visits (44.3 ± 13.7 minutes), which were significantly longer than established CM visits (29.8 ± 9.2 minutes; p = 0.001). CONCLUSIONS: TDABC may reveal opportunities to maximize value by highlighting instances of variability and high cost in each module of care delivery. Physician leaders in pediatric neurosurgery may be able to use this information to allocate costs and streamline value care pathways.

Academic productivity in pediatric neurosurgery in relation to elective surgery slowdown during the COVID-19 pandemic.

OBJECTIVE: COVID-19 has not only impacted healthcare systems directly via hospitalizations and resource utilization, but also indirectly via adaptations in healthcare practice, such as the evolution of the academic environment and the rise of telemedicine and virtual education. This void in clinical responsibilities has been filled with academic productivity in various fields. In this study the authors investigate the influence of COVID-19 on the academic focus within pediatric neurosurgery. METHODS: All data were obtained from the Journal of Neurosurgery: Pediatrics (JNS Peds). The number of submissions for each month from January 2017 to December 2021 was collected. Data including number of publications, publication level of evidence (LOE), and COVID-19-related articles were collected and verified. Each publication was categorized by manuscript and LOE according to adaptations from the Canadian Task Force on Periodic Health Examination. Publication groups were categorized as pre-COVID-19 (January 2017-February 2020), peri-COVID-19 (March 2020-July 2020), and post-COVID-19 (August 2020-December 2021). Statistical analysis was performed to compare pre-COVID-19, peri-COVID-19, and post-COVID-19 academic volume and quality. RESULTS: During the study time period, a total of 3116 submissions and 997 publications were identified for JNS Peds. Only 2 articles specifically related to COVID-19 and its impact on pediatric neurosurgery were identified, both published in 2021. When analyzing submission volume, a statistically significant increase was seen during the shutdown relative to pre-COVID-19 and post-shutdown time periods, and a significant decrease was seen post-shutdown relative to pre-COVID-19. LOE changed significantly as well. When comparing pre-COVID-19 versus post-COVID-19 articles, a statistically significant increase was identified only in level 4 publications. When analyzing pre-COVID-19 versus post-COVID-19 (2020) and post-COVID-19 (2021), a statistically significant decrease in level 3 and increases in levels 4 and 5 were identified during post-COVID-19 (2020), with a rebound increase in level 3 and a decrease in level 5 during post-COVID-19 (2021). CONCLUSIONS: There was a significant increase in manuscript submission during the initial pandemic period. However, there was no change during subsequent spikes in COVID-19-related hospitalizations. Coincident with the initial surge in academic productivity, despite steady publication volume, was an inverse decline in quality as assessed by LOE.