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Prasetyo BT, Kurniawan RG, Rilianto B, Windiani PR, Gotama KT, Salam S, Sari IM, Musridharta E, Arham A, Kusdiansah M, Kiemas LS, Bustami M. Clinical prediction score for prolonged length of hospital stay in aneurysmal subarachnoid hemorrhage. BMC Neurol 2023; 23:232. [PMID: 37328746 DOI: 10.1186/s12883-023-03279-3] [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: 02/03/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Length of stay (LOS) is an important indicator of the optimization of health services and hospital financing efficiency in aneurysmal subarachnoid hemorrhage (aSAH) patients. The purpose of this study was to develop a scoring model to predict the LOS of patients with aSAH. METHOD A clinical scoring was developed based on retrospectively collected data from the cerebral aneurysm registry of the National Brain Center Hospital, Jakarta, from January 2019 to June 2022. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted prolonged LOS. LOS predictors were obtained based on the regression coefficients and converted into a point score model. RESULTS Of the 209 aSAH patients observed, 117 patients had prolonged LOS (> 14 days of hospital stay). A clinical score was developed with a range of 0-7 points. Four variables were chosen as predictors of prolonged LOS: the presence of high-grade aSAH (1 point), aneurysm treatment (endovascular coiling: 1 point; surgical clipping: 2 points), cardiovascular comorbidities (1 point), and hospital-acquired pneumonia (3 points). The score showed good discrimination with an area under the receiving operating characteristics curve (AUC) of 0.8183 (SE 0.0278) and a p-value for the Hosmer-Lemeshow (HL) goodness-of-fit of 0.9322. CONCLUSION This simple clinical score reliably predicted prolonged LOS in aneurysmal subarachnoid hemorrhage cases and may aid clinicians in improving patient outcomes and decreasing healthcare costs.
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Affiliation(s)
- Bambang Tri Prasetyo
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Ricky Gusanto Kurniawan
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Beny Rilianto
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia.
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia.
| | - Pratiwi Raissa Windiani
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia
| | - Kelvin Theandro Gotama
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia
| | - Sardiana Salam
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Neurointensive Care, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Ita Muharram Sari
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Neurointensive Care, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Eka Musridharta
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Neurointensive Care, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Abrar Arham
- Neurointervention Division, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Letjen Mt. Haryono Street, No. Kav. 11, East Jakarta, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Department of Neurosurgery, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Muhammad Kusdiansah
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Department of Neurosurgery, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Lyna Soertidewi Kiemas
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Neuroscience Unit, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
| | - Mursyid Bustami
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
- Neurointensive Care, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia
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Kaplan A, Kaleem S, Huynh M. Quality Improvement in the Management of Subarachnoid Hemorrhage: Current State and Future Directions. Curr Pain Headache Rep 2023; 27:27-38. [PMID: 36881288 DOI: 10.1007/s11916-022-01097-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Aneurysmal subarachnoid hemorrhage carries high mortality and morbidity. Quality improvement (QI) efforts in the management of this disease process are growing as the field of neurocritical care matures. This review provides updates in QI in subarachnoid hemorrhage (SAH) and discusses gaps and future directions. RECENT FINDINGS Literature published on the topic over the past 3 years were evaluated. An assessment of current QI practices pertaining to the acute care of SAH was conducted. These include processes surrounding acute pain management, inter-hospital coordination of care, complications during the initial hospital stay, role of palliative care, and quality metrics collection, reporting, and monitoring. SAH QI initiatives have shown promise by decreasing ICU and hospital lengths of stay, health care costs, and hospital complications. The review reveals substantial heterogeneity, variability, and limitations in SAH QI protocols, measures, and reporting. Uniformity in QI research, implementation, and monitoring will be crucial as disease-specific QI develops in neurological care.
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Affiliation(s)
- Aaron Kaplan
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA
| | - Safa Kaleem
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA
| | - Margaret Huynh
- Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, NY, New York, USA.
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Bründl E, Proescholdt M, Störr EM, Schödel P, Bele S, Zeman F, Hohenberger C, Kieninger M, Schmidt NO, Schebesch KM. The endogenous neuropeptide calcitonin gene-related peptide after spontaneous subarachnoid hemorrhage–A potential psychoactive prognostic serum biomarker of pain-associated neuropsychological symptoms. Front Neurol 2022; 13:889213. [PMID: 35968282 PMCID: PMC9366609 DOI: 10.3389/fneur.2022.889213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022] Open
Abstract
Background The pronociceptive neuromediator calcitonin gene-related peptide (CGRP) is associated with pain transmission and modulation. After spontaneous subarachnoid hemorrhage (sSAH), the vasodilatory CGRP is excessively released into cerebrospinal fluid (CSF) and serum and modulates psycho-behavioral function. In CSF, the hypersecretion of CGRP subacutely after good-grade sSAH was significantly correlated with an impaired health-related quality of life (hrQoL). Now, we prospectively analyzed the treatment-specific differences in the secretion of endogenous CGRP into serum after good-grade sSAH and its impact on hrQoL. Methods Twenty-six consecutive patients (f:m = 13:8; mean age 50.6 years) with good-grade sSAH were enrolled (drop out n = 5): n = 9 underwent endovascular aneurysm occlusion, n = 6 microsurgery, and n = 6 patients with perimesencephalic SAH received standardized intensive medical care. Plasma was drawn daily from day 1 to 10, at 3 weeks, and at the 6-month follow-up (FU). CGRP levels were determined with competitive enzyme immunoassay in duplicate serum samples. All patients underwent neuropsychological self-report assessment after the onset of sSAH (t1: day 11–35) and at the FU (t2). Results During the first 10 days, the mean CGRP levels in serum (0.470 ± 0.10 ng/ml) were significantly lower than the previously analyzed mean CGRP values in CSF (0.662 ± 0.173; p = 0.0001). The mean serum CGRP levels within the first 10 days did not differ significantly from the values at 3 weeks (p = 0.304). At 6 months, the mean serum CGRP value (0.429 ± 0.121 ng/ml) was significantly lower compared to 3 weeks (p = 0.010) and compared to the first 10 days (p = 0.026). Higher mean serum CGRP levels at 3 weeks (p = 0.001) and at 6 months (p = 0.005) correlated with a significantly poorer performance in the item pain, and, at 3 weeks, with a higher symptom burden regarding somatoform syndrome (p = 0.001) at t2. Conclusion Our study reveals the first insight into the serum levels of endogenous CGRP in good-grade sSAH patients with regard to hrQoL. In serum, upregulated CGRP levels at 3 weeks and 6 months seem to be associated with a poorer mid-term hrQoL in terms of pain. In migraineurs, CGRP receptor antagonists have proven clinical efficacy. Our findings corroborate the potential capacity of CGRP in pain processing.
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Affiliation(s)
- Elisabeth Bründl
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
- *Correspondence: Elisabeth Bründl
| | - Martin Proescholdt
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Eva-Maria Störr
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Petra Schödel
- Section Neurosurgery, Department of Orthopedics, Trauma and Hand Surgery, Medical Center St. Elisabeth, Straubing, Germany
| | - Sylvia Bele
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Christoph Hohenberger
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
| | - Martin Kieninger
- Department of Anesthesiology, University Medical Center Regensburg, Regensburg, Germany
| | - Nils Ole Schmidt
- Department of Neurosurgery, University Medical Center Regensburg, Regensburg, Germany
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Kardon A, Murray RS, Khalid M, Colloca L, Simard JM, Badjatia N, Murthi SB, Morris NA. Pain Control and Anxiolysis After Subarachnoid Hemorrhage Using Immersive Virtual Reality: A Case Report. Neurohospitalist 2022; 12:563-566. [DOI: 10.1177/19418744221099412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Debilitating headache persists after acute aneurysmal subarachnoid hemorrhage (SAH). Despite high prevalence, little is known regarding optimal treatment strategies for SAH-related headache. Nonpharmacologic adjunctive therapies are emerging as tools to help treat pain and limit opioid exposure in the hospital. Virtual reality (VR) is an immersive audiovisual experience that has been shown to reduce pain perception in other patient populations. The role of VR in acute brain injury is unknown. Here we report a patient with SAH who suffered from persistent headache during her hospitalization despite escalation of analgesic pharmacotherapy. A trial of VR was used as an adjunct to medication over four days. The patient reported subjective improvement in pain and anxiety. VR may provide additional analgesia and anxiolysis over pharmacologic measures alone and warrants further study in patients with acute brain injury.
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Affiliation(s)
- Adam Kardon
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert S. Murray
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, MD, USA
| | - J. Marc. Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Sarah B. Murthi
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Park HS, Lee SH, Kim KM, Cho WS, Kang HS, Kim JE, Ha EJ. Readmission into intensive care unit in patients with aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2021; 23:327-333. [PMID: 34763380 PMCID: PMC8743824 DOI: 10.7461/jcen.2021.e2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular event; patients are routinely admitted to the intensive care unit (ICU) for initial management. Because complications may be delayed, unplanned ICU readmissions can occur. Therefore, in this study we evaluate the rate of and factors associated with readmission after aSAH and identify if readmission is associated with poor clinical outcomes. Methods We retrospectively reviewed the medical records of all patients receiving surgical or endovascular treatment for aSAH and admitted to the ICU between January 2008 and December 2019. We categorized patients by readmission and analyzed their clinical parameters. Results Of the 345 patients who transferred to ward-level care after an initial ICU stay (Group 2), 27 (7.3%) were readmitted to the ICU (Group 1). History of hypertension (HTN), initial Glasgow Coma Scale (GCS) score, modified Fisher grade, and vasospasm therapy during first ICU stay were significantly different between the groups. The most common reason for readmission was delayed cerebral ischemia (DCI; 70.3%; OR 5.545; 95% CI 1.25-24.52; p=0.024). Comorbid HTN (OR 5.311; 95% CI 1.75-16.12; p=0.03) and vasospasm therapy during first ICU stay (OR 7.234; 95% CI 2.41-21.7; p<0.01) also were associated with readmission. Readmitted patients had longer hospital stay and lower GCS scores at discharge (p<0.01). Conclusions DCI was the most common cause of ICU readmission in patients with aSAH. Readmission may indicate clinical deterioration, and patients who are at a high risk for DCI should be monitored to prevent readmission.
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Affiliation(s)
- Hye Seok Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kang Min Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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Chatrath A, Soldozy S, Sokolowski JD, Burke RM, Schultz JG, Rannigan ZC, Park MS. Endovascular and Surgical Treatment Is Predictive of Readmission Risk After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 142:e494-e501. [PMID: 32693223 DOI: 10.1016/j.wneu.2020.07.079] [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: 03/08/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating disease process accounting for 5% of strokes. Although improvements in care have reduced the case-fatality rates, patients have an increased risk of neurological and medical complications after discharge. Additionally, the readmission rates have been increasingly used as a metric for patient care quality. METHODS In the present study, we reviewed the medical records of 206 patients who had been treated for aSAH at the University of Virginia from 2011 to 2018 to identify the causes and predictors of readmission. RESULTS The all-cause readmission rate was 9.8%, 15.3%, and 21.3% within 30, 60, and 180 days, respectively. The readmission rate for neurologic causes was 7.7%, 12.6%, and 18.0% within 30, 60, and 180 days, respectively. The neurologic causes of readmission included aneurysm retreatment, cranioplasty, a fall, hydrocephalus, stroke symptoms, and syncope. Surgical treatment (odds ratio [OR], 4.11-6.30) and endovascular treatment (OR, 3.79-8.33) of vasospasm were associated with an increased risk of all-cause readmission. Endovascular aneurysm treatment (OR, 0.22) was associated with a decreased risk of all-cause readmission. The average interval to the first follow-up appointment at our institution was 55.3 ± 63.3 days. Of the patients who had been readmitted from the emergency room, 65% had not had follow-up contact with physicians at our institution until their readmission. CONCLUSIONS To the best of our knowledge, the present study is the first to have examined the readmission rates for subarachnoid hemorrhage >90 days after treatment. Our results have suggested that the readmission rates >90 days after treatment could still be predicted by the hospital and treatment course during admission and that follow-up appointments with patients earlier in the clinic could identify those patients with a greater risk of readmission.
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Affiliation(s)
- Ajay Chatrath
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca M Burke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Julianne G Schultz
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zuseen C Rannigan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Mouchtouris N, Lang MJ, Barkley K, Barros G, Turpin J, Sweid A, Starke RM, Chalouhi N, Jabbour P, Rosenwasser RH, Tjoumakaris S. Predictors of hospital-associated complications prolonging ICU stay in patients with low-grade aneurysmal subarachnoid hemorrhage. J Neurosurg 2020; 132:1829-1835. [PMID: 31051460 DOI: 10.3171/2019.1.jns182394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH). METHODS The authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications. RESULTS Out of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications. CONCLUSIONS While an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.
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Affiliation(s)
- Nikolaos Mouchtouris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michael J Lang
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kaitlyn Barkley
- 2Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Guilherme Barros
- 3Department of Neurosurgery, University of Washington, Seattle, Washington; and
| | - Justin Turpin
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ahmad Sweid
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M Starke
- 4Department of Neurosurgery, University of Miami, Miami, Florida
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Unda SR, Labagnara K, Birnbaum J, Wong M, de Silva N, Terala H, de la Garza Ramos R, Haranhalli N, Altschul DJ. Impact of hospital-acquired complications in long-term clinical outcomes after subarachnoid hemorrhage. Clin Neurol Neurosurg 2020; 194:105945. [PMID: 32480297 DOI: 10.1016/j.clineuro.2020.105945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with subarachnoid hemorrhage (SAH) usually have prolonged hospitalizations due to the need to closely monitor their neurological status. Therefore, these patients have higher risk of experiencing hospital-acquired complications (HACs), which can complicate their clinical course and recovery. However, there is no evidence on the impact of HACs of long-term clinical outcomes. We aimed to identify if HACs are independent risk factors for poor clinical outcomes at 12-18 months of follow-up. PATIENTS AND METHODS Retrospective analysis of 323 patients with SAH diagnosis from 2013 until June 2018. We collected patient-related factors (age, sex, body mass index (BMI), ethnicity), comorbidities (hypertension, smoke status, diabetes, coronary heart diseases, prothrombotic diseases and hypercholesterolemia), clinical variables (Hunt-Hess grade, modified Fisher grade, treatment, delayed cerebral ischemia), aneurysm characteristics (location, size) and HACs (pneumonia, deep vein thrombosis (DVT), urinary tract infection (UTI), external ventricular drainage (EVD) infections, sepsis, hyponatremia and acute respiratory distress syndrome). Poor outcomes were defined as mRS ≥ 3. RESULTS 204 patients were included in the primary analysis. 82 (40.2%) experienced one or more HACs during their hospital course. Patients that developed HACs have significantly increased ICU (12.1 ± 6.6 vs 24.3 ± 23.6, p < .001) and hospital (18.7 ± 14.2 vs 35.3 ± 26.3, p < .001) length of stays. Moreover, patients with HACs had significant higher rates of delayed cerebral ischemia, non-routine discharge and poor outcomes at 90 days. 177 patients had complete follow-ups at 12-18 months, HACs were independent risk factors for poor functional outcomes at 12-18 months after adjusting for demographic, comorbidities and clinical variables [OR = 3.205, 95% CI 1.231-8.347, p < 0.001]. CONCLUSIONS HACs are an independent risk factor of sustaining poor clinical outcomes 12-18 months after a SAH. Furthermore, HACs are significantly related with the occurrence of DCI, with non-routine discharge and 90-day poor functional outcomes.
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Affiliation(s)
- Santiago R Unda
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA.
| | - Kevin Labagnara
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | - Jessie Birnbaum
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | - Megan Wong
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | - Neranjan de Silva
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | - Harshit Terala
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | | | - Neil Haranhalli
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
| | - David J Altschul
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY USA
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10
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Abstract
OBJECTIVES To evaluate enhanced renal clearance over time in patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage via measured creatinine clearance and to compare measured creatinine clearance to creatinine clearance calculated by the Cockcroft-Gault equation and estimated glomerular filtration rate calculated by the Modification of Diet in Renal Diseases equation. DESIGN Prospective, observational study. SETTING Neurosciences ICU in a tertiary care academic medical center. PATIENTS Study participants had an admission diagnosis of aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage, an expected neurosciences ICU length of stay greater than 48 hours, no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL), and no history of chronic kidney disease. INTERVENTIONS Eight-hour urine collections to measure creatinine clearance were collected daily as the primary method of measuring renal function. Creatinine clearance was also calculated using the Cockcroft-Gault equation and estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Enhanced renal clearance was defined as a measured creatinine clearance greater than the calculated creatinine clearance via Cockcroft-Gault and estimated glomerular filtration rate via Modification of Diet in Renal Disease. Augmented renal clearance was defined by a measured creatinine clearance greater than or equal to 130 mL/min/1.73 m. Relevant demographic, clinical, and outcome data were recorded. MEASUREMENTS AND MAIN RESULTS Fifty aneurysmal subarachnoid hemorrhage patients and 30 intracerebral hemorrhage patients were enrolled, contributing 590 individual measurements. Patients with aneurysmal subarachnoid hemorrhage had a higher mean measured creatinine clearance compared with the mean calculated creatinine clearance based on the Cockcroft-Gault equation (147.9 ± 50.2 vs 109.1 ± 32.7 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (147.9 ± 50.2 vs 126.0 ± 41.9 mL/min/1.73 m; p = 0.04). Ninety-four percent of participants with aneurysmal subarachnoid hemorrhage experienced augmented renal clearance on at least 1 day. In patients with intracerebral hemorrhage, there was a higher mean measured creatinine clearance over the study period compared with the mean calculated creatinine clearance (119.5 ± 57.2 vs 77.8 ± 27.6 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (119.5 ± 57.2 vs 93.0.0 ± 32.8 mL/min/1.73 m; p = 0.02). Fifty percent of participants with intracerebral hemorrhage experienced augmented renal clearance on at least 1 day. CONCLUSIONS A substantial group of patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage experienced enhanced renal clearance, which may be otherwise unknown to clinicians. Enhanced renal clearance may lead to increased renal solute elimination over what is expected, resulting in subtherapeutic renally eliminated drug concentrations. This may result in underexposure to critical medications, leading to treatment failure and other medical complications.
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11
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Hoffman H, Furst T, Jalal MS, Chin LS. Annual incidences and predictors of 30-day readmissions following spontaneous intracerebral hemorrhage from 2010 to 2014 in the United States: A retrospective Nationwide analysis. Heliyon 2020; 6:e03109. [PMID: 31909273 PMCID: PMC6938885 DOI: 10.1016/j.heliyon.2019.e03109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/17/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022] Open
Abstract
Objective 30-day readmission rate is a quality metric often employed to represent hospital and provider performance. Currently, little is known regarding 30-day readmissions (30dRA) following spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to use a national database to identify risk factors and trends in 30dRAs following sICH. Patients and methods 64,909 cases with a primary diagnosis of sICH were identified within the Nationwide Readmission Database (NRD) from 2010 through 2014. Charlson Comorbidity Index (CCI) was used to adjust for the severity of each patient's comorbidities. A binary logistic regression model was constructed to identify predictors of 30-day readmission. Cochran-Mantel-Haenszel test was used to generate a pooled odd ratio (OR) describing the likelihood of experiencing a 30dRA according to year. Results The 30dRA rate following sICH decreased from 13.9% in 2010 to 12.5% in 2014 (pooled OR = 0.90, 95% CI 0.87–0.94). Cerebrovascular and cardiovascular etiologies accounted for the greatest number of admissions (36.1%). Sodium abnormality, healthcare-associated infection, gastrostomy, venous thromboembolism, and ischemic stroke during the index admission were associated with 30-day readmission. Furthermore, patients who underwent ventriculostomy (OR = 1.20, 95% CI 1.03–1.38) and craniotomy (OR = 1.20, 95% CI 1.09–1.31) were more likely to be readmitted within 30 days. Hospital volume, hospital teaching status, mechanical ventilation, and tracheostomy did not affect 30dRAs. Median readmission costs increased from $9,875 in 2012 to $11,028 in 2014 (p = 0.040). Conclusion The overall U.S. 30dRA rate after sICH from 2010 to 2014 was 12.9% and decreased slightly during this time period, but associated costs increased. Prospective studies are required to confirm the risk factors described in this study and to identify methods for preventing readmissions.
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12
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Wang J, Ji Y, Jiang L, Zhao X, Guan S, Yang P, Yu J, Liu Y, Zhang H. Analysis of factors influencing hospital-acquired infection in postoperative patients with intracranial aneurysm. BMC Neurol 2019; 19:332. [PMID: 31862011 PMCID: PMC6925514 DOI: 10.1186/s12883-019-1565-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Hospital-acquired infection (HAI) is a serious complication of neurosurgery. In recent years, the medical body has paid increasing attention to this issue. Aim We investigated the status of HAIs in patients who had undergone surgery for intracranial aneurysms and analysed their risk factors. Methods A retrospective analysis was carried out on the medical records of 542 patients with intracranial aneurysms after they were admitted for neurosurgery at Xuanwu Hospital of Capital Medical University between January and December 2016. Cases studied were divided into an infection group and a control group. Logistic regression analysis of the data was carried out. Findings Of the 542 patients with intracranial aneurysms who underwent surgery, 77 HAIs occurred in 64 patients, with an infection prevalence of 11.8% and prevalence of infection cases of 14.2%. Logistic regression showed that an admission Glasgow Coma Scale (GCS) score of less than 8 points (odds ratio = 4.261, 95% confidence interval 1.102–16.476), hyperglycaemia (2.759, 1.159–6.564), hypothermia treatment (6.557, 2.244–19.159), and central venous catheterisation (CVC) (8.853, 2.860–27.398) were independent risk factors for HAIs in patients with intracranial aneurysm who underwent surgery. Conclusion Being comatose upon hospital admission, having hyperglycaemia or hypothermia, and indwelling CVC are major risk factors for HAIs in patients undergoing surgery for intracranial aneurysms.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Yuanyuan Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Lidan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Xia Zhao
- Hospital Infection Management Division, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shaochen Guan
- Centre for Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Piao Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Jie Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Yunyun Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute (China-INI), 45 Changchun Street, Beijing, 100053, China.
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13
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Morbitzer KA, Rhoney DH, Dehne KA, Jordan JD. Enhanced renal clearance and impact on vancomycin pharmacokinetic parameters in patients with hemorrhagic stroke. J Intensive Care 2019; 7:51. [PMID: 31832200 PMCID: PMC6868795 DOI: 10.1186/s40560-019-0408-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The majority of patients with hemorrhagic stroke experience enhanced renal clearance or augmented renal clearance (ARC). The purpose of this study was to determine the impact of enhanced renal clearance or ARC on vancomycin pharmacokinetic (PK) parameters. METHODS This was a post hoc analysis of a prospective study of adult patients with aneurysmal subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH) admitted to the neurosciences intensive care unit who received vancomycin. Creatinine clearance (CrCl) was measured and also estimated using the Cockcroft-Gault equation. Predicted PK parameters were compared with calculated PK parameters using serum peak and trough concentrations. RESULTS Seventeen hemorrhagic stroke patients met inclusion criteria. All patients experienced enhanced renal clearance on the day that the vancomycin concentrations were obtained, and 12 patients (71%) experienced ARC. The mean calculated elimination rate constant was significantly higher than the predicted value (0.141 ± 0.02 vs. 0.087 ± 0.01 h-1; p = 0.004) and the mean calculated half-life was significantly lower than the predicted half-life (6.5 ± 0.9 vs. 8.7 ± 0.6 h; p = 0.03). CONCLUSIONS Patients with hemorrhagic stroke and enhanced renal clearance displayed PK alterations favoring an increased elimination of vancomycin than expected. This may result in underexposure to vancomycin, leading to treatment failure.
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Affiliation(s)
- Kathryn A. Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Denise H. Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Kelly A. Dehne
- Department of Pharmacy, UNC Health Care, Chapel Hill, NC USA
| | - J. Dedrick Jordan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of North Carolina School of Medicine, 170 Manning Drive, Physician Office Building 2118, Chapel Hill, NC 27599 USA
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14
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Liang JW, Cifrese L, Ostojic LV, Shah SO, Dhamoon MS. Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage. Neurocrit Care 2019; 29:336-343. [PMID: 29949004 DOI: 10.1007/s12028-018-0557-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown. METHODS Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates. RESULTS Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93). CONCLUSIONS SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.
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Affiliation(s)
- John W Liang
- Divisions of Cerebrovascular Disease, Critical Care, and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA. .,Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Department of Neurology, Mount Sinai Downtown, New York, NY, USA.
| | - Laura Cifrese
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Syed O Shah
- Divisions of Cerebrovascular Disease, Critical Care, and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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15
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Dietzel J, Eck T, Usichenko T. Treating Therapy-Resistant Headache After Aneurysmal Subarachnoid Hemorrhage with Acupuncture. Neurocrit Care 2019; 31:434-438. [PMID: 31037638 DOI: 10.1007/s12028-019-00718-3] [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] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Subarachnoid haemorrhage (SAH) is usually associated with severe headache, whereas the options of pharmacological analgesia are restricted. Acupuncture is a promising method in treatment of headaches associated with meningeal sensitivity or irritation, such as migraine or post-dural puncture headache. CASE REPORT We report on 3 patients, who suffered severe headache due to aneurysmal SAH, and received acupuncture when pharmacological measures were exhausted. After acupuncture treatment all patients reported at least 50% pain reduction and could stop or reduce analgesics without side effects. DISCUSSION Acupuncture may be an effective pain treatment method in patients suffering from headache due to SAH. Randomized trials using acupuncture as an add-on to standard analgesic therapy would help evaluate the role of acupuncture for this purpose.
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Affiliation(s)
- Joanna Dietzel
- Institute of Epidemiology, Social Medicine and Health Economy, Charité University Medicine Berlin, Berlin, Germany
| | - Torsten Eck
- Department of Anesthesiology, University Medicine of Greifswald, Sauerbruchstrasse, 17475, Greifswald, Germany
| | - Taras Usichenko
- Department of Anesthesiology, University Medicine of Greifswald, Sauerbruchstrasse, 17475, Greifswald, Germany. .,Department of Anesthesia, McMaster University, Hamilton, Canada.
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16
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Ansari SF, Yan H, Zou J, Worth RM, Barbaro NM. Hospital Length of Stay and Readmission Rate for Neurosurgical Patients. Neurosurgery 2019; 82:173-181. [PMID: 28402465 DOI: 10.1093/neuros/nyx160] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 03/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hospital readmission rate has become a major indicator of quality of care, with penalties given to hospitals with high rates of readmission. At the same time, insurers are increasing pressure for greater efficiency and reduced costs, including decreasing hospital lengths of stay (LOS). OBJECTIVE To analyze the authors' service to determine if there is a relationship between LOS and readmission rates. METHODS Records of patients admitted to the authors' institution from October 2007 through June 2014 were analyzed for several data points, including initial LOS, readmission occurrence, admitting and secondary diagnoses, and discharge disposition. RESULTS Out of 9409 patient encounters, there were 925 readmissions. Average LOS was 6 d. Univariate analysis indicated a higher readmission rate with more diagnoses upon admission (P < .001) and an association between insurance type and readmission (P < .001), as well as decreasing average yearly LOS (P = .0045). Multivariate analysis indicated statistically significant associations between longer LOS (P = .03) and government insurance (P < .01). CONCLUSION A decreasing LOS over time has been associated with an increasing readmission rate at the population level. However, at the individual level, a prolonged LOS was associated with a higher risk of readmission. This was attributed to patient comorbidities. However, this increasing readmission rate may represent many factors including patients' overall health status. Thus, the rate of readmission may represent a burden of illness rather than a valid metric for quality of care.
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Affiliation(s)
- Shaheryar F Ansari
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana
| | - Hong Yan
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worchester, Massachusetts
| | - Jian Zou
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worchester, Massachusetts
| | - Robert M Worth
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana.,Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Nicholas M Barbaro
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana.,Goodman Campbell Brain and Spine, Indianapolis, Indiana
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17
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Wilson MP, Jack AS, Nataraj A, Chow M. Thirty-day readmission rate as a surrogate marker for quality of care in neurosurgical patients: a single-center Canadian experience. J Neurosurg 2019; 130:1692-1698. [PMID: 29979117 DOI: 10.3171/2018.2.jns172962] [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: 11/25/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Readmission to the hospital within 30 days of discharge is used as a surrogate marker for quality and value of care in the United States (US) healthcare system. Concern exists regarding the value of 30-day readmission as a quality of care metric in neurosurgical patients. Few studies have assessed 30-day readmission rates in neurosurgical patients outside the US. The authors performed a retrospective review of all adult neurosurgical patients admitted to a single Canadian neurosurgical academic center and who were discharged to home to assess for the all-cause 30-day readmission rate, unplanned 30-day readmission rate, and avoidable 30-day readmission rate. METHODS A retrospective review was performed assessing 30-day readmission rates after discharge to home in all neurosurgical patients admitted to a single academic neurosurgical center from January 1, 2011, to December 31, 2011. The primary outcomes included rates of all-cause, unplanned, and avoidable readmissions within 30 days of discharge. Secondary outcomes included factors associated with unplanned and avoidable 30-day readmissions. RESULTS A total of 184 of 950 patients (19.4%) were readmitted to the hospital within 30 days of discharge. One-hundred three patients (10.8%) were readmitted for an unplanned reason and 81 (8.5%) were readmitted for a planned or rescheduled operation. Only 19 readmissions (10%) were for a potentially avoidable reason. Univariate analysis identified factors associated with readmission for a complication or persistent/worsening symptom, including age (p = 0.009), length of stay (p = 0.007), general neurosurgery diagnosis (p < 0.001), cranial pathology (p < 0.001), intensive care unit (ICU) admission (p < 0.001), number of initial admission operations (p = 0.01), and shunt procedures (p < 0.001). Multivariate analysis identified predictive factors of readmission, including diagnosis (p = 0.002, OR 2.4, 95% CI 1.4-5.3), cranial pathology (p = 0.002, OR 2.7, 95% CI 1.4-5.3), ICU admission (p = 0.004, OR 2.4, 95% CI 1.3-4.2), and number of first admission operations (p = 0.01, OR 0.51, 95% CI 0.3-0.87). Univariate analysis performed to identify factors associated with potentially avoidable readmissions included length of stay (p = 0.03), diagnosis (p < 0.001), cranial pathology (p = 0.02), and shunt procedures (p < 0.001). Multivariate analysis identified only shunt procedures as a predictive factor for avoidable readmission (p = 0.02, OR 5.6, 95% CI 1.4-22.8). CONCLUSIONS Almost one-fifth of neurosurgical patients were readmitted within 30 days of discharge. However, only about half of these patients were admitted for an unplanned reason, and only 10% of all readmissions were potentially avoidable. This study demonstrates unique challenges encountered in a publicly funded healthcare setting and supports the growing literature suggesting 30-day readmission rates may serve as an inappropriate quality of care metric in neurosurgical patients. Potentially avoidable readmissions can be predicted, and further research assessing predictors of avoidable readmissions is warranted.
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Affiliation(s)
- Mitchell P Wilson
- 1Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada; and
| | - Andrew S Jack
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew Nataraj
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Chow
- 2Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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18
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Franckowiak TM, Raub JN, Yost R. Derivation and validation of a hospital all-cause 30-day readmission index. Am J Health Syst Pharm 2019; 76:436-443. [DOI: 10.1093/ajhp/zxy085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Taylor M Franckowiak
- Department of Pharmacy Services, St. Mary Mercy Hospital, Livonia, MI, and Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - Joshua N Raub
- Department of Pharmacy Services, Detroit Medical Center, Detroit, MI, and Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
| | - Raymond Yost
- Department of Pharmacy Services, Detroit Medical Center, Detroit, MI, and Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI
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19
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Ng I, Du R. Thirty-day readmissions in aneurysmal subarachnoid hemorrhage: A good metric for hospital quality? J Neurosci Res 2019; 98:219-226. [PMID: 30742320 DOI: 10.1002/jnr.24398] [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: 08/09/2018] [Revised: 12/24/2018] [Accepted: 01/23/2019] [Indexed: 11/12/2022]
Abstract
Thirty-day readmission rates has been increasingly used by clinicians, hospital administrators, and policy makers as a metric for the quality of care. However, the 30-day readmission rates may be affected by other factors intrinsic to the patient and may not be a good measure of the quality of care provided by the hospital. In this review, we examined the quality of the 30-day readmissions rate as a quality metric for the quality of care provided to patients with aneurysmal subarachnoid hemorrhage (SAH). It has been shown that in this patient population, 30-day readmission rate primarily captures values, such as the number of comorbidities, disease severity, and discharge dispositions. There is little association between SAH 30-day readmission rates and mortality. However, 30-day readmissions may be reduced by increasing early discharge surveillance, providing readmission reduction programs to patients discharged to medical facilities as well as to home, and identifying patients most at risk for readmission.
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Affiliation(s)
- Isaac Ng
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
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20
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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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Rumalla K, Smith KA, Arnold PM, Mittal MK. Subarachnoid Hemorrhage and Readmissions: National Rates, Causes, Risk Factors, and Outcomes in 16,001 Hospitalized Patients. World Neurosurg 2018; 110:e100-e111. [DOI: 10.1016/j.wneu.2017.10.089] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 11/24/2022]
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Abstract
Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.
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Fehnel CR, Gormley WB, Dasenbrock H, Lee Y, Robertson F, Ellis AG, Mor V, Mitchell SL. Advanced Age and Post-Acute Care Outcomes After Subarachnoid Hemorrhage. J Am Heart Assoc 2017; 6:e006696. [PMID: 29066443 PMCID: PMC5721871 DOI: 10.1161/jaha.117.006696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 09/12/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Older patients with aneurysmal subarachnoid hemorrhage (aSAH) are unique, and determinants of post-acute care outcomes are not well elucidated. The primary objective was to identify hospital characteristics associated with 30-day readmission and mortality rates after hospital discharge among older patients with aSAH. METHODS AND RESULTS This cohort study used Medicare patients ≥65 years discharged from US hospitals from January 1, 2008, to November 30, 2010, after aSAH. Medicare data were linked to American Hospital Association data to describe characteristics of hospitals treating these patients. Using multivariable logistic regression to adjust for patient characteristics, hospital factors associated with (1) hospital readmission and (2) mortality within 30 days after discharge were identified. A total of 5515 patients ≥65 years underwent surgical repair for aSAH in 431 hospitals. Readmission rate was 17%, and 8.5% of patients died within 30 days of discharge. In multivariable analyses, patients treated in hospitals with lower annualized aSAH volumes were more likely to be readmitted 30 days after discharge (lowest versus highest quintile, 1-2 versus 16-30 cases; adjusted odds ratio, 2.10; 95% confidence interval, 1.56-2.84). Patients treated in hospitals with lower annualized aSAH volumes (lowest versus highest quintile: adjusted odds ratio, 1.52; 95% confidence interval, 1.05-2.19) had a greater likelihood of dying 30 days after discharge. CONCLUSIONS Older patients with aSAH discharged from hospitals treating lower volumes of such cases are at greater risk of readmission and dying within 30 days. These findings may guide clinician referrals, practice guidelines, and regulatory policies influencing which hospitals should care for older patients with aSAH.
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Affiliation(s)
- Corey R Fehnel
- Hebrew SeniorLife, Institute for Aging Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hormuzdiyar Dasenbrock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yoojin Lee
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | | | - Alexandra G Ellis
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Susan L Mitchell
- Hebrew SeniorLife, Institute for Aging Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Dasenbrock HH, Angriman F, Smith TR, Gormley WB, Frerichs KU, Aziz-Sultan MA, Du R. Readmission After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Readmission Database Analysis. Stroke 2017; 48:2383-2390. [PMID: 28754828 DOI: 10.1161/strokeaha.117.016702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/09/2017] [Accepted: 06/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The goal of this nationwide study is to evaluate the suitability of readmission as a quality indicator in the aneurysmal subarachnoid hemorrhage (SAH) population. METHODS Patients with aneurysmal SAH were extracted from the Nationwide Readmission Database (2013). Multivariable Cox proportional hazard regression was used to evaluate predictors of a 30-day readmission, and multivariable linear regression was used to analyze the association of hospital readmission rates with hospital mortality rates. Predictors screened included patient demographics, comorbidities, severity of SAH, complications from the SAH hospitalization, and hospital characteristics. RESULTS The 30-day readmission rate was 10.2% (n=346) among the 3387 patients evaluated, and the most common reasons for readmission were neurological, hydrocephalus, infectious, and venous thromboembolic complications. Greater number of comorbidities, increased severity of SAH, and discharge disposition other than to home were independent predictors of readmission (P≤0.03). Although hydrocephalus during the SAH hospitalization was associated with readmission for the same diagnosis, other readmissions were not associated with having sustained the same complication during the SAH hospitalization. Hospital mortality rate was inversely associated with hospital SAH volume (P=0.03) but not significantly associated with hospital readmission rate; hospital SAH volume was also not associated with SAH readmissions. CONCLUSIONS In this national analysis, readmission was primarily attributable to new medical complications in patients with greater comorbidities and severity of SAH rather than exacerbation of complications from the SAH hospitalization. Additionally, hospital readmission rates did not correlate with other established quality metrics. Therefore, readmission may be a suboptimal quality indicator in the SAH population.
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Affiliation(s)
- Hormuzdiyar H Dasenbrock
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - Frederico Angriman
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - Timothy R Smith
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - William B Gormley
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - Kai U Frerichs
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - M Ali Aziz-Sultan
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.)
| | - Rose Du
- From the Cushing Neurosurgical Outcomes Center, Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (H.H.D., T.R.S., W.B.G., K.U.F., M.A.A.-S., R.D.); and T. H. Chan School of Public Health, Harvard University, Boston, MA (H.H.D., F.A.).
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Ramayya AG, Abdullah KG, Mallela AN, Pierce JT, Thawani J, Petrov D, Baltuch GH. Thirty-Day Readmission Rates Following Deep Brain Stimulation Surgery. Neurosurgery 2017; 81:259-267. [DOI: 10.1093/neuros/nyx019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 01/23/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Deep brain stimulation (DBS) has emerged as a safe and efficacious surgical intervention for several movement disorders; however, the 30-day all-cause readmission rate associated with this procedure has not previously been documented.
OBJECT: To perform a retrospective cohort study to estimate the 30-day all-cause readmission rate associated with DBS.
METHODS: We reviewed medical records of patients over the age of 18 who underwent DBS surgery at Pennsylvania Hospital of the University of Pennsylvania between 2009 and 2014. We identified patients who were readmitted to an inpatient medical facility within 30 days from their initial discharge.
RESULTS: Over the study period, 23 (6.6%) of 347 DBS procedures resulted in a readmission to the hospital within 30 days. Causes of readmission were broadly categorized into surgery-related (3.7%): intracranial lead infection (0.6%), battery-site infection (0.6%), intracranial hematoma along the electrode tract (0.6%), battery-site hematoma (0.9%), and seizures (1.2%); and nonsurgery-related (2.9%): altered mental status (1.8%), nonsurgical-site infections (0.6%), malnutrition and poor wound healing (0.3%), and a pulse generator malfunction requiring reprogramming (0.3%). Readmissions could be predicted by the presence of medical comorbidities (P < .001), but not by age, gender, or length of stay (Ps > .15).
CONCLUSION: All-cause 30-day readmission for DBS is 6.6%. This compares favorably to previously studied neurosurgical procedures. Readmissions frequently resulted from surgery-related complications, particularly infection, seizures, and hematomas, and were significantly associated with the presence of medical comorbidities (P < .001).
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Affiliation(s)
- Ashwin G. Ramayya
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - Kalil G. Abdullah
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - Arka N. Mallela
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - John T. Pierce
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - Jayesh Thawani
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - Dmitry Petrov
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
| | - Gordon H. Baltuch
- Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania
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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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Wang H, Johnson C, Robinson RD, Nejtek VA, Schrader CD, Leuck J, Umejiego J, Trop A, Delaney KA, Zenarosa NR. Roles of disease severity and post-discharge outpatient visits as predictors of hospital readmissions. BMC Health Serv Res 2016; 16:564. [PMID: 27724889 PMCID: PMC5057382 DOI: 10.1186/s12913-016-1814-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 10/01/2016] [Indexed: 11/24/2022] Open
Abstract
Background Risks prediction models of 30-day all-cause hospital readmissions are multi-factorial. Severity of illness (SOI) and risk of mortality (ROM) categorized by All Patient Refined Diagnosis Related Groups (APR-DRG) seem to predict hospital readmission but lack large sample validation. Effects of risk reduction interventions including providing post-discharge outpatient visits remain uncertain. We aim to determine the accuracy of using SOI and ROM to predict readmission and further investigate the role of outpatient visits in association with hospital readmission. Methods Hospital readmission data were reviewed retrospectively from September 2012 through June 2015. Patient demographics and clinical variables including insurance type, homeless status, substance abuse, psychiatric problems, length of stay, SOI, ROM, ICD-10 diagnoses and medications prescribed at discharge, and prescription ratio at discharge (number of medications prescribed divided by number of ICD-10 diagnoses) were analyzed using logistic regression. Relationships among SOI, type of hospital visits, time between hospital visits, and readmissions were also investigated. Results A total of 6011 readmissions occurred from 55,532 index admissions. The adjusted odds ratios of SOI and ROM predicting readmissions were 1.31 (SOI: 95 % CI 1.25–1.38) and 1.09 (ROM: 95 % CI 1.05–1.14) separately. Ninety percent (5381/6011) of patients were readmitted from the Emergency Department (ED) or Urgent Care Center (UCC). Average time interval from index discharge date to ED/UCC visit was 9 days in both the no readmission and readmission groups (p > 0.05). Similar hospital readmission rates were noted during the first 10 days from index discharge regardless of whether post-index discharge patient clinic visits occurred when time-to-event analysis was performed. Conclusions SOI and ROM significantly predict hospital readmission risk in general. Most readmissions occurred among patients presenting for ED/UCC visits after index discharge. Simply providing early post-discharge follow-up clinic visits does not seem to prevent hospital readmissions.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA.
| | - Carol Johnson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Vicki A Nejtek
- Institute for Health Aging, Center for Alzheimer's and Neurodegenerative Disease Research, University of North Texas Health Science Center, 3500 Camp Bowie Blvd., Fort Worth, TX, 76107, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - JoAnna Leuck
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Johnbosco Umejiego
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Allison Trop
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Kathleen A Delaney
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA
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Greenberg JK, Guniganti R, Arias EJ, Desai K, Washington CW, Yan Y, Weng H, Xiong C, Fondahn E, Cross DT, Moran CJ, Rich KM, Chicoine MR, Dhar R, Dacey RG, Derdeyn CP, Zipfel GJ. Predictors of 30-day readmission after aneurysmal subarachnoid hemorrhage: a case-control study. J Neurosurg 2016; 126:1847-1854. [PMID: 27494820 DOI: 10.3171/2016.5.jns152644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite persisting questions regarding its appropriateness, 30-day readmission is an increasingly common quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence to identify which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, to focus preventative efforts, and to provide guidance to funding agencies seeking to risk-adjust comparisons among hospitals. METHODS The authors performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center between 2003 and 2013. To control for geographic distance from the hospital and year of treatment, the authors randomly matched each case (30-day readmission) with approximately 2 SAH controls (no readmission) based on home ZIP code and treatment year. They evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g., Hunt and Hess grade), and clinical course (e.g., need for gastrostomy or tracheostomy, length of stay). Conditional logistic regression was used to identify significant predictors, accounting for the matched design of the study. RESULTS Among 82 SAH patients with unplanned 30-day readmission, the authors matched 78 patients with 153 nonreadmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, multiple variables were significantly associated with readmission, including Hunt and Hess grade (OR 3.0 for Grade IV/V vs I/II), need for gastrostomy placement (OR 2.0), length of hospital stay (OR 1.03 per day), discharge disposition (OR 3.2 for skilled nursing vs other disposition), and Charlson Comorbidity Index (OR 2.3 for score ≥ 2 vs 0). However, the only significant predictor in the multivariate analysis was discharge to a skilled nursing facility (OR 3.2), and the final model was sensitive to criteria used to enter and retain variables. Furthermore, despite the significant association between discharge disposition and readmission, less than 25% of readmitted patients were discharged to a skilled nursing facility. CONCLUSIONS Although discharge disposition remained significant in multivariate analysis, most routinely collected variables appeared to be weak independent predictors of 30-day readmission after SAH. Consequently, hospitals interested in decreasing readmission rates may consider multifaceted, cost-efficient interventions that can be broadly applied to most if not all SAH patients.
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Affiliation(s)
| | | | | | | | | | | | - Hua Weng
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | - Chengjie Xiong
- Division of Biostatistics, Washington University School of Medicine in St. Louis, Missouri; and
| | | | - DeWitte T Cross
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | - Christopher J Moran
- Departments of 1 Neurological Surgery.,Mallinckrodt Institute of Radiology, and
| | | | | | | | | | - Colin P Derdeyn
- Departments of 1 Neurological Surgery.,Neurology.,Mallinckrodt Institute of Radiology, and.,Departments of Radiology, Neurology, and Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Low JCM, Welbourne J, McMillan H, Whitfield PC. Early versus late readmission of subarachnoid haemorrhage patients into neurocritical care. Br J Neurosurg 2016; 30:545-8. [PMID: 27333293 DOI: 10.1080/02688697.2016.1199782] [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] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Subarachnoid haemorrhage (SAH) patients will typically require monitoring in a specialised Neurocritical Care Unit (NCCU) regardless of the primary treatment modality. Once discharged from NCCU, readmission within 48 h is regarded as a "failed" discharge. The aims of this study are to (1) Evaluate the readmission rate of SAH patients into NCCU, (2) Identify the indications for readmission, (3) Analyse clinical parameters on discharge between patients readmitted early and late. MATERIALS AND METHODS Retrospective observational study of the Intensive Care National Audit and Research Centre (ICNARC) database of patients from our unit diagnosed with SAH from January 2009-December 2014, who were readmitted into NCCU. Demographic data, World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, length of initial and subsequent NCCU stay, time of readmission, indication for readmission, and mortality rate data were collected. Patients were categorised by early (<48 h) and late (>48 h) readmission, and their clinical parameters on NCCU discharge were statistically analysed. RESULTS Five hundred and seventy-five SAH patients were admitted into NCCU, of which 49 patients (9%) were readmitted after discharge to ward-level care. The mean age of readmitted patients was 64.1 ± 11.6 years old. The most common indications were delayed cerebral ischaemia (DCI) (50%) and infection (19%). Readmitted SAH patients were typically WFNS grade I-II (n = 22) and Fisher grade III-IV (n = 44). 17 (35%) patients were readmitted early, and were older (p = 0.0049) with a lower GCS (p = 0.0077) compared to patients readmitted later. White cell count and C-reactive protein were higher in patients readmitted early, but did not reach statistical significance (p = 0.09, p = 0.07). CONCLUSION DCI and infection were the most common indications for NCCU readmission in SAH patients. "Failed" discharged patients from NCCU are typically older with a lower GCS than patients readmitted after 48 h, and therefore clinicians should be more cautious in discharging these patients prematurely.
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Affiliation(s)
- Jacob C M Low
- a South West Neurosurgical Centre , Derriford Hospital , Plymouth , UK
| | - Jessie Welbourne
- b Department of Critical Care , Derriford Hospital , Plymouth , UK
| | - Helen McMillan
- b Department of Critical Care , Derriford Hospital , Plymouth , UK
| | - Peter C Whitfield
- a South West Neurosurgical Centre , Derriford Hospital , Plymouth , UK
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Bina RW, Lemole GM, Dumont TM. Measuring Quality of Neurosurgical Care: Readmission Is Affected by Patient Factors. World Neurosurg 2016; 88:21-24. [DOI: 10.1016/j.wneu.2015.12.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/25/2015] [Accepted: 12/26/2015] [Indexed: 11/16/2022]
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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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Greenberg JK, Washington CW, Guniganti R, Dacey RG, Derdeyn CP, Zipfel GJ. Causes of 30-day readmission after aneurysmal subarachnoid hemorrhage. J Neurosurg 2015; 124:743-9. [PMID: 26361278 DOI: 10.3171/2015.2.jns142771] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care. METHODS The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization. RESULTS Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3-17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming. CONCLUSIONS Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.
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Affiliation(s)
| | | | | | | | - Colin P Derdeyn
- Departments of 1 Neurological Surgery and.,Neurology, and.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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The effects of data sources, cohort selection, and outcome definition on a predictive model of risk of thirty-day hospital readmissions. J Biomed Inform 2014; 52:418-26. [PMID: 25182868 DOI: 10.1016/j.jbi.2014.08.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 08/13/2014] [Accepted: 08/14/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital readmission risk prediction remains a motivated area of investigation and operations in light of the hospital readmissions reduction program through CMS. Multiple models of risk have been reported with variable discriminatory performances, and it remains unclear how design factors affect performance. OBJECTIVES To study the effects of varying three factors of model development in the prediction of risk based on health record data: (1) reason for readmission (primary readmission diagnosis); (2) available data and data types (e.g. visit history, laboratory results, etc); (3) cohort selection. METHODS Regularized regression (LASSO) to generate predictions of readmissions risk using prevalence sampling. Support Vector Machine (SVM) used for comparison in cohort selection testing. Calibration by model refitting to outcome prevalence. RESULTS Predicting readmission risk across multiple reasons for readmission resulted in ROC areas ranging from 0.92 for readmission for congestive heart failure to 0.71 for syncope and 0.68 for all-cause readmission. Visit history and laboratory tests contributed the most predictive value; contributions varied by readmission diagnosis. Cohort definition affected performance for both parametric and nonparametric algorithms. Compared to all patients, limiting the cohort to patients whose index admission and readmission diagnoses matched resulted in a decrease in average ROC from 0.78 to 0.55 (difference in ROC 0.23, p value 0.01). Calibration plots demonstrate good calibration with low mean squared error. CONCLUSION Targeting reason for readmission in risk prediction impacted discriminatory performance. In general, laboratory data and visit history data contributed the most to prediction; data source contributions varied by reason for readmission. Cohort selection had a large impact on model performance, and these results demonstrate the difficulty of comparing results across different studies of predictive risk modeling.
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