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Zheng K, Murphy MC, Camerucci E, Plitt AR, Shan X, Sui Y, Manduca A, Van Gompel JJ, Ehman RL, Huston J, Yin Z. Improved quantification of tumor adhesion in meningiomas using MR elastography-based slip interface imaging. PLoS One 2024; 19:e0305247. [PMID: 38917107 PMCID: PMC11198761 DOI: 10.1371/journal.pone.0305247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Meningiomas, the most prevalent primary benign intracranial tumors, often exhibit complicated levels of adhesion to adjacent normal tissues, significantly influencing resection and causing postoperative complications. Surgery remains the primary therapeutic approach, and when combined with adjuvant radiotherapy, it effectively controls residual tumors and reduces tumor recurrence when complete removal may cause a neurologic deficit. Previous studies have indicated that slip interface imaging (SII) techniques based on MR elastography (MRE) have promise as a method for sensitively determining the presence of tumor-brain adhesion. In this study, we developed and tested an improved algorithm for assessing tumor-brain adhesion, based on recognition of patterns in MRE-derived normalized octahedral shear strain (NOSS) images. The primary goal was to quantify the tumor interfaces at higher risk for adhesion, offering a precise and objective method to assess meningioma adhesions in 52 meningioma patients. We also investigated the predictive value of MRE-assessed tumor adhesion in meningioma recurrence. Our findings highlight the effectiveness of the improved SII technique in distinguishing the adhesion degrees, particularly complete adhesion. Statistical analysis revealed significant differences in adhesion percentages between complete and partial adherent tumors (p = 0.005), and complete and non-adherent tumors (p<0.001). The improved technique demonstrated superior discriminatory ability in identifying tumor adhesion patterns compared to the previously described algorithm, with an AUC of 0.86 vs. 0.72 for distinguishing complete adhesion from others (p = 0.037), and an AUC of 0.72 vs. 0.67 for non-adherent and others. Aggressive tumors exhibiting atypical features showed significantly higher adhesion percentages in recurrence group compared to non-recurrence group (p = 0.042). This study validates the efficacy of the improved SII technique in quantifying meningioma adhesions and demonstrates its potential to affect clinical decision-making. The reliability of the technique, coupled with potential to help predict meningioma recurrence, particularly in aggressive tumor subsets, highlights its promise in guiding treatment strategies.
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Affiliation(s)
- Keni Zheng
- Radiology, Mayo Clinic, Rochester, MN, United States of America
| | | | | | - Aaron R. Plitt
- Neurosurgery, Mayo Clinic, Rochester, MN, United States of America
| | - Xiang Shan
- Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Yi Sui
- Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Armando Manduca
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States of America
| | - Jamie J. Van Gompel
- Neurosurgery, Mayo Clinic, Rochester, MN, United States of America
- Otolaryngology, Mayo Clinic, Rochester, MN, United States of America
| | | | - John Huston
- Radiology, Mayo Clinic, Rochester, MN, United States of America
| | - Ziying Yin
- Radiology, Mayo Clinic, Rochester, MN, United States of America
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Yu C, Liu Y, Tang Z, Zhang H. Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis. Brain Res 2023; 1816:148467. [PMID: 37348748 DOI: 10.1016/j.brainres.2023.148467] [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: 04/27/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy. METHODS Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care. RESULT Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group. CONCLUSION ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.
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Affiliation(s)
- Chunyang Yu
- Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuqing Liu
- Department of Rehabilitation Medicine, Peking University Third Hospital, China
| | - Zhiqing Tang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China; University of Health and Rehabilitation Sciences, China; Cheeloo College of Medicine, Shandong University, China.
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Soto JM, Nguyen AV, van Zyl JS, Huang JH. Outcomes After Supratentorial Craniotomy for Primary Malignant Brain Tumor Resection in Adult Patients: A National Surgical Quality Improvement Program Analysis. World Neurosurg 2023; 175:e780-e789. [PMID: 37061032 DOI: 10.1016/j.wneu.2023.04.020] [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: 10/28/2022] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The rate of complications remains significant after craniotomy for supratentorial primary malignant brain tumors despite recent advances. OBJECTIVE The goal of this study is to characterize factors associated with these complications. METHODS Data were extracted from the National Surgical Quality Improvement Program database from 2016 to 2019. Patients who underwent a craniotomy for resection of supratentorial primary malignant brain tumors were included. Covariates included demographics/comorbidities, preoperative laboratory values, American Society of Anesthesiologists (ASA) classification, operative time, and postoperative complications. Multivariable logistic regression with backward and forward selection was used to evaluate independent predictors of death, prolonged hospitalization, postoperative stroke with neurologic deficit (CVA), and unplanned readmission. Predictive fit of the model was evaluated using the area under the receiver operating curve (AUC). RESULTS Of 8965 included cases, the 30-day postoperative risks were 1.9% for CVA, 10.1% for unplanned readmission, 1.2% for prolonged hospitalization, and 2.4% for death. Age, ASA category, disseminated cancer, preoperative functional dependence, and postoperative respiratory complications were predictors of 30-day mortality (AUC, 0.83; P < 0.001). CVA was best predicted by increased operation time (P < 0.001), age, ASA category, and recent weight loss (AUC, 0.63; P = 0.009). Prolonged hospitalization was predicted by nonelective surgery status, time from admission to surgery, reintubation, and postoperative sepsis (AUC, 0.78; P < 0.001). Unplanned readmission was predicted by chronic steroid use, postoperative thrombotic complications after surgery, organ/space surgical site infection, deep vein thrombosis, postoperative systemic sepsis, and septic shock (AUC, 0.68; P < 0.001). CONCLUSIONS Our study identifies predictors of major 30-day complications after craniotomy for this subset of patients with brain tumor.
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Affiliation(s)
- Jose M Soto
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Anthony V Nguyen
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA
| | - Johanna S van Zyl
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Health, Scott and White Medical Center, Temple, Texas, USA; Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA.
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Quality of life outcomes in incidental and operated meningiomas (QUALMS): a cross-sectional cohort study. J Neurooncol 2023; 161:317-327. [PMID: 36525165 PMCID: PMC9756745 DOI: 10.1007/s11060-022-04198-y] [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: 09/12/2022] [Accepted: 11/12/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Few studies have evaluated meningioma patients' longer-term health-related quality of life (HRQoL) following diagnosis and treatment, particularly in those with incidental, actively monitored tumours. METHODS A single-center, cross-sectional study was completed. Adult patients with surgically managed or actively monitored meningioma with more than five years of follow-up were included. The patient-reported outcome measures RAND SF-36, EORTC QLQ-C30 and QLQ-BN20 were used to evaluate HRQoL. HRQoL scores were compared to normative population data. Outcome determinants were evaluated using multivariate linear regression analysis. RESULTS 243 patient responses were analyzed, and the mean time from diagnosis was 9.8 years (range 5.0-40.3 years). Clinically relevant, statistically significant HRQoL impairments were identified across several SF-36 and QLQ-C30 domains. Increasing education level (β = 2.9, 95% CI 0.9 to 4.9), P = .004), employment (β = 7.7, 95% CI 2.2 to 13.1, P = .006) and absence of postoperative complications (β=-6.7, 95% CI -13.2 to (-)0.3, P = .041) were associated with a better QLQ-C30 summary score. Other tumour and treatment variables were not. CONCLUSION This study highlights the longer-term disease burden of patients with meningioma nearly one decade after diagnosis or surgery. Patients with actively monitored meningioma have similar HRQoL to operated meningioma patients. Healthcare professionals should be mindful of HRQoL impairments and direct patients to sources of support as needed.
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Wang L, Cai H, Wang Y, Liu J, Chen T, Liu J, Huang J, Guo Q, Zou W. Enhanced recovery after elective craniotomy: A randomized controlled trial. J Clin Anesth 2021; 76:110575. [PMID: 34739947 DOI: 10.1016/j.jclinane.2021.110575] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Enhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation. DESIGN A prospective randomized controlled trial. SETTING The setting is at an operating room, a post-anesthesia care unit, and a hospital ward. PATIENTS This randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020. INTERVENTIONS The neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care. MEASUREMENTS The primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status. MAIN RESULTS After ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [1 to 2], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1-0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3-6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6-15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [1 to 4], P < 0.001), and improved perioperative pain management. CONCLUSIONS Implementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications.
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Affiliation(s)
- Lei Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hongwei Cai
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yanjin Wang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Tiange Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jing Liu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, United States of America
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, Hunan, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
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McHayle A, Pertsch NJ, Toms SA, Weil RJ. Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis. J Clin Neurosci 2021; 92:207-214. [PMID: 34509254 DOI: 10.1016/j.jocn.2021.08.005] [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: 12/30/2020] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012-2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.
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Affiliation(s)
- Allison McHayle
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States.
| | - Nathan J Pertsch
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Southcoast Brain & Spine, North Dartmouth, MA, United States
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Time course of neurological deficits after surgery for primary brain tumours. Acta Neurochir (Wien) 2020; 162:3005-3018. [PMID: 32617678 PMCID: PMC7593278 DOI: 10.1007/s00701-020-04425-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/21/2020] [Indexed: 12/18/2022]
Abstract
Background The postoperative course after surgery for primary brain tumours can be difficult to predict. We examined the time course of postoperative neurological deficits and analysed possible predisposing factors. Method Hundred adults with a radiological suspicion of low- or high-grade glioma were prospectively included and the postoperative course analysed. Possible predictors of postoperative neurological deterioration were evaluated. Results New postoperative neurologic deficits occurred in 37% of the patients, and in 4%, there were worsening of a preoperative deficit. In 78%, the deficits occurred directly after surgery. The probable cause of deterioration was EEG-verified seizures in 7, ischemic lesion in 5 and both in 1, resection of eloquent tissue in 6, resection close to eloquent tissue including SMA in 11 and postoperative haematoma in 1 patient. Seizures were the main cause of delayed neurological deterioration. Two-thirds of patients with postoperative deterioration showed complete regression of the deficits, and in 6% of all patients, there was a slight disturbance of the function after 3 months. Remaining deficits were found in 6% and only in patients with preoperative neurological deficits and high-grade tumours with mainly eloquent locations. Eloquent tumour location was a predictor of postoperative neurological deterioration and preoperative neurological deficits of remaining deficits. Conclusions Postoperative neurological deficits occurred in 41% and remained in 6% of patients. Remaining deficits were found in patients with preoperative neurological deficits and high-grade tumours with mainly eloquent locations. Eloquent tumour location was a predictor of neurological deterioration and preoperative neurological deficits of remaining deficits. Electronic supplementary material The online version of this article (10.1007/s00701-020-04425-3) contains supplementary material, which is available to authorized users.
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Schiavolin S, Raggi A, Scaratti C, Toppo C, Silvaggi F, Sattin D, Broggi M, Ferroli P, Leonardi M. Outcome prediction in brain tumor surgery: a literature review on the influence of nonmedical factors. Neurosurg Rev 2020; 44:807-819. [PMID: 32377881 DOI: 10.1007/s10143-020-01289-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/05/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
The purpose of the present study was to review the existing data on preoperative nonmedical factors that are predictive of outcome in brain tumor surgery. Our hypothesis was that also the individual characteristics (e.g., emotional state, cognitive status, social relationships) could influence the postoperative course in addition to clinical factors usually investigated in brain tumor surgery. PubMed, Embase, and Scopus were searched from 2008 to 2018 using terms relating to brain tumors, craniotomy, and predictors. All types of outcome were considered: clinical, cognitive, and psychological. Out of 6.288 records identified, 16 articles were selected for analysis and a qualitative synthesis of the prognostic factors was performed. The following nonmedical factors were found to be predictive of surgical outcomes: socio-demographic (age, marital status, type of insurance, gender, socio-economic status, type of hospital), cognitive (preoperative language and cognitive deficits, performance at TMT-B test), and psychological (preoperative depressive symptoms, personality traits, autonomy for daily activities, altered mental status). This review showed that nonmedical predictors of outcome exist in brain tumor surgery. Consequently, individual characteristics (e.g., emotional state, cognitive status, social relationships) can influence the postoperative course in addition to clinical factors.
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Affiliation(s)
- Silvia Schiavolin
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy.
| | - Alberto Raggi
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Chiara Scaratti
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Claudia Toppo
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Fabiola Silvaggi
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Davide Sattin
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Morgan Broggi
- Division of Neurosurgery II, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Paolo Ferroli
- Division of Neurosurgery II, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Matilde Leonardi
- Neurology, Public Health and Disability Unit, Fondazione IRCSS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
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Gupta S, Ahmed AK, Bi WL, Dawood HY, Iorgulescu JB, Corrales CE, Dunn IF, Smith TR. Predicting Readmission and Reoperation for Benign Cranial Nerve Neoplasms: A Nationwide Analysis. World Neurosurg 2018; 121:e223-e229. [PMID: 30261394 DOI: 10.1016/j.wneu.2018.09.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Readmission and reoperation are risks in the resection of benign cranial nerve tumors (BCNTs). This report analyzes the impact of patient-level and surgical factors on these adverse outcomes. METHODS This retrospective cohort review comprised patients with a diagnosis of BCNT enrolled in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2015. Multivariate logistic regression was used to determine the impact of select medical and operative factors on the primary outcomes of readmission and reoperation within 30 days, adjusted for relevant covariates. RESULTS We identified 996 patients who underwent resection of a BCNT. The most frequent major complications were readmission (11%), reoperation (8%), surgical site infections (2.6%), and venous thromboembolism (1.5%). The most frequent indications for readmission were management of infection (2.5%), cerebrospinal fluid leak (2.3%), and hydrocephalus (0.5%). Repair of cranial and meningeal defects (3.0%), correction of lagophthalmos (1.2%), and repair of middle ear defects (1.0%) were the most common indications for reoperation. Logistic regression revealed that extremes of age were associated with readmission, whereas preoperative steroid usage, long operative time, and postoperative length of stay >3 days were associated with reoperation (P < 0.05). Obesity trended toward an association with readmission and reoperation. CONCLUSIONS Extremes of age were associated with readmission; preoperative steroid use, long operative time, and postoperative length of stay >3 days were associated with reoperation. Surgeons should consider these factors when assessing risk of postoperative complications for BCNTs.
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Affiliation(s)
- Saksham Gupta
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland Medical College, Baltimore, Maryland, USA
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Y Dawood
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Bryan Iorgulescu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian F Dunn
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Ehresman JS, Garzon-Muvdi T, Rogers D, Lim M, Gallia GL, Weingart J, Brem H, Bettegowda C, Chaichana KL. Risk of Developing Postoperative Deficits Based on Tumor Location after Surgical Resection of an Intracranial Meningioma. J Neurol Surg B Skull Base 2018; 80:59-66. [PMID: 30733902 DOI: 10.1055/s-0038-1667066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/06/2018] [Indexed: 02/01/2023] Open
Abstract
Object Meningiomas occur in various intracranial locations. Each location is associated with a unique set of surgical nuances and risk profiles. The incidence and risk factors that predispose patients to certain deficits based on tumor locations are unclear. This study aimed to determine which preoperative factors increase the risk of patients having new deficits after surgery based on tumor location for patients undergoing intracranial meningioma surgery. Methods Adult patients who underwent primary, nonbiopsy resection of a meningioma at a tertiary care institution between 2007 and 2015 were retrospectively reviewed. Stepwise multivariate logistic regression analyses were used to identify associations with postoperative deficits based on tumor location. Results Postoperatively, from the 761 included patients, there were 39 motor deficits (5.1%), 23 vision deficits (3.0%), 19 language deficits (2.5%), 27 seizures (3.5%), and 26 cognitive deficits (3.4%). The factors independently associated with any postoperative deficits were preoperative radiation (hazard ratio [HR] [95% confidence interval, CI] 3.000 [1.346-6.338], p = 0.008), cerebellopontine angle tumors (HR [95% CI] 2.126 [1.094-3.947], p = 0.03), Simpson grade 4 resections (HR [95% CI] 2.000 [1.271-3.127], p = 0.003), preoperative motor deficits (HR [95% CI] 1.738 [1.005-2.923], p = 0.048), preoperative cognitive deficits (HR [95% CI] 2.033 [1.144-3.504], p = 0.02), and perioperative pulmonary embolisms (HR [95% CI] 11.741 [2.803-59.314], p = 0.0009). Conclusion Consideration of the factors associated with postoperative deficits in this study may help guide treatment strategies for patients with meningiomas.
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Affiliation(s)
- Jeff S Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Davis Rogers
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Kaisorn L Chaichana
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, United States
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Dasenbrock HH, Yan SC, Chavakula V, Gormley WB, Smith TR, Claus EB, Dunn IF. Unplanned Reoperation After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis. Neurosurgery 2018; 81:761-771. [PMID: 28655201 DOI: 10.1093/neuros/nyx089] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 04/06/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Reoperation has been increasingly utilized as a metric evaluating quality of care. OBJECTIVE To evaluate the rate of, reasons for, and predictors of unplanned reoperation after craniotomy for tumor in a nationally accrued population. METHODS Patients who underwent cranial tumor resection were extracted from the prospective National Surgical Quality Improvement Program registry (2012-2014). Multivariate logistic regression examined predictors of unplanned cranial reoperation. Predictors screened included patient age, sex, tumor location and histology, functional status, comorbidities, preoperative laboratory values, operative urgency, and time. RESULTS Of the 11 462 patients included, 3.1% (n = 350) underwent an unplanned cranial reoperation. The most common reasons for cranial reoperation were intracranial hematoma evacuation (22.5%), superficial or intracranial surgical site infections (11.9%), re-resection of tumor (8.4%), decompressive craniectomy (6.1%), and repair of cerebrospinal fluid leakage (5.6%). The strongest predictor of any cranial reoperation was preoperative thrombocytopenia (less than 100 000/μL, odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.23-5.10, P = .01). Thrombocytopenia, hypertension, emergent surgery, and longer operative time were predictors of reoperation for hematoma (P ≤ .004), while dependent functional status, morbid obesity, leukocytosis, and longer operative time were predictors of reoperation for infection (P < .05). Although any unplanned cranial reoperation was not associated with differential odds of mortality (OR = 1.68, 95% CI: 0.94-3.00, P = .08), hematoma evacuation was significantly associated with thirty-day death (P = .04). CONCLUSION In this national analysis, unplanned cranial reoperation was primarily associated with operative indices, rather than preoperative characteristics, suggesting that reoperation may have some utility as a quality indicator. However, hypertension and thrombocytopenia were potentially modifiable predictors of reoperation.
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Affiliation(s)
| | - Sandra C Yan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vamsi Chavakula
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Dasenbrock HH, Smith TR, Rudy RF, Gormley WB, Aziz-Sultan MA, Du R. Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis. J Neurosurg 2018; 128:756-767. [DOI: 10.3171/2016.10.jns161810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVEAlthough reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms.METHODSAdult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011–2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications.RESULTSAmong the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2–17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5–13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m2), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm.CONCLUSIONSIn this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.
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Lakomkin N, Hadjipanayis CG. Non-routine discharge disposition is associated with post-discharge complications and 30-day readmissions following craniotomy for brain tumor resection. J Neurooncol 2017; 136:595-604. [PMID: 29209875 DOI: 10.1007/s11060-017-2689-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 11/18/2017] [Indexed: 11/28/2022]
Abstract
Several studies have reported an association between high-volume brain tumor centers and greater rates of routine discharge disposition in the context of better outcomes. However, the relationship between in-hospital complications, discharge destination, and postoperative adverse events (AEs) remains unexplored. The purpose of this study was thus to use a large, prospectively collected database to examine the association between discharge destination, post-discharge complications, readmissions, and reoperations among patients undergoing craniotomy for brain tumor. The 2011-2014 National Surgical Quality Improvement (NSQIP) database was employed to identify all adult patients who underwent a craniotomy for brain tumor resection. Demographics, comorbidities, and perioperative variables were collected for each patient. Univariate statistics with subsequent binary logistic regression analyses were used to explore the relationship between these perioperative factors and postoperative events, including major post-discharge complications, minor post-discharge AEs, readmissions, and return to the operating room (ROR). Significant variables such as demographics, comorbidities, operative time, body mass index, ASA classification and pre-discharge complications were controlled for in each model. Of the 14,854 patients identified, 11,409 (77.9%) were discharged home. After controlling for comorbidities and in-hospital AEs, discharge to skilled rehabilitation was an independent predictor of major post-discharge complications (OR 1.74, 95% CI 1.31-2.30, p < 0.001), minor post-discharge events (OR 1.60, 95% CI 1.07-2.41, p = 0.024), and ROR (OR 1.68, 95% CI 1.27-2.22, p < 0.001). Discharge to a care facility was predictive of major complications (OR 1.51, 95% CI 1.04-2.19, p = 0.030) and ROR (OR 2.02, 95% CI 1.46-2.80, p < 0.001). These factors may be considered in discharge planning and further outcomes studies for patients undergoing resection.
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Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine, Mount Sinai, Mount Sinai Health System, New York, USA.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine, Mount Sinai, Mount Sinai Health System, New York, USA. .,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, USA. .,Mount Sinai Beth Israel - Phillips Ambulatory Care Center, 10 Union Square East, Suite 5E, New York, NY, 10003, USA.
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Missios S, Bekelis K. Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State. J Neurosurg 2017; 127:1213-1218. [DOI: 10.3171/2016.9.jns161575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEFragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.METHODSA cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.RESULTSOf the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.CONCLUSIONSUsing a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.
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Affiliation(s)
- Symeon Missios
- 1Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Kimon Bekelis
- 2Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
- 3Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- 4The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon; and
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Lakomkin N, Hadjipanayis CG. Hospital-acquired conditions: predictors and implications for outcomes following spine tumor resection. J Neurosurg Spine 2017; 27:717-722. [DOI: 10.3171/2017.5.spine17439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEHospital-acquired conditions (HACs) significantly compromise patient safety, and have been identified by the Centers for Medicare and Medicaid Services as events that will be associated with penalties for surgeons. The mitigation of HACs must be an important consideration during the postoperative management of patients undergoing spine tumor resection. The purpose of this study was to identify the risk factors for HACs and to characterize the relationship between HACs and other postoperative adverse events following spine tumor resection.METHODSThe 2008–2014 American College of Surgeons’ National Surgical Quality Improvement Program database was used to identify adult patients undergoing the resection of intramedullary, intradural extramedullary, and extradural spine lesions via current procedural terminology and ICD-9 codes. Demographic, comorbidity, and operative variables were evaluated via bivariate statistics before being incorporated into a multivariable logistic regression model to identify the independent risk factors for HACs. Associations between HACs and other postoperative events, including death, readmission, prolonged length of stay, and various complications were determined through multivariable analysis while controlling for other significant variables. The c-statistic was computed to evaluate the predictive capacity of the regression models.RESULTSOf the 2170 patients included in the study, 195 (9.0%) developed an HAC. Only 2 perioperative variables, functional dependency and high body mass index, were risk factors for developing HACs (area under the curve = 0.654). Hospital-acquired conditions were independent predictors of all examined outcomes and complications, including death (OR 2.26, 95% CI 1.24–4.11, p = 0.007), prolonged length of stay (OR 2.74, 95% CI 1.98–3.80, p < 0.001), and readmission (OR 9.16, 95% CI 6.27–13.37, p < 0.001). The areas under the curve for these models ranged from 0.750 to 0.917.CONCLUSIONSThe comorbidities assessed in this study were not strongly predictive of HACs. Other variables, including hospital-associated factors, may play a role in the development of these conditions. The presence of an HAC was found to be an independent risk factor for a variety of adverse events. These findings highlight the need for continued development of evidence-based protocols designed to reduce the incidence and severity of HACs.
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16
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Does scope of practice correlate with the outcomes of craniotomy for tumor resection in children? Acta Neurochir (Wien) 2017; 159:975-979. [PMID: 28382397 DOI: 10.1007/s00701-017-3160-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The relationship of scope of practice (predominantly adult, versus predominantly pediatric) with the outcomes of brain tumor surgery in children remains uncertain. We investigated the association of practice focus with the outcomes of neurosurgical oncology operations in pediatric patients. METHODS We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent craniotomies for tumor resections from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning with mixed effects analysis to account for clustering at the hospital level. RESULTS During the study period, there were 770 pediatric patients who underwent craniotomy for tumor resection and met the inclusion criteria. Of these, 370 (48.1%) underwent treatment by providers with predominantly adult practices and 400 (51.9%) by physicians who operated predominantly on children. Mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.12; 95% CI, 0.48-2.58), and discharge to a facility (OR, 1.25; 95% CI, 0.77-2.03). These associations persisted in propensity-adjusted models. CONCLUSIONS In a cohort of pediatric patients undergoing craniotomy for tumor resection from a comprehensive all-payer database, we did not demonstrate a difference in mortality, and discharge to a facility between providers with predominantly adult and predominantly pediatric practices.
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Zygourakis CC, Liu CY, Yoon S, Moriates C, Boscardin C, Dudley RA, Lawton MT, Theodosopoulos P, Berger MS, Gonzales R. Analysis of Cost Variation in Craniotomy for Tumor Using 2 National Databases. Neurosurgery 2017; 81:972-979. [DOI: 10.1093/neuros/nyx133] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 02/23/2017] [Indexed: 12/26/2022] Open
Abstract
Abstract
BACKGROUND
There is a significant increase and large variation in craniotomy costs. However, the causes of cost differences in craniotomies remain poorly understood.
OBJECTIVE
To examine the patient and hospital factors that underlie the cost variation in tumor craniotomies using 2 national databases: the National Inpatient Sample (NIS) and Vizient, Inc. (Irving, Texas).
METHODS
For 41 483 patients who underwent primary surgery for supratentorial brain tumors from 2001 to 2013 in the NIS, we created univariate and multivariate models to evaluate the effect of several patient factors and hospital factors on total hospital cost. Similarly, we performed multivariate analysis with 15 087 cases in the Vizient 2012 to 2015 database.
RESULTS
In the NIS, the mean inflation-adjusted cost per tumor craniotomy increased 30%, from $23 021 in 2001 to $29 971 in 2013. In 2001, the highest cost region was the Northeast ($24 486 ± $1184), and by 2013 the western United States was the highest cost region ($36 058 ± $1684). Multivariate analyses with NIS data showed that male gender, white race, private insurance, higher mortality risk, higher severity of illness, longer length of stay, elective admissions, higher wage index, urban teaching hospitals, and hospitals in the western United States were associated with higher tumor craniotomy costs (all P < .05). Multivariate analyses with Vizient data confirmed that longer length of stay and the western United States were significantly associated with higher costs (P < .001).
CONCLUSION
After controlling for patient/clinical factors, hospital type, bed size, and wage index, hospitals in the western United States had higher costs than those in other parts of the country, based on analyses from 2 separate national databases.
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Affiliation(s)
- Corinna C Zygourakis
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
- Center for Health-care Value, University of California, San Francisco, San Francisco, Cali-fornia
| | - Caterina Y Liu
- School of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Christopher Moriates
- Center for Health-care Value, University of California, San Francisco, San Francisco, Cali-fornia
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Christy Boscardin
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - R Adams Dudley
- Center for Health-care Value, University of California, San Francisco, San Francisco, Cali-fornia
- Department of Medicine, University of California, San Francisco, San Francisco, California
- Philip Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Philip Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ralph Gonzales
- Center for Health-care Value, University of California, San Francisco, San Francisco, Cali-fornia
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Dasenbrock HH, Liu KX, Chavakula V, Devine CA, Gormley WB, Claus EB, Smith TR, Dunn IF. Body habitus, serum albumin, and the outcomes after craniotomy for tumor: a National Surgical Quality Improvement Program analysis. J Neurosurg 2017; 126:677-689. [DOI: 10.3171/2016.2.jns152345] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE
Although there is a growing body of research highlighting the negative impact of obesity and malnutrition on surgical outcomes, few studies have evaluated these parameters in patients undergoing intracranial surgery. The goal of this study was to use a national registry to evaluate the association of body mass index (BMI) and hypoalbuminemia with 30-day outcomes after craniotomy for tumor.
METHODS
Adult patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry. Patients were stratified by body habitus according to the WHO classification, as well as by preoperative hypoalbuminemia (< 3.5 g/dl). Multivariable logistic regression evaluated the association of body habitus and hypoalbuminemia with 30-day mortality, complications, and discharge disposition. Covariates included patient age, sex, race or ethnicity, tumor histology, American Society of Anesthesiology class, preoperative functional status, comorbidities (including hypertension and diabetes mellitus), and additional preoperative laboratory values.
RESULTS
Among the 11,510 patients included, 28.7% were classified as normal weight (BMI 18.5–24.9 kg/m2), 1.9% as underweight (BMI < 18.5 kg/m2), 33.4% as overweight (BMI 25.0–29.9 kg/m2), 19.1% as Class I obese (BMI 30.0–34.9 kg/m2), 8.3% as Class II obese (BMI 35.0–39.9 kg/m2), 5.5% as Class III obese (BMI ≥ 40.0 kg/m2), and 3.1% had missing BMI data. In multivariable regression models, body habitus was not associated with differential odds of mortality, postoperative stroke or coma, or a nonroutine hospital discharge. However, the adjusted odds of a major complication were significantly higher for Class I obese (OR 1.28, 99% CI 1.01–1.62; p = 0.008), Class II obese (OR 1.53, 99% CI 1.13–2.07; p < 0.001), and Class III obese (OR 1.67, 99% CI 1.19–2.36; p < 0.001) patients compared with those of normal weight; a dose-dependent effect was seen, with increased effect size with greater adiposity. The higher odds of major complications was primarily due to significantly increased odds of a venous thromboembolism in overweight and obese patients, as well as of a surgical site infection in those with Class II or III obesity. Additionally, 41.0% of patients had an albumin level ≥ 3.5 g/dl, 9.6% had hypoalbuminemia, and 49.4% had a missing albumin value. Hypoalbuminemia was associated with significantly higher odds of mortality (OR 1.91, 95% CI 1.41–2.60; p < 0.001) or a nonroutine hospital discharge (OR 1.46, 95% CI 1.21–1.76; p < 0.001).
CONCLUSIONS
In this National Surgical Quality Improvement Program analysis evaluating patients who underwent craniotomy for tumor, body habitus was not associated with differential mortality or neurological complications. However, obese patients had increased odds of a major perioperative complication, primarily due to higher rates of venous thromboembolic events and surgical site infections. Preoperative hypoalbuminemia was associated with increased odds of mortality and a nonroutine hospital discharge, suggesting that serum albumin may have utility in stratifying risk preoperatively in patients undergoing craniotomy.
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Affiliation(s)
- Hormuzdiyar H. Dasenbrock
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
| | - Kevin X. Liu
- 2Harvard Medical School, Boston, Massachusetts; and
| | - Vamsidhar Chavakula
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
| | | | - William B. Gormley
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
| | - Elizabeth B. Claus
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
- 3School of Public Health, Yale University, New Haven, Connecticut
| | - Timothy R. Smith
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
| | - Ian F. Dunn
- 1Department of Neurosurgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts; and
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Bekelis K, Labropoulos N, Coy S. Risk of Venous Thromboembolism and Operative Duration in Patients Undergoing Neurosurgical Procedures. Neurosurgery 2017; 80:787-792. [DOI: 10.1093/neuros/nyw129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/12/2016] [Indexed: 11/14/2022] Open
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Dasenbrock HH, Yan SC, Smith TR, Valdes PA, Gormley WB, Claus EB, Dunn IF. Readmission After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis. Neurosurgery 2017; 80:551-562. [DOI: 10.1093/neuros/nyw062] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 06/21/2016] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery.
OBJECTIVE: To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection.
METHODS: Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization.
RESULTS: Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P < .05).
CONCLUSION: Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management.
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Affiliation(s)
- Hormuzdiyar H. Dasenbrock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sandra C. Yan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pablo A. Valdes
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B. Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ian F. Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Bekelis K, Rahmani R, Kim-Hyung J, Calnan D, MacKenzie TA. Association of Prior Falls with Adverse Outcomes After Neurosurgical Operations in the Elderly. World Neurosurg 2016; 99:320-325. [PMID: 28003169 DOI: 10.1016/j.wneu.2016.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite the increasing number of elderly patients undergoing neurosurgical interventions, there are limited resources for preoperative assessment of frailty in this population. We investigated the association between recent history of falls and surgical outcomes for these patients. METHODS We performed a prospective cohort study of all patients, 65 years and older, undergoing elective neurosurgical procedures from 2014-2015 in a tertiary referral medical center. We examined the association of sustaining a fall in the 6 months before the operation with discharge to a facility, readmissions, and complications in the first 30 days after discharge. In order to control for confounding, we used multivariable regression models and propensity score conditioning. Mixed-effects models were used to control for clustering at the surgeon level. RESULTS During the study period, 143 elderly patients underwent a neurosurgical procedure and met the inclusion criteria. Of these, 53.1% had a history of falls preoperatively. Mixed-effects multivariable logistic regression analysis demonstrated an association between preoperative falls and discharge to a facility (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.23-1.47), 30-day readmissions (OR, 1.57; 95% CI, 1.36-1.78), and 30-day complications (OR, 1.13; 95% CI, 1.03-1.23). Similar associations were present in propensity score-adjusted models and models stratified by cranial and spinal procedures. CONCLUSIONS History of at least 1 fall in the 6 months before a neurosurgical operation was associated with increased risk of discharge to a facility, readmissions, and complications in the first 30 days after discharge. History of prior falls should be taken into account during the preoperative risk assessment of neurosurgical patients.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.
| | - Redi Rahmani
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Joon Kim-Hyung
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Daniel Calnan
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Todd A MacKenzie
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Impact of operative length on post-operative complications in meningioma surgery: a NSQIP analysis. J Neurooncol 2016; 131:59-67. [PMID: 27864707 DOI: 10.1007/s11060-016-2262-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/27/2016] [Indexed: 10/20/2022]
Abstract
Many studies have implicated operative length as a predictor of post-operative complications, including venous thromboembolism [deep vein thrombosis (DVT) and pulmonary embolism (PE)]. We analyzed the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2014, to evaluate whether length of operation had a statistically significant effect on post-operative complications in patients undergoing surgical resection of meningioma. Patients were included for this study if they had a post-operative diagnosis of meningioma. Patient demographics, pre-operative comorbidities, and post-operative 30-day complications were analyzed. Of 3743 patients undergoing craniotomy for meningioma, 13.6 % experienced any complication. The most common complications and their median time to occurrence were urinary tract infection (2.6 %) at 10 days postoperatively (IQR 7-15), unplanned intubation (2.5 %) at 3 days (IQR 1-7), failure to wean from ventilator (2.4 %) at 2.0 days (IQR 2-4), and DVT (2.4 %) at 6 days (IQR 11-19). Postoperatively, 3.6 % developed VTE; 2.4 % developed DVT and 1.7 % developed PE. Multivariable analysis identified older age (third and upper quartile), obesity, preoperative ventilator dependence, preoperative steroid use, anemia, and longer operative time as significant risk factors for VTE. Separate multivariable logistic regression models demonstrated longer operative time as a significant risk factor for VTE, all complications, major complications, and minor complications. Meningioma resection is associated with various post-operative complications that increase patient morbidity and mortality risk. this large, multi-institutional patient sample, longer operative length was associated with increased risk for postoperative venous thromboembolisms, as well as major and minor complications.
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Bekelis K, Coy S, Simmons N. Operative Duration and Risk of Surgical Site Infection in Neurosurgery. World Neurosurg 2016; 94:551-555.e6. [DOI: 10.1016/j.wneu.2016.07.077] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
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United States neurosurgery annual case type and complication trends between 2006 and 2013: An American College of Surgeons National Surgical Quality Improvement Program analysis. J Clin Neurosci 2016; 31:106-11. [DOI: 10.1016/j.jocn.2016.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/14/2016] [Indexed: 12/14/2022]
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25
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Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study. Can J Anaesth 2016; 63:1245-57. [DOI: 10.1007/s12630-016-0717-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/21/2016] [Accepted: 08/03/2016] [Indexed: 11/24/2022] Open
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Karhade AV, Vasudeva VS, Dasenbrock HH, Lu Y, Gormley WB, Groff MW, Chi JH, Smith TR. Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis. Neurosurg Focus 2016; 41:E5. [DOI: 10.3171/2016.5.focus16168] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE
The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors.
METHODS
Data from adult patients who underwent surgery for spinal tumors (2011–2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.
RESULTS
Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12–23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8–20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4–5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4–19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14–25 days), and sepsis (2.9%) at 13 days (IQR 7–21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3–5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3–9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5–26 days).
CONCLUSIONS
In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.
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Missios S, Bekelis K. Regional disparities in hospitalization charges for patients undergoing craniotomy for tumor resection in New York State: correlation with outcomes. J Neurooncol 2016; 128:365-71. [PMID: 27072560 DOI: 10.1007/s11060-016-2122-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 04/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH, 03756, USA.
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Dasenbrock HH, Liu KX, Devine CA, Chavakula V, Smith TR, Gormley WB, Dunn IF. Length of hospital stay after craniotomy for tumor: a National Surgical Quality Improvement Program analysis. Neurosurg Focus 2015; 39:E12. [DOI: 10.3171/2015.10.focus15386] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Although the length of hospital stay is often used as a measure of quality of care, data evaluating the predictors of extended hospital stay after craniotomy for tumor are limited. The goals of this study were to use multivariate regression to examine which preoperative characteristics and postoperative complications predict a prolonged hospital stay and to assess the impact of length of stay on unplanned hospital readmission.
METHODS
Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2013. Patients who underwent craniotomy for resection of a brain tumor were included. Stratification was based on length of hospital stay, which was dichotomized by the upper quartile of the interquartile range (IQR) for the entire population. Covariates included patient age, sex, race, tumor histology, comorbidities, American Society of Anesthesiologists (ASA) class, functional status, preoperative laboratory values, preoperative neurological deficits, operative time, and postoperative complications. Multivariate logistic regression with forward prediction was used to evaluate independent predictors of extended hospitalization. Thereafter, hierarchical multivariate logistic regression assessed the impact of length of stay on unplanned readmission.
RESULTS
The study included 11,510 patients. The median hospital stay was 4 days (IQR 3-8 days), and 27.7% (n = 3185) had a hospital stay of at least 8 days. Independent predictors of extended hospital stay included age greater than 70 years (OR 1.53, 95% CI 1.28%-1.83%, p < 0.001); African American (OR 1.75, 95% CI 1.44%-2.14%, p < 0.001) and Hispanic (OR 1.68, 95% CI 1.36%-2.08%) race or ethnicity; ASA class 3 (OR 1.52, 95% CI 1.34%-1.73%) or 4-5 (OR 2.18, 95% CI 1.82%-2.62%) designation; partially (OR 1.94, 95% CI 1.61%-2.35%) or totally dependent (OR 3.30, 95% CI 1.95%-5.55%) functional status; insulin-dependent diabetes mellitus (OR 1.46, 95% CI 1.16%-1.84%); hematological comorbidities (OR 1.68, 95% CI 1.25%-2.24%); and preoperative hypoalbuminemia (OR 1.78, 95% CI 1.51%-2.09%, all p ≤ 0.009). Several postoperative complications were additional independent predictors of prolonged hospitalization including pulmonary emboli (OR 13.75, 95% CI 4.73%-39.99%), pneumonia (OR 5.40, 95% CI 2.89%-10.07%), and urinary tract infections (OR 11.87, 95% CI 7.09%-19.87%, all p < 0.001). The C-statistic of the model based on preoperative characteristics was 0.79, which increased to 0.83 after the addition of postoperative complications. A length of stay after craniotomy for tumor score was created based on preoperative factors significant in regression models, with a moderate correlation with length of stay (p = 0.43, p < 0.001). Extended hospital stay was not associated with differential odds of an unplanned hospital readmission (OR 0.97, 95% CI 0.89%-1.06%, p = 0.55).
CONCLUSIONS
In this NSQIP analysis that evaluated patients who underwent craniotomy for tumor, much of the variance in hospital stay was attributable to baseline patient characteristics, suggesting length of stay may be an imperfect proxy for quality. Additionally, longer hospitalizations were not found to be associated with differential rates of unplanned readmission.
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Abstract
STUDY DESIGN Retrospective review of clinical data registry. OBJECTIVE In the current era of quality reporting and pay for performance, neurosurgeons must develop models to identify patients at high risk of complications. We sought to identify risk factors for complications in spine surgery and to develop a score predictive of complications. SUMMARY OF BACKGROUND DATA We examined spinal surgeries from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. 22,430 cases were identified based on common procedural terminology. METHODS Univariate analysis followed by multivariate regression was used to identify significant factors. RESULTS The overall complication rate for the cohort was 9.9%. The most common complications were postoperative bleeding requiring transfusion (4.1%), nonwound infections (3.1%), and wound-related infections (2.2%). Multivariate regression analysis identified 20 factors associated with complications. Assigning 1 point for the presence of each factor a risk model was developed. The range of scores for the cohort was 0 to 13 with a median score of 4. Complication rates for a risk score of 0 to 4 was 3.7% and for scores 5 to 13 was 18.5%. The risk model robustly predicted complication rates, with complication rate of 1.2% for score of 0 (n = 412, 1.8% of total) and 63.6% and 100% for scores of 12 and 13 (n = 22 patients, 0.1% of total cohort) respectively (P < 0.001). The risk score also correlated strongly with total length of stay, mortality, and total work relative value units for the case. CONCLUSION Patient-specific risk factors including comorbidities are strongly associated with surgical complications, length of stay, cost of care, and mortality in spine surgery and can be used to develop risk models that are highly predictive of complications. LEVEL OF EVIDENCE 3.
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Hagan KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, Gottumukkala V, Popat K, Pratt G, Rahlfs T, Cata JP. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci 2015; 24:10-6. [PMID: 26474504 DOI: 10.1016/j.jocn.2015.08.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/02/2015] [Indexed: 01/12/2023]
Abstract
Enhanced recovery after surgery (ERAS) initiatives in the fields of gastrointestinal and pelvic surgery have contributed to improved postoperative functional status for patients and decreased length of stay. A similar comprehensive protocol is lacking for patients undergoing craniotomy for tumor resection. A literature search was performed using PubMed. These references were reviewed with a preference for recent high quality studies. Cohort and retrospective studies were also included if higher levels of evidence were lacking. A literature search was conducted for scalp blocks and minimally invasive craniotomies. Papers were scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria for evidence level and recommendation grade. Seventeen ERAS items were reviewed and recommendations made. The current body of evidence is insufficient to create a standardized protocol for craniotomy and tumor resection. However, this initial review of the literature supports pursuing future research initiatives that explore modalities to improve functional recovery and decrease length of stay in craniotomy patients.
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Affiliation(s)
- Katherine B Hagan
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shreyas Bhavsar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Shaan M Raza
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Benjamin Arnold
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Radha Arunkumar
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Anh Dang
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Vijay Gottumukkala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Keyuri Popat
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Greg Pratt
- Systems Analyst, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Rahlfs
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA; Anesthesia and Surgical Oncology Research Group, Houston, TX, USA.
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A Predictive Model of Unfavorable Outcomes After Benign Intracranial Tumor Resection. World Neurosurg 2015; 84:82-9. [DOI: 10.1016/j.wneu.2015.02.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 01/31/2015] [Accepted: 02/23/2015] [Indexed: 11/20/2022]
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32
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Alan N, Seicean A, Seicean S, Neuhauser D, Benzel EC, Weil RJ. Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor. J Clin Neurosci 2015; 22:1413-9. [PMID: 26073371 DOI: 10.1016/j.jocn.2015.03.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/21/2015] [Indexed: 12/21/2022]
Abstract
We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.
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Affiliation(s)
- Nima Alan
- School of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Andreea Seicean
- School of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Sinziana Seicean
- Department of Pulmonary, Critical Care and Sleep Medicine, University Hospitals, Cleveland, OH, USA; Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Duncan Neuhauser
- Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, USA
| | - Edward C Benzel
- Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Robert J Weil
- The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
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Missios S, Kalakoti P, Nanda A, Bekelis K. Craniotomy for Glioma Resection: A Predictive Model. World Neurosurg 2015; 83:957-64. [DOI: 10.1016/j.wneu.2015.04.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
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