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Pecorari IL, Reynolds JA, Agarwal V. The Relationship Between Race, Social Vulnerability Index, and Clinical Follow-Up After Surgical Resection of Pituitary Tumors. World Neurosurg 2024:S1878-8750(24)01362-7. [PMID: 39116941 DOI: 10.1016/j.wneu.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE Socioeconomic status and race have been found to influence patient outcomes for various cancer subtypes. In particular, minority and economically vulnerable patients present with more advanced disease and experience decreased survival compared to others. The aim of this study was to analyze the association between demographic or socioeconomic variables and rates of postsurgical follow-up after pituitary neuroendocrine tumor (PitNET) resection. METHODS A retrospective review was completed for patients with PitNETs who underwent surgery between 2018 and 2021. Patient demographics and information related to postoperative appointments and magnetic resonance imagings were obtained. Social vulnerability index (SVI) scores were recorded from the Centers for Disease Control based on nationwide census tracts. RESULTS One hundred and sixteen patients were included in the analysis (57 males). In this cohort, 50% were Black, 34% Hispanic, 9% White, and 1% Asian. The mean overall SVI score was 0.81 ± 0.23. The mean number of canceled appointments was significantly higher in the moderate-high/high SVI group (P = 0.034). Additionally, 30% of patients with moderate-high/high SVI had ≥2 canceled follow-up visits compared to 0% among patients with low/low-moderate SVI (P = 0.035). On average, White patients were less likely than non-White patients to have at least one canceled follow-up appointment (P = 0.048). CONCLUSIONS Black patients and those with high social vulnerability have decreased rates of follow-up after PitNET resection. Follow-up delays can lead to failed identification of tumor recurrence, potentially resulting in more advanced disease by the time medical care is reinitiated and increasing rates of patient morbidity and mortality. As a result, further work is needed to address and bridge these care gaps.
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Affiliation(s)
- Isabella L Pecorari
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA.
| | - Joshua A Reynolds
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Vijay Agarwal
- Department of Neurological Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Lee SW, Thantacheva TD, Mack D. Characteristics of Patients Hospitalized to Community Hospitals With Malignant Brain Tumors and Factors Associated With Discharge Destination. HCA HEALTHCARE JOURNAL OF MEDICINE 2024; 5:435-443. [PMID: 39290478 PMCID: PMC11404599 DOI: 10.36518/2689-0216.1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Background Our main objective was to compare the characteristics and hospital outcomes of patients with primary and metastatic brain malignancies and to investigate the associated factors related to hospital outcomes. Methods We conducted a retrospective, cross-sectional study of 1628 patients with brain malignancies from 8 community hospitals between 2017 and 2022 who were identified using International Classification of Disease codes. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge. Results The median age was 65 years old, with 72.5% of patients having metastatic brain malignancies. After 7.2 days of hospital stay, 49.2% were discharged home, and 102 patients expired during hospitalization. Increased age, medical coverage by Medicare, hemiplegia or paraplegia, lower initial hemoglobin level, increased length of stay, and the use of electrolyte replacement, antibiotics, laxatives, heparin, and anticonvulsants were associated with a decreased likelihood of discharge to home. No medical insurance, Medicaid insurance coverage, comorbidities of cerebrovascular disorder, the need to stay in the intensive care unit, patient safety indicator events, and the use of antibiotics, oral analgesics, and ipratropium-albuterol were associated with increased odds of in-hospital mortality. Conclusion We identified several predictor variables that delineate differences between both mortality risk and home discharge in patients with primary and metastatic brain tumors. Understanding these predictor variables can be helpful in improving the acute and post-acute care of this population.
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Affiliation(s)
- Se Won Lee
- Sunrise Health GME Consortium, MountainView Hospital, Las Vegas, NV
| | | | - Denny Mack
- Southern Nevada VA Healthcare System, Las Vegas, NV
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Chakravarti S, Kuo CC, Oak A, Ranganathan S, Jimenez AE, Kazemi F, Saint-Germain MA, Gallia G, Rincon-Torroella J, Jackson C, Bettegowda C, Mukherjee D. The Socioeconomic Distressed Communities Index Predicts 90-Day Mortality Among Intracranial Tumor Patients. World Neurosurg 2024; 186:e552-e565. [PMID: 38599377 DOI: 10.1016/j.wneu.2024.03.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Socioeconomic status (SES) is a major determinant of quality of life and outcomes. However, SES remains difficult to measure comprehensively. Distress communities index (DCI), a composite of 7 socioeconomic factors, has been increasingly recognized for its correlation with poor outcomes. As a result, the objective of the present study is to determine the predictive value of the DCI on outcomes following intracranial tumor surgery. METHODS A single institution, retrospective review was conducted to identify adult intracranial tumor patients undergoing resection (2016-2021). Patient ZIP codes were matched to DCI and stratified by DCI quartiles (low:0-24.9, low-intermediate:25-49.9, intermediate-high:50-74.9, high:75-100). Univariate followed by multivariate regressions assessed the effects of DCI on postoperative outcomes. Receiver operating curves were generated for significant outcomes. RESULTS A total of 2389 patients were included: 1015 patients (42.5%) resided in low distress communities, 689 (28.8%) in low-intermediate distress communities, 445 (18.6%) in intermediate-high distress communities, and 240 (10.0%) in high distress communities. On multivariate analysis, risk of fracture (adjusted odds ratio = 1.60, 95% confidence interval 1.26-2.05, P < 0.001) and 90-day mortality (adjusted odds ratio = 1.58, 95% confidence interval 1.21-2.06, P < 0.001) increased with increasing DCI quartile. Good predictive accuracy was observed for both models, with receiver operating curves of 0.746 (95% CI 0.720-0.766) for fracture and 0.743 (95% CI 0.714-0.772) for 90-day mortality. CONCLUSIONS Intracranial tumor patients from distressed communities are at increased risk for adverse events and death in the postoperative period. DCI may be a useful, holistic measure of SES that can help risk stratifying patients and should be considered when building healthcare pathways.
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Affiliation(s)
- Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cathleen C Kuo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Atharv Oak
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sruthi Ranganathan
- School of Clinical Medicine, University of Cambridge, Cambridge, England
| | - Adrian E Jimenez
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Foad Kazemi
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Max A Saint-Germain
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.
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Sanmartin MX, Katz JM, Wang J, Malhotra A, Sangha K, Bastani M, Martinez G, Sanelli PC. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg 2023; 15:e166-e171. [PMID: 36175016 DOI: 10.1136/jnis-2022-019460] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) <6. This study evaluates the cost-effectiveness of EVT, compared with standard care (SC), in acute ischemic stroke (AIS) patients with ASPECTS 3-5. METHODS An economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3-5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model. RESULTS Compared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS The results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3-5), compared with SC alone over the patient's lifetime.
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Affiliation(s)
- Maria X Sanmartin
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jason Wang
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kinpritma Sangha
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Tuohy K, Ba DM, Bhanja D, Leslie D, Liu G, Mansouri A. Early costs and complications of first-line low-grade glioma treatment using a large national database: Limitations and future perspectives. Front Surg 2023; 10:1001741. [PMID: 36816005 PMCID: PMC9935584 DOI: 10.3389/fsurg.2023.1001741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 01/12/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Diffuse Low-grade gliomas (DLGG, WHO Grade II) are a heterogenous group of tumors comprising 13-16% of glial tumors. While maximal safe resection is endorsed as the best approach to DLGG, compared to more conservative interventions like stereotactic biopsy, the added costs and risks have not been systematically evaluated. The purpose of this study was to better understand the complication rates and costs associated with each intervention. Methods A retrospective cohort study using data from the IBM Watson Health MarketScan® Commercial Claims and Encounters database was conducted, using the International Classification of Diseases, Ninth Revision (ICD-9) codes corresponding to DLGG (2005-2014). Current Procedure Terminology, 4th Edition (CPT-4) codes were used to differentiate resection and biopsy cohorts. Inverse weighting by the propensity score was used to balance baseline potential confounders (age, sex, pre-op seizure, geographic region, year, Charleston Comorbidity Index). Complication rates, hospital mortality, readmission, and costs were compared between groups. Results We identified 5,784 and 3,635 patients undergoing resection and biopsy, respectively, for initial DLGG management. Resection was associated with greater 30-day complications (29.17% vs. 26.34%; p < 0.05). However, this association became non-significant after inverse propensity weighting (adjusted odds ratio = 1.09; 0.98-1.20). There was no statistically significant difference in unadjusted, 30-day hospital mortality (p = 0.06) or re-admission (p = 0.52). Resection was associated with higher 90-day total costs (p < 0.0001) and drug costs (p < 0.0001). Biopsy was associated with greater index procedure costs (p < 0.0001). Long-term outcomes and evaluation of DLGG subtypes was not possible given limitations in the metrics recorded in MarketScan and lack of specificity in the ICD coding system. Conclusion Resection was not associated with an increase in the adjusted complication rate after balancing for baseline prognostic factors. Total costs and drug costs were higher with resection of DLGG, but the index procedure costs were higher for biopsy. This data should help to facilitate prospective health economic analyses in the future to understand the cost-effectiveness, and impact on quality of life, for DLGG interventions. However, the use of large national databases for studying long-term outcomes in DLGG management should be discouraged until there is greater specificity in the ICD coding system for DLGG subtypes.
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Affiliation(s)
- Kyle Tuohy
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States,Correspondence: Kyle Tuohy
| | - Djibril M. Ba
- Department of Public Health Sciences, Penn State University, University park, PA, United States,Center for Applied Studies in Health Economics (CASHE), Penn State College of Medicine, Hershey, PA, United States
| | - Debarati Bhanja
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States
| | - Douglas Leslie
- Department of Public Health Sciences, Penn State University, University park, PA, United States,Center for Applied Studies in Health Economics (CASHE), Penn State College of Medicine, Hershey, PA, United States
| | - Guodong Liu
- Department of Public Health Sciences, Penn State University, University park, PA, United States,Center for Applied Studies in Health Economics (CASHE), Penn State College of Medicine, Hershey, PA, United States
| | - Alireza Mansouri
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, PA, United States,Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, United States
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Predicting access to postoperative treatment after glioblastoma resection: an analysis of neighborhood-level disadvantage using the Area Deprivation Index (ADI). J Neurooncol 2022; 158:349-357. [PMID: 35503190 DOI: 10.1007/s11060-022-04020-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/16/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Social determinants of health (SDoH)-socioeconomic and environmental factors-impact outcomes. The Area Deprivation Index (ADI), a composite of seventeen SDoH factors, has been correlated with poorer outcomes. We aimed to compare outcomes and treatment access for glioblastoma, a universally fatal malignant brain tumor, in patients more (ADI 34-100%) versus less disadvantaged (ADI 0-33%). METHODS A 5-year retrospective study of Rhode Island Hospital and Mayo Clinic databases was conducted from 2012 to 2017 for patients ≥ 18 years with glioblastoma. Patient addresses were matched to ADI percentiles and grouped into more (top 66% ADI) and less disadvantaged. Adjusted multivariable regressions were used to compare outcomes between groups. RESULTS A total of 434 patients met inclusion; 92.9% were insured, 56.2% were more disadvantaged (n = 244), and the more disadvantaged cohort was younger on average (62 years). After adjustment, the more disadvantaged group had decreased odds of receiving gross total resection (adjusted odds ratio (aOR) 0.43, 95% CI [0.27-0.68]; p < 0.001). This cohort also had decreased odds of undergoing chemotherapy (aOR 0.51[0.26-0.98]), radiation (aOR 0.39[0.20-0.77]), chemoradiation (aOR 0.42[0.23-0.77]), tumor-treating fields (aOR 0.39[0.16-0.93]), and clinical trial participation (aOR 0.47[0.25-0.91]). No differences in length of survival or postoperative Karnofsky Performance Status Scale were observed. CONCLUSION More disadvantaged glioblastoma patients had decreased odds of receiving gross total resection. They also exhibited decreased odds of receiving standard of care like chemoradiation as well as participating in a clinical trial, compared to the less disadvantaged group. More research is needed to identify modifiable SDoH barriers to post-operative treatment in disadvantaged patients with glioblastoma.
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Willer BL, Mpody C, Tobias JD, Nafiu OO. Association of Race and Family Socioeconomic Status With Pediatric Postoperative Mortality. JAMA Netw Open 2022; 5:e222989. [PMID: 35302629 PMCID: PMC8933731 DOI: 10.1001/jamanetworkopen.2022.2989] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Racial disparities in postoperative outcomes have remained difficult to eliminate. It is commonly understood that socioeconomic status (SES) is an important factor associated with excess risk of postoperative morbidity and death. To date, comparable data exploring the association of family SES with pediatric postoperative mortality are unavailable, and it is unknown whether the advantage provided by higher income status is equitable across racial groups. OBJECTIVE To assess whether increasing family SES is associated with lower pediatric postoperative mortality and, if so, whether this association is equitable among Black and White children. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from 51 freestanding pediatric tertiary care hospitals across the US that reported to the Children's Hospital Association Pediatric Health Information System. The study included 1 378 111 Black and White children younger than 18 years who underwent inpatient surgical procedures between January 1, 2004, and December 31, 2020. EXPOSURES The exposures of interest were race (Black and White) and parental income quartile (used as a proxy for SES and measured by median income quartile of the zip code of residence). Race was self-reported by parents or guardians at admission or assessed by the registration team consistent with each hospital's policy and state legislation. MAIN OUTCOMES AND MEASURES The primary outcome was risk-adjusted in-hospital mortality rates by race and parental income quartile controlled for baseline covariates. To evaluate whether belonging to the highest income quartile modified the association between race and postoperative mortality, multiplicative and additive interactions were examined. RESULTS Among 1 378 111 children (773 364 [56.1%] male; mean [SD] age, 7 [6] years) who received inpatient surgical procedures during the study period, 248 464 children (18.0%) were Black, and 1 129 647 children (82.0%) were White; 211 127 children (15.3%) were Hispanic, and 825 477 (59.9%) were non-Hispanic. Only 49 541 Black children (20.3%) belonged to the highest income quartile compared with 482 758 White children (43.0%). The overall mortality rate was 1.2%, and mortality rates decreased as income quartile increased (1.4% in quartile 1 [lowest income], 1.3% in quartile 2, 1.0% in quartile 3, and 0.9% in quartile 4 [highest income]; P < .001). Among those belonging to the 3 lowest income quartiles, Black children had 33% higher odds of postoperative death compared with White children (adjusted odds ratio, 1.33; 95% CI, 1.27-1.39; P < .001). This racial disparity gap persisted among children belonging to the highest income quartile (adjusted odds ratio, 1.39; 95% CI, 1.25-1.54; P < .001). Postoperative mortality rates among Black children in the highest income quartile (1.30%; 95% CI, 1.19%-1.42%) were comparable to those of White children in the lowest income quartile (1.20%; 95% CI, 1.16%-1.25%). The interaction between Black race and income was not statistically significant on either the multiplicative scale (β for interaction = 1.04; 95% CI, 0.93-1.17; P = .45) or the additive scale (relative excess risk due to interaction = 0.01; 95% CI, -0.11 to 0.11; P > .99), suggesting no reduction in the disparity gap across increasing income levels. CONCLUSIONS AND RELEVANCE In this cohort study, increasing SES was associated with lower pediatric postoperative mortality. However, postoperative mortality rates were significantly higher among Black children in the highest SES category compared with White children in the same category, and mortality rates among Black children in the highest SES category were comparable to those of White children in the lowest SES category. These findings suggest that increasing family SES did not provide equitable advantage to Black compared with White children, and interventions that target socioeconomic inequities alone may not fully address persistent racial disparities in pediatric postoperative mortality.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
| | - Olubukola O Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- College of Medicine, The Ohio State University, Columbus
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Tang OY, Clarke RA, Rivera Perla KM, Corcoran Ruiz KM, Toms SA, Weil RJ. Brain tumor craniotomy outcomes for dual-eligible medicare and medicaid patients: a 10-year nationwide analysis. J Neurooncol 2022; 156:387-398. [PMID: 35023004 DOI: 10.1007/s11060-021-03922-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dual-eligible (DE) patients, simultaneous Medicare and Medicaid beneficiaries, have been shown to have poorer clinical outcomes while incurring higher resource utilization. However, neurosurgical oncology outcomes for DE patients are poorly characterized. Accordingly, we examined the impact of DE status on perioperative outcomes following glioma, meningioma, or metastasis resection. METHODS We identified all admissions undergoing a craniotomy for glioma, meningioma, or metastasis resection in the National Inpatient Sample from 2002 to 2011. Assessed outcomes included inpatient mortality, complications, discharge disposition, length of stay (LOS), and hospital costs. Multivariable regression adjusting for 13 patient, severity, and hospital characteristics assessed the association between DE status and outcomes, relative to four reference insurance groups (Medicare-only, Medicaid-only, private insurance, self-pay). RESULTS Of 195,725 total admissions analyzed, 3.0% were dual-eligible beneficiaries (n = 5933). DEs were younger than Medicare admissions (P < 0.001) but older than Medicaid, private, and self-pay admissions (P < 0.001). Relative to other insurance groups, DEs also exhibited higher severity of illness, risk of mortality, and Charlson Comorbidity Index scores as well as treatment at low-volume hospitals (all P < 0.001). DEs had lower mortality than self-pay admissions (odds ratio [OR] 0.47, P = 0.017). Compared to Medicare, Medicaid, private, and self-pay admissions, DEs had lower rates of discharge disposition (OR 0.53, 0.50, 0.34, and 0.27, respectively, all P < 0.001). DEs also had higher complications (OR 1.23 and 1.20, respectively, both P < 0.05) and LOS (β = 1.06 and 1.13, respectively, both P < 0.01) than Medicare and private insurance beneficiaries. Differences in discharge disposition remained significant for all three tumor subtypes, but only glioma DE admissions continued to exhibit higher complications and LOS. CONCLUSIONS DEs undergoing definitive craniotomy for brain tumor had higher rates of unfavorable discharge disposition compared to all other insurance groups and, especially for glioma surgery, had higher inpatient complication rates and LOS. Practice and policy reforms to improve outcomes for this vulnerable clinical population are warranted.
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Affiliation(s)
- Oliver Y Tang
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ross A Clarke
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Krissia M Rivera Perla
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Harvard T.H Chan School of Public Health, Boston, MA, USA
| | | | - Steven A Toms
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Robert J Weil
- Southcoast Brain & Spine, Southcoast Health, Dartmouth, MA, USA
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Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in Neurosurgical Care for Intracranial Tumors. World Neurosurg 2021; 158:38-64. [PMID: 34710578 DOI: 10.1016/j.wneu.2021.10.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The impact of race, socioeconomic status (SES), insurance status, and other social metrics on the outcomes of patients with intracranial tumors has been reported in several studies. However, these findings have not been comprehensively summarized. METHODS We conducted a PRISMA systematic review of all published articles between 1990 and 2020 that analyzed intracranial tumor disparities, including race, SES, insurance status, and safety-net hospital status. Outcomes measured include access, standards of care, receipt of surgery, extent of resection, mortality, complications, length of stay (LOS), discharge disposition, readmission rate, and hospital charges. RESULTS Fifty-five studies were included. Disparities in mortality were reported in 27 studies (47%), showing minority status and lower SES associated with poorer survival outcomes in 14 studies (52%). Twenty-seven studies showed that African American patients had worse outcomes across all included metrics including mortality, rates of surgical intervention, extent of resection, LOS, discharge disposition, and complication rates. Thirty studies showed that privately insured patients and patients with higher SES had better outcomes, including lower mortality, complication, and readmission rates. Six studies showed that worse outcomes were associated with treatment at safety-net and/or low-volume hospitals. The influence of Medicare or Medicaid status, or inequities affecting other minorities, was less clearly delineated. Ten studies (18%) were negative for evidence of disparities. CONCLUSIONS Significant disparities exist among patients with intracranial tumors, particularly affecting patients of African American race and lower SES. Efforts at the hospital, state, and national level must be undertaken to identify root causes of these issues.
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Distance traveled to glioblastoma treatment: A measure of the impact of socioeconomic status on survival. Clin Neurol Neurosurg 2021; 209:106909. [PMID: 34500342 DOI: 10.1016/j.clineuro.2021.106909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/31/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Previous studies have shown improved post-surgical outcomes in patients who travel farther for glioblastoma treatment. This study investigates socioeconomic and facility factors that may influence this relationship. METHODS Overall survival was calculated and compared by distance to treatment facility using univariate and multivariate survival models. The analysis was stratified by facility type, income quartile and insurance status and the association re-evaluated. Kaplan-Meier survival curves were created to analyze the relationship between overall survival and distance group. RESULTS Individuals who traveled less than 5 miles to treatment had the shortest overall survival (11.8 months), while those who traveled greater than 50 miles had the longest survival (12.9 months). Stratification by income quartile failed to demonstrate an association between distance traveled and survival for those making less than $63,000 (adjusted hazard ratio range: 0.94-1.01). There was no association between survival and distance traveled for patients treated at a community cancer center, comprehensive community cancer center or an integrated network cancer program (adjusted hazard ratio range: 0.86-1.04). CONCLUSION Financial strain, rather than distance traveled to treatment, may be associated with glioblastoma survival.
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Ahmed I, Merchant FM, Curtis JP, Parzynski CS, Lampert R. Impact of insurance status on ICD implantation practice patterns: Insights from the NCDR ICD registry. Am Heart J 2021; 235:44-53. [PMID: 33503408 DOI: 10.1016/j.ahj.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether insurance status influences practice patterns in implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) defibrillators, when indicated, is not known. METHODS AND RESULTS We analyzed the NCDR ICD Registry to evaluate associations of insurance status with guidelines-based receipt of CRT, as well as device-type, complication rates, and use of optimal medical therapy defined by guidelines. Among 798,028 patients with de novo ICD implants, we included only patients < 65 years (those older have Medicare) and excluded those admitted before 2006 (n=1,835) or with insurance coverage other than Medicare, Medicaid or private insurance (n=25,695) leaving 286,556 for analysis. Inverse probability of treatment weighting was used to control for imbalances between groups. Mean age was 53 years, 29% were female. Patients with private insurance and Medicare were more likely to receive CRT-D when indicated (79.6%, OR 1.19 95% CI 1.09-1.28, P <.001 and 78.5%, OR 1.11 95% CI 1.01-1.21 P = .03, respectively) compared to the uninsured (76.7%). The uninsured were also more likely than other groups to receive a single-chamber device. Complication rates did not differ. Uninsured patients were, however, more likely to receive optimal medical therapy, particularly in the subgroup receiving the implant for primary prevention. CONCLUSIONS In propensity-weighted analysis, uninsured patients are less likely to receive CRT when indicated but more likely to be receiving optimal medical therapy at discharge. Reasons for differences in device implantation practices based on insurance status require further study.
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Cyprich J, Pangal DJ, Rutkowski M, Donoho DA, Shiroishi M, Jason Liu CS, Carmichael JD, Zada G. Comparative preoperative characteristics and postoperative outcomes at a private versus a safety-net hospital following endoscopic endonasal transsphenoidal resection of pituitary adenomas. J Neurosurg 2021; 134:742-749. [PMID: 32109866 DOI: 10.3171/2019.12.jns192506] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sociodemographic disparities in health outcomes are well documented, but the effects of such disparities on preoperative presentation of pituitary adenomas (PA) and surgical outcomes following resection are not completely understood. In this study the authors sought to compare the preoperative clinical characteristics and postoperative outcomes in patients undergoing PA resection at a private hospital (PH) versus a safety-net hospital (SNH). METHODS The authors conducted a retrospective review over a 36-month period of patients with PAs who underwent endoscopic endonasal transsphenoidal surgery performed by the same attending neurosurgeon at either a PH or an SNH at a single academic medical institution. RESULTS A total of 92 PH patients and 69 SNH patients were included. SNH patients were more likely to be uninsured or have Medicaid (88.4% vs 10.9%, p < 0.0001). A larger percentage of SNH patients were Hispanic (98.7% vs 32.6% p < 0.0001), while PH patients were more likely to be non-Hispanic white (39.1% vs 4.3%, p < 0.0001). SNH patients had a larger mean PA diameter (26.2 vs 22.4 mm, p = 0.0347) and a higher rate of bilateral cavernous sinus invasion (13% vs 4.3%, p = 0.0451). SNH patients were more likely to present with headache (68.1% vs 45.7%, p = 0.0048), vision loss (63.8% vs 35.9%, p < 0.0005), panhypopituitarism (18.8% vs 4.3%, p = 0.0031), and pituitary apoplexy (18.8% vs 7.6%, p = 0.0334). Compared to PH patients, SNH patients were as likely to undergo gross-total resection (73.9% vs 76.1%, p = 0.7499) and had similar rates of postoperative improvement in headache (80% vs 89%, p = 0.14) and vision (82% vs 84%, p = 0.74), but had higher rates of postoperative panhypopituitarism (23% vs 10%, p = 0.04) driven by preoperative endocrinopathies. Although there were no differences in tumor recurrence or progression, loss to follow-up was seen in 7.6% of PH versus 18.6% (p = 0.04) of SNH patients. CONCLUSIONS Patients presenting to the SNH were more often uninsured or on Medicaid and presented with larger, more advanced pituitary tumors. SNH patients were more likely to present with headaches, vision loss, and apoplexy, likely translating to greater improvements in headache and vision observed after surgery. These findings highlight the association between medically underserved populations and more advanced disease states at presentation, and underscore the likely role of academic tertiary multidisciplinary care teams and endoscopic PA resection in somewhat mitigating sociodemographic factors known to portend poorer outcomes, though longer-term follow-up is needed to confirm these findings.
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Affiliation(s)
| | | | | | | | - Mark Shiroishi
- 2Division of Neuroradiology, Department of Radiology, and
| | | | - John D Carmichael
- 3Division of Endocrinology, Department of Medicine, Keck School of Medicine, University of Southern California; and
- 4USC Pituitary Center, Los Angeles, California
| | - Gabriel Zada
- 1Department of Neurosurgery
- 4USC Pituitary Center, Los Angeles, California
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Tang OY, Rivera Perla KM, Lim RK, Weil RJ, Toms SA. The impact of hospital safety-net status on inpatient outcomes for brain tumor craniotomy: a 10-year nationwide analysis. Neurooncol Adv 2021; 3:vdaa167. [PMID: 33506205 PMCID: PMC7813162 DOI: 10.1093/noajnl/vdaa167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Outcome disparities have been documented at safety-net hospitals (SNHs), which disproportionately serve vulnerable patient populations. Using a nationwide retrospective cohort, we assessed inpatient outcomes following brain tumor craniotomy at SNHs in the United States. Methods We identified all craniotomy procedures in the National Inpatient Sample from 2002–2011 for brain tumors: glioma, metastasis, meningioma, and vestibular schwannoma. Safety-net burden was calculated as the number of Medicaid plus uninsured admissions divided by total admissions. Hospitals in the top quartile of burden were defined as SNHs. The association between SNH status and in-hospital mortality, discharge disposition, complications, hospital-acquired conditions (HACs), length of stay (LOS), and costs were assessed. Multivariate regression adjusted for patient, hospital, and severity characteristics. Results 304,719 admissions were analyzed. The most common subtype was glioma (43.8%). Of 1,206 unique hospitals, 242 were SNHs. SNH admissions were more likely to be non-white (P < .001), low income (P < .001), and have higher severity scores (P = .034). Mortality rates were higher at SNHs for metastasis admissions (odds ratio [OR] = 1.48, P = .025), and SNHs had higher complication rates for meningioma (OR = 1.34, P = .003) and all tumor types combined (OR = 1.17, P = .034). However, there were no differences at SNHs for discharge disposition or HACs. LOS and hospital costs were elevated at SNHs for all subtypes, culminating in a 10% and 9% increase in LOS and costs for the overall population, respectively (all P < .001). Conclusions SNHs demonstrated poorer inpatient outcomes for brain tumor craniotomy. Further analyses of the differences observed and potential interventions to ameliorate interhospital disparities are warranted.
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Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Krissia M Rivera Perla
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Rachel K Lim
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Toor H, Savla P, Podkovik S, Patchana T, Ghanchi H, Kashyap S, Tashjian V, Miulli D. Timing of Chemoradiation in Newly Diagnosed Glioblastoma: Comparative Analysis Between County and Managed Care Health Care Models. World Neurosurg 2021; 149:e1038-e1042. [PMID: 33476782 DOI: 10.1016/j.wneu.2021.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Glioblastoma multiforme (GBM) is a primary brain malignancy with significant morbidity and mortality. The current standard of treatment for GBM is surgery followed by radiotherapy and temozolomide. Despite an established treatment protocol, there exists heterogeneity in outcomes due to patients not receiving all treatments. We analyzed patients in different health care models to investigate this heterogeneity. METHODS A retrospective analysis was performed at 2 hospitals in San Bernardino County, California, for patients with newly diagnosed GBM from 2004 to 2019. Patients younger than 18 years of age, with history of low-grade glioma, who had undergone prior treatment, and those lost to follow-up were excluded. RESULTS A total of 57 patients were included in our study. Chemotherapy was started at 41 ± 30 and 77 ± 68 days in the health maintenance organization (HMO) and county model, respectively (P = 0.050); radiation therapy was started at 46 ± 34 and 85 ± 76 days in the HMO and county models, respectively (P = 0.036). In individuals who underwent both chemotherapy and radiation therapy (XRT), the difference in time to XRT was no longer significant (P = 0.060). Recurrence time was 309 ± 263 and 212 ± 180 days in the HMO and county groups, respectively (P = 0.379). The time to death was 412 ± 285 and 343 ± 304 days for HMO and county models, respectively (P = 0.334). CONCLUSIONS Our study demonstrates a statistically significant difference in time to adjuvant therapies between patients within a county hospital and a managed health care organization. This information has the potential to inform future policies and care coordination for patients within the county model.
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Affiliation(s)
- Harjyot Toor
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Paras Savla
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA.
| | - Stacey Podkovik
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Tye Patchana
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Hammad Ghanchi
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Samir Kashyap
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
| | - Vartan Tashjian
- Department of Neurological Surgery, Kaiser Permanente Fontana Medical Center, Fontana, California, USA
| | - Dan Miulli
- Department of Neurological Surgery, Riverside University Health System, Moreno Valley, California, USA; Department of Neurological Surgery, Arrowhead Regional Medical Center, Colton, California, USA
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Nguembu S, Kanmounye US, Tétinou F, Djiofack D, Takoukam R. Barriers to Management of Nontraumatic Neurosurgical Diseases at 2 Cameroonian Neurosurgical Centers: Cross-Sectional Study. World Neurosurg 2020; 139:e774-e783. [PMID: 32376382 DOI: 10.1016/j.wneu.2020.04.162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although nontraumatic diseases affect fewer people than traumatic neurosurgical diseases, they require expertise more often. The authors sought to understand the barriers to nontraumatic neurosurgical diseases (NTNSDs) in a country with limited access to neurosurgical care. METHODS This cross-sectional study with retrospective data collection was carried out in 2 Cameroonian reference hospitals for a year. Multiple imputations were used to generate data for the missing variables-death and discharge with sequelae. Bivariate relationships were evaluated using the chi-square and Mann-Whitney U tests. Odds ratios were equally calculated, and the results were considered significant for a P value <0.05. RESULTS NTNSDs represented 44.1% of neurosurgical activity. Our study included 177 patients with a mean age of 43.7 ± 21.2 years. More than half (53.1%) were female, 78% lived in a different region from that of the neurosurgical center, 18.1% had health insurance, 39.5% were referrals, and the mean symptom-to-admission delay was 409.0 ± 1301.7 days. Most (87%) of the patients had undergone at least 1 of the diagnostic examinations prescribed to them. Men (P = 0.029) and rural dwellers (P = 0.017) had shorter symptom-to-admission delays than women and urban dwellers, respectively. The mean length of stay was 18.2 ± 13.4, and 80.8% of patients were treated surgically. Thirty-one (17.5%) patients died in the hospital: 9 were treated surgically, and 22 were treated conservatively or expectantly. CONCLUSIONS Patients with NTNSD present at the definitive care facilities late. This delay is attributable to financial and geographic barriers.
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Affiliation(s)
- Stéphane Nguembu
- Neurosurgery Unit, Department of Surgery, Laquintinie Hospital, Douala, Cameroon; Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon
| | - Ulrick Sidney Kanmounye
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; Faculty of Medicine, Bel Campus University of Technology, Kinshasa, DR Congo.
| | - Francklin Tétinou
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon
| | - Dylan Djiofack
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; Faculty of Medicine, Higher Institute of Medical Technologies, Nkolondom, Cameroon
| | - Régis Takoukam
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon; Faculty of Medicine, Higher Institute of Health Sciences, Université des Montagnes, Bangangte, Cameroon; Department of Neurosurgery, Felix-Houphouet Boigny University, Abidjan, Côte d'Ivoire
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Sharma M, Ugiliweneza B, Wang D, Boakye M, Andaluz N, Neimat J, Mohammadi A, Barnett GH, Williams BJ. National Trends and Factors Predicting Outcomes Following Laser Interstitial Thermal Therapy for Brain Lesions: Nationwide Inpatient Sample Analysis. World Neurosurg 2020; 139:e88-e97. [PMID: 32251808 DOI: 10.1016/j.wneu.2020.03.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) is a stereotactic-guided technique, which is increasingly being performed for brain lesions. The aim of our study was to report the national trends and factors predicting the clinical outcomes following LITT using the Nationwide Inpatient Sample. METHODS We extracted data from 2011-2016 using ICD-9/10 codes. Patients with a primary procedure of LITT were included. Patient demographics, complications, length of hospital stay, discharge disposition, and index-hospitalization charges were analyzed. RESULTS A cohort of 1768 patients was identified from the database. Mean length of hospital stay was 3.2 days, 82% of patients were discharged to home, and in-hospitalization cost was $124,225. Complications and mortality were noted in 12.9% and 2.5% of patients following LITT, respectively. Non-Caucasian patients (estimate ratio [ER] 4.26), those with other insurance (compared with commercial, ER: 5.35), 3 and 4+ comorbidity indexes, patients with higher quartile median household income (second, third, and fourth quartile compared with first quartile), and those who underwent nonelective procedures were likely to have higher complications and less likely to be discharged home. Patients with 4+ comorbidity indexes were likely to have longer length of hospital stay (ER 1.39) and higher complications (ER: 7.95) and were less likely to be discharged home (ER: 0.17) and have higher in-hospitalization cost (ER: 1.21). CONCLUSIONS LITT is increasingly being performed with low complication rates. Non-Caucasian race, higher comorbidity index, noncommercial insurance, and nonelective procedures were predictors of higher complications and being less likely to be discharged home. In-hospitalization charges were higher in patients with higher comorbidity index and those with noncommercial insurance.
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Affiliation(s)
- Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | | | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Joseph Neimat
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Alireza Mohammadi
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Gene H Barnett
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian J Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA.
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Chandra A, Rick JW, Dalle Ore C, Lau D, Nguyen AT, Carrera D, Bonte A, Molinaro AM, Theodosopoulos PV, McDermott MW, Berger MS, Aghi MK. Disparities in health care determine prognosis in newly diagnosed glioblastoma. Neurosurg Focus 2019; 44:E16. [PMID: 29852776 DOI: 10.3171/2018.3.focus1852] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Glioblastoma (GBM) is an aggressive brain malignancy with a short overall patient survival, yet there remains significant heterogeneity in outcomes. Although access to health care has previously been linked to impact on prognosis in several malignancies, this question remains incompletely answered in GBM. METHODS This study was a retrospective analysis of 354 newly diagnosed patients with GBM who underwent first resection at the authors' institution (2007-2015). RESULTS Of the 354 patients (median age 61 years, and 37.6% were females), 32 (9.0%) had no insurance, whereas 322 (91.0%) had insurance, of whom 131 (40.7%) had Medicare, 45 (14%) had Medicaid, and 146 (45.3%) had private insurance. On average, insured patients survived almost 2-fold longer (p < 0.0001) than those who were uninsured, whereas differences between specific insurance types did not influence survival. The adjusted hazard ratio (HR) for death was higher in uninsured patients (HR 2.27 [95% CI 1.49-3.33], p = 0.0003). Age, mean household income, tumor size at diagnosis, and extent of resection did not differ between insured and uninsured patients, but there was a disparity in primary care physician (PCP) status-none of the uninsured patients had PCPs, whereas 72% of insured patients had PCPs. Postoperative adjuvant treatment rates with temozolomide (TMZ) and radiation therapy (XRT) were significantly less in uninsured (TMZ in 56.3%, XRT in 56.3%) than in insured (TMZ in 75.2%, XRT in 79.2%; p = 0.02 and p = 0.003) patients. Insured patients receiving both agents had better prognosis than uninsured patients receiving the same treatment (9.1 vs 16.34 months; p = 0.025), suggesting that the survival effect in insured patients could only partly be explained by higher treatment rates. Moreover, having a PCP increased survival among the insured cohort (10.7 vs 16.1 months, HR 1.65 [95% CI 1.27-2.15]; p = 0.0001), which could be explained by significant differences in tumor diameter at initial diagnosis between patients with and without PCPs (4.3 vs 4.8 cm, p = 0.003), and a higher rate of clinical trial enrollment, suggesting a critical role of PCPs for a timelier diagnosis of GBM and proactive cancer care management. CONCLUSIONS Access to health care is a strong determinant of prognosis in newly diagnosed patients with GBM. Any type of insurance coverage and having a PCP improved prognosis in this patient cohort. Higher rates of treatment with TMZ plus XRT, clinical trial enrollment, fewer comorbidities, and early diagnosis may explain survival disparities. Lack of health insurance or a PCP are major challenges within the health care system, which, if improved upon, could favorably impact the prognosis of patients with GBM.
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Kakusa BW, Xu LW, Vaca SD, Nalwanga J, Kiryabwire J, Ssenyonjo H, Mukasa J, Muhumuza M, Haglund MM, Grant GA. Central Nervous System Tumors in Uganda: Outcomes of Surgical Treatment and Complications Assessed Through Telephone Survey. World Neurosurg 2019; 129:e866-e880. [PMID: 31303566 DOI: 10.1016/j.wneu.2019.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Uganda has one of the largest unmet neurosurgical needs in the world, but has seen major improvements in neurosurgery-largely centered at Mulago National Referral Hospital (MNRH). This study implements the first long-term follow-up and outcomes analysis of central nervous system tumor patients in Uganda. METHODS Inpatient data were collected using a prospective database of patients presenting to the MNRH neurosurgical ward between 2014 and 2015. Follow-up health care status was assessed in the patient's language using phone surveys. Analysis was performed to identify which factors were associated with patient outcomes. RESULTS The MNRH neurosurgical ward saw 112 patients with central nervous system tumors (adult N = 87, female: 70%, median age: 37 years). Meningiomas (21%) comprised the most common tumor diagnosis. In-hospital mortality (18%), 30-day mortality (22%), and 1-year mortality (35%) were high. Thirty percent of patients underwent tumor resection in-patient and had greater median overall survival (66.5 months vs. 5.1 months for nonsurgical patients, P = 0.025). For those with known pathologic diagnoses, patients with glioblastomas had decreased median overall survival (0.83 months vs. 59 months for meningiomas, P = 0.02). Phone interviews yielded an 85% response rate. Of the survivors at the time of follow-up, 55% reported a subjective return to normalcy, and 75% received follow-up care for their tumor with most returning to MNRH. CONCLUSIONS We show evidence for improved overall survival with surgical care at MNRH. In addition, phone interviews as a method of measuring health outcomes provided an effective means of follow-up, showing that most patients do seek follow-up care.
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Affiliation(s)
- Bina W Kakusa
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA; Stanford Center for Global Health Innovation, Palo Alto, California, USA
| | - Linda W Xu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA; Stanford Center for Global Health Innovation, Palo Alto, California, USA; Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Silvia D Vaca
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA; Stanford Center for Global Health Innovation, Palo Alto, California, USA
| | - Juliet Nalwanga
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Joel Kiryabwire
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Hussein Ssenyonjo
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - John Mukasa
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Michael Muhumuza
- Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda
| | - Michael M Haglund
- Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA; Stanford Center for Global Health Innovation, Palo Alto, California, USA.
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Cho KH, Nam CM, Lee SG, Kim TH, Lee SH, Park EC. Measuring of quality of care in patients with stroke and acute myocardial infarction: An application of algebra effectiveness model. Medicine (Baltimore) 2019; 98:e15353. [PMID: 31096434 PMCID: PMC6531128 DOI: 10.1097/md.0000000000015353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases with golden hour. This study aimed to identify and compare factors that affect in-hospital mortality in patients with stroke and AMI who admitted via the emergency department.This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7693 patients who had an ischemic stroke, 2828 patients who had a hemorrhagic stroke, and 4916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged ≥20 years. This study was analyzed by using Cox's proportional hazards frailty model.Five hundred (6.5%) of 7693 patients with ischemic stroke, 569 (20.1%) of 2828 patients with hemorrhagic stroke, and 399 (8.1%) of 4916 patients with AMI were dead. The clinical factors were associated with in-hospital mortality such as age, CCI, hypertension, and diabetes of patient characteristics. In treatment characteristics, performing PCI and weekday admission was associated with in-hospital mortality (aHR, 0.43; 95% CI, 0.27-0.67; aHR, 1.42; 95% CI, 1.14-1.77, respectively). In hospital characteristics, the volume, the proportion of transferred patient to other hospital and ratio of beds per one nurse was associated with in-hospital mortality.Clinical factors of patient characteristics, intervention such as performing PCI and reducing ICP of treatment characteristics, and the volume, transferred rate, and the number of nurse of hospital characteristics were associated with in-hospital mortality.
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Affiliation(s)
- Kyoung Hee Cho
- Department of Public Health, Graduate School
- Institute of Health Services Research, College of Medicine
- Health Insurance Policy Research Insititue, National Health Insurance Service, Wonju
| | - Chung Mo Nam
- Institute of Health Services Research, College of Medicine
- Department of Biostatistics, College of Medicine
| | - Sang Gyu Lee
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Tae Hyun Kim
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Seon-Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon
| | - Eun-Cheol Park
- Institute of Health Services Research, College of Medicine
- Department of Preventive Medicine, College of Medicine, Yonsei University, Seoul, Korea
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Brown DA, Himes BT, Major BT, Mundell BF, Kumar R, Kall B, Meyer FB, Link MJ, Pollock BE, Atkinson JD, Van Gompel JJ, Marsh WR, Lanzino G, Bydon M, Parney IF. Cranial Tumor Surgical Outcomes at a High-Volume Academic Referral Center. Mayo Clin Proc 2018; 93:16-24. [PMID: 29304919 DOI: 10.1016/j.mayocp.2017.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/15/2017] [Accepted: 08/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine adverse event rates for adult cranial neuro-oncologic surgeries performed at a high-volume quaternary academic center and assess the impact of resident participation on perioperative complication rates. PATIENTS AND METHODS All adult patients undergoing neurosurgical intervention for an intracranial neoplastic lesion between January 1, 2009, and December 31, 2013, were included. Cases were categorized as biopsy, extra-axial/skull base, intra-axial, or transsphenoidal. Complications were categorized as neurologic, medical, wound, mortality, or none and compared for patients managed by a chief resident vs a consultant neurosurgeon. RESULTS A total of 6277 neurosurgical procedures for intracranial neoplasms were performed. After excluding radiosurgical procedures and pediatric patients, 4151 adult patients who underwent 4423 procedures were available for analysis. Complications were infrequent, with overall rates of 9.8% (435 of 4423 procedures), 1.7% (73 of 4423), and 1.4% (63 of 4423) for neurologic, medical, and wound complications, respectively. The rate of perioperative mortality was 0.3% (14 of 4423 procedures). Case performance and management by a chief resident did not negatively impact outcome. CONCLUSION In our large-volume brain tumor practice, rates of complications were low, and management of cases by chief residents in a semiautonomous manner did not negatively impact surgical outcomes.
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Affiliation(s)
- Desmond A Brown
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Brittny T Major
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Ravi Kumar
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Bruce Kall
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - John D Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - W Richard Marsh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Ian F Parney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
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Alotaibi AF, Mekary RA, Zaidi HA, Smith TR, Pandya A. Safety and Efficacy of Antibacterial Prophylaxis After Craniotomy: A Decision Model Analysis. World Neurosurg 2017; 105:906-912.e5. [DOI: 10.1016/j.wneu.2017.05.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/21/2017] [Indexed: 10/19/2022]
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Davies JM, Lawton MT. Improved outcomes for patients with cerebrovascular malformations at high-volume centers: the impact of surgeon and hospital volume in the United States, 2000–2009. J Neurosurg 2017; 127:69-80. [DOI: 10.3171/2016.7.jns15925] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVETreatment of cerebrovascular malformations has grown in complexity with the development of multimodal approaches, including microsurgery, endovascular treatments, and radiosurgery. In spite of this changing standard of care, the provision of care continues across a variety of settings. The authors sought to determine the risk of adverse outcome after treatment of patients with vascular malformations in the US. Patient, surgeon, and hospital characteristics, including volume, were tested as potential outcome predictors.METHODSThe authors examined data collected between 2000 and 2009 in the Nationwide Inpatient Sample (NIS) database, assessing safety, quality, and cost-effectiveness. They performed multivariate analyses of trends in microsurgical, radiosurgical, and endovascular treatment by hospital and surgeon volume, using death, routine discharge percentage, length of stay (LOS), complications, and hospital charges as end points. They further computed the value of care, which was defined as the ratio of the functional outcome (routine discharge percentage) to cost of care to the payer (hospital charges).RESULTSThe authors identified 8227 patients with vascular malformations who were treated at US hospitals. Hospitals and surgeons were classified by yearly case volume. Compared with low-volume hospitals (2 or fewer cases/year), high-volume hospitals (16 or more cases/year) had shorter LOS (3 vs 2 days, p = 0.005), higher total charges ($37,374 vs $19,986, p = 0.003), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.16%, p = 0.010). High-volume surgeons (7 or more cases/year) likewise had superior outcomes compared with low-volume surgeons (1 or fewer cases/year), with shorter LOS (2 vs 3 days, p = 0.03), more frequent discharge to home (p < 0.001), and lower mortality rates (0.7% vs 1.10%, p = 0.005). Underlying these outcomes, the rates of intervention for surgery, angiography, embolization, and radiosurgery were likewise significantly different in high- versus low-volume practices.Based on these results the authors modeled how outcomes might change if care were consolidated at designated centers of excellence (COEs), and found that on an annual basis, care at high-volume hospital COEs would result in 18.5 fewer deaths, 1252.1 fewer hospital days, 182.7 more discharges home without additional services, 48.5 fewer medical complications, and 117.4 fewer perioperative complications. Surgeon-level rates for high-volume COEs demonstrated an even larger benefit over current standards, with 27.4 fewer deaths, 10,713.7 fewer hospital days, a $51.6-million reduction in charges, 370.9 additional routine discharges, and reduced complications in all categories (27.8 fewer surgical, 198.0 fewer medical, and 32.1 fewer perioperative) compared with care at non-COEs.CONCLUSIONSFor patients with vascular malformations who were treated in the US between 2000 and 2009, treatment performed at high-volume centers was associated with significantly lower morbidity and, for high-volume surgeons, with lower mortality rates. These data suggest that treatment by high-volume institutions and surgeons will yield superior outcomes and superior value. The authors therefore advocate the creation of care paradigms that triage patients to high-volume institutions and surgeons, which can serve as cerebrovascular COEs.
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Differences in Use of High-quality and Low-quality Hospitals Among Working-age Individuals by Insurance Type. Med Care 2017; 55:148-154. [PMID: 28079673 DOI: 10.1097/mlr.0000000000000633] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality. RESEARCH DESIGN We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality. RESULTS Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results. CONCLUSIONS Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.
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Influence of insurance status and income in anaplastic astrocytoma: an analysis of 4325 patients. J Neurooncol 2016; 132:89-98. [PMID: 27864706 DOI: 10.1007/s11060-016-2339-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 11/12/2016] [Indexed: 10/20/2022]
Abstract
To determine the impact of insurance status and income for anaplastic astrocytoma (AA). Data were extracted from the National Cancer Data Base. Chi square test, Kaplan-Meier method, and Cox regression models were employed in SPSS 22.0 (Armonk, NY: IBM Corp.) for data analyses. 4325 patients with AA diagnosed from 2004 to 2013 were identified. 2781 (64.3%) had private insurance, 925 (21.4%) Medicare, 396 (9.2%) Medicaid, and 223 (5.2%) were uninsured. Those uninsured were more likely to be Black or Hispanic versus White or Asian (p < 0.001), have lower median income (p < 0.001), less educated (p < 0.001), and not receive adjuvant chemoradiation (p < 0.001). 1651 (38.2%) had income ≥$63,000, 1204 (27.8%) $48,000-$62,999, 889 (20.5%) $38,000-$47,999, and 581 (13.4%) had income <$38,000. Those with lower income were more likely to be Black or Hispanic versus White or Asian (p < 0.001), uninsured (p < 0.001), reside in a rural area (p < 0.001), less educated (p < 0.001), and not receive adjuvant chemoradiation (p < 0.001). Those with private insurance had significantly higher overall survival (OS) than those uninsured, on Medicaid, or on Medicare (p < 0.001). Those with income ≥$63,000 had significantly higher OS than those with lower income (p < 0.001). On multivariate analysis, age, insurance status, income, and adjuvant therapy were independent prognostic factors for OS. Being uninsured and having income <$38,000 were independent prognostic factors for worse OS in AA. Further investigations are warranted to help determine ways to ensure adequate medical care for those who may be socially disadvantaged so that outcome can be maximized for all patients regardless of socioeconomic status.
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Humble SS, Wilson LD, McKenna JW, Leath TC, Song Y, Davidson MA, Ehrenfeld JM, Guillamondegui OD, Pandharipande PP, Patel MB. Tracheostomy risk factors and outcomes after severe traumatic brain injury. Brain Inj 2016; 30:1642-1647. [PMID: 27740854 DOI: 10.1080/02699052.2016.1199915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. METHODS This retrospective cohort study compared adult trauma patients with severe TBI (n = 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy's influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months. RESULTS In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09-3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49-6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00-3.19]), but age, gender and insurance were not. CONCLUSIONS Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.
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Affiliation(s)
- Stephen S Humble
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Laura D Wilson
- b Department of Hearing and Speech Sciences , Vanderbilt University School of Medicine , Nashville , TN , USA.,c Department of Communication Sciences and Disorders , University of Tulsa , Tulsa , OK , USA
| | - John W McKenna
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Taylor C Leath
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | | | | | - Jesse M Ehrenfeld
- e Departments of Anesthesiology , Surgery, and Biomedical Informatics, Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Oscar D Guillamondegui
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Pratik P Pandharipande
- e Departments of Anesthesiology , Surgery, and Biomedical Informatics, Vanderbilt University School of Medicine , Nashville , TN , USA.,f Veterans Affairs (VA) Tennessee Valley Healthcare System , Nashville VA Medical Center , Nashville , TN , USA
| | - Mayur B Patel
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA.,b Department of Hearing and Speech Sciences , Vanderbilt University School of Medicine , Nashville , TN , USA.,f Veterans Affairs (VA) Tennessee Valley Healthcare System , Nashville VA Medical Center , Nashville , TN , USA
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Joseph B, Haider AA, Azim A, Kulvatunyou N, Tang A, O'Keeffe T, Latifi R, Green DJ, Friese RS, Rhee P. The impact of patient protection and Affordable Care Act on trauma care. J Trauma Acute Care Surg 2016; 81:427-34. [DOI: 10.1097/ta.0000000000001082] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pontes L, Shafaee MN, Haaland B, Lopes G. Surgery for CNS Tumors in the Brazilian National Health Care System. J Glob Oncol 2016; 3:157-161. [PMID: 28717753 PMCID: PMC5493277 DOI: 10.1200/jgo.2016.004911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Resource limitations in low- and middle-income countries make the management of CNS tumors challenging, particularly in Brazil, a country with major disparities in socioeconomic status and access to health care. We aimed to evaluate cancer-related neurosurgical procedures in the public health care system. Methods On the basis of Brazil’s public health system database, we collected data for neurosurgical procedures related to CNS tumors performed between January 2008 and November 2013. Information about the number of procedures, costs, length of stay, and number of inpatient deaths were analyzed for each state and then correlated to the state-specific population, gross domestic product per capita, and number of procedures. Results In all, 57,361 procedures were performed, the majority of them in the Southeast region. The mean length of hospital stay was 14.4 days, but longer hospital stay was reported for patients treated in the North. The inpatient mortality rate was 7.11%. Mortality rates decreased as the number of procedures (P < .001), gross domestic product per capita (P < .001), or state population increased (P < .001). On multivariate analysis, only the number of procedures (odds ratio, 0.93; 95% CI, 0.91 to 0.96; P < .001) and state population (odds ratio, 1.25; 95% CI, 1.13 to 1.38; P < .001) had an independent association with mortality. Conclusion To the best of our knowledge, this is the first study to evaluate disparities in CNS tumor surgery in a middle-income country, confirming that regional disparities exist and that clinical and economic outcomes correlate with income level, number of procedures, and state population.
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Affiliation(s)
- Luciola Pontes
- , Hospital das Clínicas Instituto do Coração, São Paulo, Brazil; , MD Anderson Cancer Center, Houston, TX; , Georgia Institute of Technology, Atlanta, GA; and , Oncoclinicas Group, São Paulo, Brazil, and The Johns Hopkins University, Baltimore, MD
| | - Maryam Nemati Shafaee
- , Hospital das Clínicas Instituto do Coração, São Paulo, Brazil; , MD Anderson Cancer Center, Houston, TX; , Georgia Institute of Technology, Atlanta, GA; and , Oncoclinicas Group, São Paulo, Brazil, and The Johns Hopkins University, Baltimore, MD
| | - Benjamin Haaland
- , Hospital das Clínicas Instituto do Coração, São Paulo, Brazil; , MD Anderson Cancer Center, Houston, TX; , Georgia Institute of Technology, Atlanta, GA; and , Oncoclinicas Group, São Paulo, Brazil, and The Johns Hopkins University, Baltimore, MD
| | - Gilberto Lopes
- , Hospital das Clínicas Instituto do Coração, São Paulo, Brazil; , MD Anderson Cancer Center, Houston, TX; , Georgia Institute of Technology, Atlanta, GA; and , Oncoclinicas Group, São Paulo, Brazil, and The Johns Hopkins University, Baltimore, MD
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Jackson C, Westphal M, Quiñones-Hinojosa A. Complications of glioma surgery. HANDBOOK OF CLINICAL NEUROLOGY 2016; 134:201-18. [PMID: 26948356 DOI: 10.1016/b978-0-12-802997-8.00012-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Even with current advances in adjunctive therapies, including radiation, chemotherapy, and various clinical trials of gene therapy and immunotherapy, surgical resection remains one of the most effective treatment for intra-axial gliomas. Survival in these patients has been shown to be related to the extent of resection. In some cases, it can provide cures of long-term remission; in others, it can provide disease control when combined with the above adjunctive treatments. However, surgical resection carries its own risks and complications. These complications can be broadly divided into neurologic, regional, and systemic, including direct cortical and vascular injury, surgical wound complications, and postsurgical medical complications. Certain patient characteristics, including Karnofsky performance status score (KPS) and pathology of the tumor, have been shown to have an impact on the risk of postsurgical complications. Advancement in preoperative and intraoperative adjunct technology such as cortical mapping and navigation has improved the surgeon's ability to safely and maximally resect the tumors. It is therefore important to understand the perioperative complications after craniotomy and tumor resection and factors affecting morbidity and mortality in order for surgeons to optimally select and counsel patients who will benefit the most from surgical resection. This chapter will focus on the complications associated with craniotomy for intrinsic glioma and ways of avoiding these events.
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Affiliation(s)
- Christina Jackson
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Loureiro LVM, Pontes LDB, Callegaro-Filho D, Koch LDO, Weltman E, Victor EDS, Santos AJ, Borges LRR, Segreto RA, Malheiros SMF. Initial care and outcome of glioblastoma multiforme patients in 2 diverse health care scenarios in Brazil: does public versus private health care matter? Neuro Oncol 2015; 16:999-1005. [PMID: 24463356 DOI: 10.1093/neuonc/not306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study was to describe the epidemiological and survival features of patients with glioblastoma multiforme treated in 2 health care scenarios--public and private--in Brazil. METHODS We retrospectively analyzed clinical, treatment, and outcome characteristics of glioblastoma multiforme patients from 2003 to 2011 at 2 institutions. RESULTS The median age of the 171 patients (117 public and 54 private) was 59.3 years (range, 18-84). The median survival for patients treated in private institutions was 17.4 months (95% confidence interval, 11.1-23.7) compared with 7.1 months (95% confidence interval, 3.8-10.4) for patients treated in public institutions (P < .001). The time from the first symptom to surgery was longer in the public setting (median of 64 days for the public hospital and 31 days for the private institution; P = .003). The patients at the private hospital received radiotherapy concurrent with chemotherapy in 59.3% of cases; at the public hospital, only 21.4% (P < .001). Despite these differences, the institution of treatment was not found to be an independent predictor of outcome (hazard ratio, 1.675; 95% confidence interval, 0.951-2.949; P = .074). The Karnofsky performance status and any additional treatment after surgery were predictors of survival. A hazard ratio of 0.010 (95% confidence interval, 0.003-0.033; P < .001) was observed for gross total tumor resection followed by radiotherapy concurrent with chemotherapy. CONCLUSIONS Despite obvious disparities between the hospitals, the medical assistance scenario was not an independent predictor of survival. However, survival was directly influenced by additional treatment after surgery. Therefore, increasing access to resources in developing countries like Brazil is critical.
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Krings JG, Kallogjeri D, Wineland A, Nepple KG, Piccirillo JF, Getz AE. Complications following primary and revision transsphenoidal surgeries for pituitary tumors. Laryngoscope 2015; 125:311-7. [PMID: 25263939 PMCID: PMC4305002 DOI: 10.1002/lary.24892] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/11/2014] [Accepted: 07/24/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications. STUDY DESIGN Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008. METHODS The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications. RESULTS There were 5,277 primary cases and 192 revision cases that met inclusion criteria. There was a nonsignificant absolute difference of 3.09% (95% confidence interval [CI]: -11.00 to 16.14) between the rate of complications following primary (n = 443, 8.39%) and revision (n = 22, 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (odds ratio [OR]:1.74, 95% CI: 1.17 to 2.61), Medicaid (OR: 2.13, 95% CI: 1.59 to 2.86), or a malignant neoplasm (OR: 3.10, 95% CI: 1.62 to 5.93) were more likely to have complications. CONCLUSIONS The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications. LEVEL OF EVIDENCE 2C.
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Affiliation(s)
- James G. Krings
- Department of Otolaryngology-Head and Neck Surgery Washington University School of Medicine Saint Louis, MO 63110
- Stanford Medical Scholars Fellowship, Stanford University School of Medicine Stanford, California 94305
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery Washington University School of Medicine Saint Louis, MO 63110
| | - Andre Wineland
- Department of Otolaryngology-Head and Neck Surgery Washington University School of Medicine Saint Louis, MO 63110
| | - Kenneth G. Nepple
- Department of Urology University of Iowa School of Medicine Iowa City, Iowa 52242
| | - Jay F. Piccirillo
- Department of Otolaryngology-Head and Neck Surgery Washington University School of Medicine Saint Louis, MO 63110
| | - Anne E. Getz
- Department of Otolaryngology-Head and Neck Surgery University of Colorado School of Medicine Aurora, CO 80045
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Murthy SB, Moradiya Y, Shah S, Shastri A, Bershad EM, Suarez JI. In-hospital outcomes of thrombolysis for acute ischemic stroke in patients with primary brain tumors. J Clin Neurosci 2015; 22:474-8. [PMID: 25564270 DOI: 10.1016/j.jocn.2014.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/07/2014] [Accepted: 09/14/2014] [Indexed: 10/24/2022]
Abstract
Data on thrombolysis outcomes in patients with primary brain tumors are limited. Our aim was to study stroke outcomes following thrombolysis in these patients in a population-based study. Patients with acute ischemic stroke who received thrombolysis were identified from the 2002-2011 USA Nationwide Inpatient Sample. We compared demographics, comorbidities, and outcomes between primary brain tumor-associated strokes (BTS) and non-brain tumor associated strokes (NBTS). The main outcomes were inpatient mortality, home discharge and intracranial hemorrhage (ICH) rate. Of the 124,083 thrombolysis-treated stroke patients, 416 (0.34%) had brain tumors. In adjusted analysis, inpatient mortality (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.77-1.26, p=0.918), rate of home discharge (OR: 1.15; 95% CI: 0.87-1.53, p=0.40) and rate of ICH (OR: 0.94; 95% CI: 0.62-1.44, p=0.801) were similar between BTS and NBTS. Analysis of brain tumor subtypes showed that compared to NBTS, malignant BTS were independently associated with higher in-hospital mortality (OR: 2.51; 95% CI: 1.66-3.79, p<0.001), lower home discharge (OR: 0.36, 95% CI: 0.18-0.72, p=0.004), and increased risk of ICH (OR: 2.33, 95% CI: 1.49-3.65, p<0.001). Additionally, among the BTS, intraparenchymal location of tumor was associated with higher mortality (OR: 2.51; 95% CI: 1.20-5.23, p=0.014) and lower home discharge (OR: 0.26; 95% CI: 0.13-0.53, p<0.001). Thrombolytic therapy for acute stroke appears to be safe in patients with primary brain tumors, with similar rates of ICH. Malignant BTS have worse outcomes, while benign BTS have outcomes comparable to NBTS. Careful consideration of tumor pathology may aid selection of patients with poor thrombolysis outcomes.
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Affiliation(s)
- Santosh B Murthy
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, 600 N Wolf Street, Meyer 8-140, MD 21287, USA.
| | - Yogesh Moradiya
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, 600 N Wolf Street, Meyer 8-140, MD 21287, USA
| | - Shreyansh Shah
- Department of Vascular Neurology, National Institutes of Health, Bethesda, MD, USA
| | - Aditi Shastri
- Department of Hematology and Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eric M Bershad
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
| | - Jose I Suarez
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
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Trinh VT, Davies JM, Berger MS. Surgery for primary supratentorial brain tumors in the United States, 2000-2009: effect of provider and hospital caseload on complication rates. J Neurosurg 2014; 122:280-96. [PMID: 25397366 DOI: 10.3171/2014.9.jns131648] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to examine how procedural volume and patient demographics impact complication rates and value of care in those who underwent biopsy or craniotomy for supratentorial primary brain tumors. METHODS The authors conducted a retrospective cohort study using data from the Nationwide Inpatient Sample (NIS) on 62,514 admissions for biopsy or resection of supratentorial primary brain tumors for the period from 2000 to 2009. The main outcome measures were in-hospital mortality, routine discharge proportion, length of hospital stay, and perioperative complications. Associations between these outcomes and hospital or surgeon case volumes were examined in logistic regression models stratified across patient characteristics to control for presentation of disease and comorbid risk factors. The authors further computed value of care, defined as the ratio of functional outcome to hospital charges. RESULTS High-case-volume surgeons and hospitals had superior outcomes. After adjusting for patient characteristics, high-volume surgeon correlated with reduced complication rates (OR 0.91, p=0.04) and lower in-hospital mortality (OR 0.43, p<0.0001). High-volume hospitals were associated with reduced in-hospital mortality (OR 0.76, p=0.003), higher routine discharge proportion (OR 1.29, p<0.0001), and lower complication rates (OR 0.93, p=0.04). Patients treated by high-volume surgeons were less likely to experience postoperative hematoma, hydrocephalus, or wound complications. Patients treated at high-volume hospitals were less likely to experience mechanical ventilation, pulmonary complications, or infectious complications. Worse outcomes tended to occur in African American and Hispanic patients and in those without private insurance, and these demographic groups tended to underutilize high-volume providers. CONCLUSIONS A high-volume status for hospitals and surgeons correlates with superior value of care, as well as reduced in-hospital mortality and complications. These findings suggest that regionalization of care may enhance patient outcomes and improve value of care for patients with primary supratentorial brain tumors.
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Affiliation(s)
- Victoria T Trinh
- Department of Neurological Surgery, University of California, San Francisco, California
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Hobson C, Dortch J, Ozrazgat Baslanti T, Layon DR, Roche A, Rioux A, Harman JS, Fahy B, Bihorac A. Insurance status is associated with treatment allocation and outcomes after subarachnoid hemorrhage. PLoS One 2014; 9:e105124. [PMID: 25141303 PMCID: PMC4139299 DOI: 10.1371/journal.pone.0105124] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/18/2014] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Subarachnoid hemorrhage (SAH) is a particularly devastating type of stroke which is responsible for one third of all stroke-related years of potential life lost before age 65. Surgical treatment has been shown to decrease both morbidity and mortality after subarachnoid hemorrhage. We hypothesized that payer status other than private insurance is associated with lower allocation to surgical treatment for patients with SAH and worse outcomes. DESIGN We examined the association between insurance type and surgical treatment allocation and outcomes for patients with SAH while adjusting for a wide range of patient and hospital factors. We analyzed the Nationwide Inpatient Sample hospital discharge database using survey procedures to produce weighted estimates representative of the United States population. PATIENTS We studied 21047 discharges, representing a weighted estimate of 102595 patients age 18 and above with a discharge diagnosis of SAH between 2003 and 2008. MEASUREMENTS Multivariable logistic and generalized linear regression analyses were used to assess for any associations between insurance status and surgery allocation and outcomes. MAIN RESULTS Despite the benefits of surgery 66% of SAH patients did not undergo surgical treatment to prevent rebleeding. Mortality was more than twice as likely for patients with no surgical treatment compared to those who received surgery. Medicare patients were significantly less likely to receive surgical treatment. CONCLUSIONS Nearly two thirds of patients with SAH don't receive operative care, and Medicare patients were significantly less likely to receive surgical treatment than other patients. Bias against the elderly and those with chronic illness and disability may play a part in these findings. A system of regionalized care for patients presenting with SAH may reduce disparities and improve appropriate allocation to surgical care and deserves prospective study.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VA Medical Center, Gainesville, Florida, United States of America
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, United States of America
| | - John Dortch
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Tezcan Ozrazgat Baslanti
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Daniel R. Layon
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Alina Roche
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Alison Rioux
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Jeffrey S. Harman
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, United States of America
| | - Brenda Fahy
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America
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Tyson MD, Humphreys MR. Postoperative complications after percutaneous nephrolithotomy: a contemporary analysis by insurance status in the United States. J Endourol 2013; 28:291-7. [PMID: 24148028 DOI: 10.1089/end.2013.0624] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE No published data to date have assessed the insurance-related disparities among patients undergoing percutaneous nephrolithotomy (PCNL). Our objective was to examine whether being uninsured is associated with more perioperative complications after PCNL in the United States and to determine possible risk factors that influence PCNL outcomes. PATIENTS AND METHODS This retrospective cohort study evaluated 13,982 patients who underwent PCNL and were included in Nationwide Inpatient Sample from 1998 through 2010. The main outcome measure was ≥1 perioperative complication stratified by insurance status. Associations between this outcome and insurance status were examined using logistic regression models. RESULTS The overall percentage of patients with ≥1 perioperative complication after PCNL was 14.4% (n=2008). When stratified by insurance status, the unadjusted analysis showed significantly higher complication rates among Medicare (17.1%) and Medicaid (16.9%) beneficiaries than privately insured (12.3%) and uninsured (13.4%) patients (P<0.001). In a fully adjusted analysis of patients without medical comorbidity, however, these differences were no longer statistically significant, even when stratified by hospital teaching status. Multivariable-adjusted analysis of preoperative medical comorbidity showed that pulmonary disorders (odds ratio [OR], 7.77; 95% confidence interval [CI], 4.54-13.31), coagulopathy (OR, 6.16; 95% CI, 4.27-8.89), deficiency anemias (OR, 3.82; 95% CI, 3.29-4.44), and paralysis (OR, 2.16; 95% CI, 1.78-2.61) were the strongest predictors of ≥1 perioperative complication. CONCLUSIONS Perioperative morbidity after PCNL varied significantly with insurance status, but this variation was explained mostly by differences in overall health status.
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Affiliation(s)
- Mark D Tyson
- Department of Urology, Mayo Clinic Hospital , Phoenix, Arizona
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The impact of insurance status on the outcomes after aneurysmal subarachnoid hemorrhage. PLoS One 2013; 8:e78047. [PMID: 24205085 PMCID: PMC3812119 DOI: 10.1371/journal.pone.0078047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 09/08/2013] [Indexed: 11/19/2022] Open
Abstract
Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001–2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer–including in-hospital post-procedural mortality–were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.
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Cheung MR. Lack of health insurance increases all cause and all cancer mortality in adults: an analysis of National Health and Nutrition Examination Survey (NHANES III) data. Asian Pac J Cancer Prev 2013; 14:2259-63. [PMID: 23725123 DOI: 10.7314/apjcp.2013.14.4.2259] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Public use National Health and Nutrition Examination Survey (NHANES III) and NHANES III linked mortality data were here applied to investigate the association between health insurance coverage and all cause and all cancer mortality in adults. PATIENTS AND METHODS NHANES III household adult, laboratory and mortality data were merged. Only patients examined in the mobile examination center (MEC) were included in this study. The sampling weight employed was WTPFEX6, SDPPSU6 being used for the probability sampling unit and SDPSTRA6 to designate the strata for the survey analysis. All cause and all cancer mortalities were used as binary outcomes. The effect of health insurance coverage status on all cause and all cancer mortalities were analyzed with potential socioeconomic, behavioral and health status confounders. RESULTS There were 2398 sample persons included in this study. The mean age was 40 years and the mean (S.E.) follow up was 171.85 (3.12) person months from the MEC examination. For all cause mortality, the odds ratios (significant p-values) of the covariates were: age, 1.0095 (0.000); no health insurance coverage (using subjects with health insurance), 1.71 (0.092); black race (using non-Hispanic white subjects as the reference group) 1.43, (0.083); Mexican-Americans, 0.60 (0.089); DMPPIR, 0.82, (0.000); and drinking hard liquor, 1.014 (0.007). For all cancer mortality, the odds ratio (significant p-values) of the covariates were: age, 1.0072 (0.00); no health insurance coverage, using with health coverage as the reference group, 2.91 (0.002); black race, using non-Hispanic whites as the reference group, 1.64 (0.047); Mexican Americans, 0.33 (0.008) and smoking, 1.017 (0.118). CONCLUSION There was a 70% increase in risk of all cause death and almost 300% of all cancer death for people without any health insurance coverage.
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