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Batra S, Bernacki EJ, Kalia N. Incorporating Social Determinants of Health Into Occupational Medicine Practice. J Occup Environ Med 2024; 66:e256-e257. [PMID: 38509657 DOI: 10.1097/jom.0000000000003101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
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Tavakol S, Zieles K, Peters M, Omini M, Chen S, Jea A. The impact of social determinants of health on early outcomes after adult Chiari surgery. GeroScience 2024; 46:1451-1459. [PMID: 37996723 PMCID: PMC10828512 DOI: 10.1007/s11357-023-01021-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/19/2023] [Indexed: 11/25/2023] Open
Abstract
We sought to identify social determinants of health (SDoH) for adult patients undergoing Chiari decompression surgery and to analyze their association with postoperative outcomes, including length of stay (LOS), return to the system within 30 days, and the Chicago Chiari Outcomes Score (CCOS). This is a retrospective study of adult patients who underwent Chiari decompression surgery between June 2021 and January 2023. Data was gathered through electronic medical record review and telephone surveys. Descriptive statistics were used to evaluate demographics of all patients meeting inclusion criteria. Fisher's exact tests and logistic regression were used for data analysis. A total of 37 patients underwent Chiari decompression (23 CCOS/SDoH survey respondents): 48% bony decompression only, 30% bony decompression plus intradural exploration, and 22% occipitocervical fusion. Seven patients (30%) had a LOS > 2 days, 1 patient (4%) required inpatient rehabilitation postoperatively, 4 patients (17%) returned to the system within 30 days, 10 patients (43%) had an extremely favorable CCOS (15-16), and 11 patients (48%) reported interaction with a Chiari support group. Mean follow-up was 9.5 months. Patients with occipitocervical fusion were more likely to have a LOS > 2 days (p = 0.03), patients who exercised ≥ 3 days per week were more likely to have a favorable CCOS (p = 0.04), and patients who participated in a Chiari support group were less likely to have a favorable CCOS (p = 0.03). Chiari decompression plus occipitocervical fusion may be associated with increased LOS. While more frequent exercise may be associated with better post-surgical outcomes, participation in a Chiari support group may be correlated with worse outcomes.
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Affiliation(s)
- Sherwin Tavakol
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Kristin Zieles
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mikayla Peters
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael Omini
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Andrew Jea
- Department of Neurosurgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Rostoft S, Thomas MJ, Slaaen M, Møller B, Nesbakken A, Syse A. Hospital use and cancer treatment by age and socioeconomic status in the last year of life: A Norwegian population-based study of patients dying of cancer. J Geriatr Oncol 2024; 15:101683. [PMID: 38065011 DOI: 10.1016/j.jgo.2023.101683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/10/2023] [Accepted: 12/01/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Cancer is the leading cause of death in Norway. In this nationwide study we describe the number and causes of hospital admissions and treatment in the final year of life for patients who died of cancer, as well as the associations to age and socioeconomic status (SES). MATERIALS AND METHODS From nationwide registries covering 2010-2014, we identified all patients who were diagnosed with cancer 12-60 months before death and had cancer as their reported cause of death. We examined the number of overnight hospital stays, causes of admission, and treatment (chemotherapy, radiotherapy, surgical procedures) offered during the last year of life by individual (age, sex, comorbidity), cancer (type, stage, months since diagnosis), and socioeconomic variables (co-residential status, income, education). RESULTS The analytical sample included 17,669 patients; 8,247 (47%) were female, mean age was 71.7 years (standard deviation 13.7). At diagnosis, 31% had metastatic disease, while 29% had an intermediate or high comorbidity burden. Altogether, 94% were hospitalized during their final year, 82% at least twice, and 33% six times or more. Patients spent a median of 23 days in hospital (interquartile range 11-41), and altogether 38% died there. Younger age, bladder and ovarian cancer, not living alone, and higher income were associated with having ≥6 hospitalizations. Cancer-related diagnoses were the main causes of hospitalizations (65%), followed by infections (11%). Around 51% had ≥1 chemotherapy episode, with large variations according to patient age and SES; patients who were younger, did not live alone, had high education, and high income received more chemotherapy. Radiotherapy was received by 15% and declined with age, and the variation according to SES characteristics was minor. Of the 12,940 patients with a cancer type where surgery is a main treatment modality, only 835 (6%) underwent surgical procedures for their primary tumor in the last year of life. DISCUSSION Most patients who die of cancer are hospitalized multiple times during the last year of life. Hospitalizations and treatment decline with advancing age. Living alone and having low income is associated with fewer hospitalizations and less chemotherapy treatment. Whether this indicates over- or undertreatment across various groups warrants further exploration.
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Affiliation(s)
- Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | - Marit Slaaen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; The Research Center for Age-Related Functional Decline and Disease, Innlandet Hospital Trust, Ottestad, Norway
| | - Bjørn Møller
- Department of Registration, Cancer Registry of Norway, Oslo, Norway
| | - Arild Nesbakken
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Astri Syse
- Department of Health and Inequality, Norwegian Institute of Public Health, Norway
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Borja AJ, Karsalia R, Chauhan D, Gallagher RS, Malhotra EG, Punchak MA, Na J, McClintock SD, Marcotte PJ, Yoon JW, Ali ZS, Malhotra NR. Association Between Race and Short-Term Outcomes Across 3988 Consecutive Single-Level Spinal Fusions. Neurosurgery 2024:00006123-990000000-01046. [PMID: 38334372 DOI: 10.1227/neu.0000000000002860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/09/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Race has implications for access to medical care. However, the impact of race, after access to care has been attained, remains poorly understood. The objective of this study was to isolate the relationship between race and short-term outcomes across patients undergoing a single, common neurosurgical procedure. METHODS In this retrospective cohort study, 3988 consecutive patients undergoing single-level, posterior-only open lumbar fusion at a single, multihospital, academic medical center were enrolled over a 6-year period. Among them, 3406 patients self-identified as White, and 582 patients self-identified as Black. Outcome disparities between all White patients vs all Black patients were estimated using logistic regression. Subsequently, coarsened exact matching controlled for outcome-mitigating factors; White and Black patients were exact-matched 1:1 on key demographic and health characteristics (matched n = 1018). Primary outcomes included 30-day and 90-day hospital readmissions, emergency department (ED) visits, reoperations, mortality, discharge disposition, and intraoperative complication. RESULTS Before matching, Black patients experienced increased rate of nonhome discharge, readmissions, ED visits, and reoperations (all P < .001). After exact matching, Black patients were less likely to be discharged to home (odds ratio [OR] 2.68, P < .001) and had higher risk of 30-day and 90-day readmissions (OR 2.24, P < .001; OR 1.91, P < .001; respectively) and ED visits (OR 1.79, P = .017; OR 2.09, P < .001). Black patients did not experience greater risk of intraoperative complication (unintentional durotomy). CONCLUSION Between otherwise homogenous spinal fusion cohorts, Black patients experienced unfavorable short-term outcomes. These disparities were not explained by differences in intraoperative complications. Further investigation must characterize and mitigate institutional and societal factors that contribute to outcome disparities.
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Affiliation(s)
- Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ritesh Karsalia
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daksh Chauhan
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan S Gallagher
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emelia G Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria A Punchak
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jianbo Na
- McKenna EpiLog Fellowship in Population Health at the Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D McClintock
- Department of Mathematics, The West Chester Statistical Institute, West Chester University, West Chester, Pennsylvania, USA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jang W Yoon
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- McKenna EpiLog Fellowship in Population Health at the Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Covell MM, Roy JM, Rumalla K, Dicpinigaitis AJ, Kazim SF, Hall DE, Schmidt MH, Bowers CA. The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:251-262. [PMID: 37695046 DOI: 10.1227/neu.0000000000002668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards "frailty" points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Joanna Mary Roy
- Topiwala National Medical College, Mumbai , India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla , New York , USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh , Pennsylvania , USA
- Wolff Center at UPMC, Pittsburgh , Pennsylvania , USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
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Mathew DM, Koff BM, Khusid E, Lui B, Bustillo MA, White RS. Enhanced recovery after neurosurgery: gaps in literature regarding social determinants of health. Neurosurg Rev 2024; 47:67. [PMID: 38267658 DOI: 10.1007/s10143-024-02299-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Affiliation(s)
| | - Benjamin M Koff
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Elizabeth Khusid
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Maria A Bustillo
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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Aguirre AO, Lim J, Kuo CC, Ruggiero N, Siddiqi M, Monteiro A, Baig AA, Housley SB, Recker MJ, Li V, Reynolds RM. Social Determinants of Health and Associations With Outcomes in Pediatric Patients With Brain Tumors. Neurosurgery 2024; 94:108-116. [PMID: 37526439 DOI: 10.1227/neu.0000000000002624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/25/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Social determinants of health (SDOH) are nonmedical factors that affect health outcomes. Limited investigation has been completed on the potential association of these factors to adverse outcomes in pediatric populations. In this study, the authors aimed to analyze the effects of SDOH disparities and their relationship with outcomes after brain tumor resection or biopsy in children. METHODS The authors retrospectively reviewed the records of their center's pediatric patients with brain tumor. Black race, public insurance, median household income, and distance to hospital were the investigated SDOH factors. Univariate analysis was completed between number of SDOH factors and patient demographics. Multivariate linear regression models were created to identify coassociated determinants and outcomes. RESULTS A total of 272 patients were identified and included in the final analysis. Among these patients, 81 (29.8%) had no SDOH disparities, 103 (37.9%) had 1, 71 (26.1%) had 2, and 17 (6.2%) had 3. An increased number of SDOH disparities was associated with increased percentage of missed appointments ( P = .002) and emergency room visits ( P = .004). Univariate analysis demonstrated increased missed appointments ( P = .01), number of postoperative imaging ( P = .005), and number of emergency room visits ( P = .003). In multivariate analysis, decreased median household income was independently associated with increased length of hospital stay ( P = .02). CONCLUSION The SDOH disparities are prevalent and impactful in this vulnerable population. This study demonstrates the need for a shift in research focus toward identifying the full extent of the impact of these factors on postoperative outcomes in pediatric patients with brain tumor.
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Affiliation(s)
- Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Manhal Siddiqi
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Steven B Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Matthew J Recker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo , New York , USA
| | - Veetai Li
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Pediatric Neurosurgery, John R. Oishei Children's Hospital, Buffalo , New York , USA
| | - Renée M Reynolds
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Pediatric Neurosurgery, John R. Oishei Children's Hospital, Buffalo , New York , USA
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Khalid SI, Hunter BM, Shah P, Patel A, Thomson KB, LoPresti MA, Roblin DW, Lam S, Mehta AI. The Impact of Social Determinants of Health in Pediatric Shunted Hydrocephalus. Neurosurgery 2023; 92:1066-1072. [PMID: 36749102 DOI: 10.1227/neu.0000000000002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/27/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Social risk factors have been shown to negatively affect health outcomes in children. However, this has not been characterized regarding pediatric shunted hydrocephalus. OBJECTIVE To explore the impact of social risk factors on outcomes in pediatric shunted hydrocephalus with the goal of identifying specific areas of intervention that might improve the outcomes of children undergoing cerebrospinal fluid (CSF) diversion. METHODS In an all-payer administrative database, records between January 2010 and October 2020 were analyzed to identify children undergoing CSF shunting procedures. Children with social risk factors were compared with those without regarding rates of infection, shunt-related interventions, and mortality within 5 years of their shunting procedure. RESULTS Among the 5420 children who underwent first-time shunting procedures, 263 (4.9%) were identified to have social risk factors. Children with identified social risk factors had increased odds of central nervous system infection (odds ratio [OR] 2.06, 95% CI 1.45-2.91), revision (OR 2.43, 95% I 1.89-3.12), and mortality (OR 2.86, 95% CI 1.23-5.72). The mean numbers of computed tomography studies (14.60 ± 17.78 vs 6.34 ± 6.10), MRI studies (18.76 ± 24.37 vs 7.88 ± 24.37), and shunt series X-rays (17.22 ± 19.04 vs 7.66 ± 8.54) were increased among children with social risk factors. CONCLUSION Children with social risk factors had increased rates of central nervous system infection, shunt-related interventions, and mortality within 5 years of CSF shunting. We underscore the importance of characterizing the impact of social risk factors in specific conditions, such as pediatric shunted hydrocephalus, and look to future directions aimed to mitigate these risk factors with coordination and direction of individualized resources, encouragement of advocacy, and community partnership.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Brittany M Hunter
- Division of Hospital-Based Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Pal Shah
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Aashka Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kyle B Thomson
- Chicago Medical School, Rosalind Franklin University, North Chicago, Illinois, USA
| | - Melissa A LoPresti
- Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, Maryland, USA
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Shlobin NA, Kolcun JPG, Leland BD, Ackerman LL, Lam SK, Raskin JS. Disability or Death: A Focused Review of Informed Consent in Pediatric Neurosurgery. Semin Pediatr Neurol 2022; 45:101030. [PMID: 37003629 DOI: 10.1016/j.spen.2022.101030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/04/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
The management of pediatric neurosurgical disease often requires families to choose between long-term disability and premature death. This decision-making is codified by informed consent. In practice, decision-making is heavily weighted toward intervening to prevent death, often with less consideration of the realities of long-term disability. We analyze long-term disability in pediatric neurosurgical disease from the perspectives of patients, families, and society. We then present a pragmatic framework and conversational approach for addressing informed consent discussions when the outcome is expected to be death or disability. We performed a focused review of literature regarding informed consent in pediatric neurosurgery by searching PubMed and Google Scholar with search terms including "pediatric neurosurgery," "informed consent," and "disability." The literature was focused on patients with diagnoses including spina bifida, neuro-oncology, trauma, and hydrocephalus. Patient perspective elements were physical/mental disability, lack of autonomy, and role in community/society. The family perspective involves caregiver burden, emotional toll, and financial impact. Societal considerations include the availability of public resources for disabled children, large-scale financial cost, and impacts on global health. Practical conversational steps with patients/caregivers include opening the discussion, information provision and acknowledgement of uncertainty, assessment of understanding and clarifying questions, decision-making, and decision maintenance, all while remaining sensitive to the emotional burden commensurate with these decisions. The "death or disability" paradigm represents a common challenge to informed consent in pediatric neurosurgery. Patient, family, and societal factors that inform surrogate decisions vary and sometimes conflict. Pediatric neurosurgeons must use a comprehensive approach to address the informational and relational needs of caregivers during the informed consent process.
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Jimenez AE, Cicalese KV, Chakravarti S, Porras JL, Azad TD, Jackson CM, Gallia GL, Bettegowda C, Weingart J, Mukherjee D. Social determinants of health and the prediction of 90-day mortality among brain tumor patients. J Neurosurg 2022; 137:1338-1346. [PMID: 35353473 DOI: 10.3171/2022.1.jns212829] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Within the neurosurgical oncology literature, the effect of structural and socioeconomic factors on postoperative outcomes remains unclear. In this study, the authors quantified the effects of social determinant of health (SDOH) disparities on hospital complications, length of stay (LOS), nonroutine discharge, 90-day readmission, and 90-day mortality following brain tumor surgery. METHODS The authors retrospectively reviewed the records of brain tumor patients who had undergone resection at a single institution in 2017-2019. The prevalence of SDOH disparities among patients was tracked using International Classification of Diseases Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Bivariate (Mann-Whitney U-test and Fisher's exact test) and multivariate (logistic and linear) regressions revealed whether there was an independent relationship between SDOH status and postoperative outcomes. RESULTS The patient cohort included 2519 patients (mean age 55.27 ± 15.14 years), 187 (7.4%) of whom experienced at least one SDOH disparity. Patients who experienced an SDOH disparity were significantly more likely to be female (OR 1.36, p = 0.048), Black (OR 1.91, p < 0.001), and unmarried (OR 1.55, p = 0.0049). Patients who experienced SDOH disparities also had significantly higher 5-item modified frailty index (mFI-5) scores (p < 0.001) and American Society of Anesthesiologists (ASA) classes (p = 0.0012). Experiencing an SDOH disparity was associated with a significantly longer hospital LOS (p = 0.0036), greater odds of a nonroutine discharge (OR 1.64, p = 0.0092), and greater odds of 90-day mortality (OR 2.82, p = 0.0016) in the bivariate analysis. When controlling for patient demographics, tumor diagnosis, mFI-5 score, ASA class, surgery number, and SDOH status, SDOHs independently predicted hospital LOS (coefficient = 1.22, p = 0.016) and increased odds of 90-day mortality (OR 2.12, p = 0.028). CONCLUSIONS SDOH disparities independently predicted a prolonged hospital LOS and 90-day mortality in brain tumor patients. Working to address these disparities offers a new avenue through which to reduce patient morbidity and mortality following brain tumor surgery.
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Affiliation(s)
- Adrian E Jimenez
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Kyle V Cicalese
- 2Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Sachiv Chakravarti
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Jose L Porras
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Tej D Azad
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Christopher M Jackson
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Gary L Gallia
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Chetan Bettegowda
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Jon Weingart
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Debraj Mukherjee
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Shlobin NA, Huang J, Lam S. Health Literacy in Neurosurgery: A Scoping Review. World Neurosurg 2022; 166:71-87. [PMID: 35835323 DOI: 10.1016/j.wneu.2022.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Low health literacy is prevalent and associated with suboptimal health outcomes. In neurosurgery, social determinants of health are increasingly recognized as factors underpinning outcomes, as well as access to and use of care. We conducted a scoping review to delineate the scope of existing literature regarding health literacy in the field and facilitate future research. METHODS A scoping review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were screened for relevance. Studies meeting prespecified inclusion criteria underwent full text review. Relevant data were extracted. RESULTS Of 5056 resultant articles, 57 manuscripts were included. Thirty-seven studies (64.9%) investigated personal health literacy, while the remaining 20 (35.1%) investigated organizational health literacy. Domains of health literacy investigated were science (36, 63.2%), fundamental (20, 35.1%), and civic (1, 1.7%). No studies investigated numeracy. Recall among patients after discussions with neurosurgeons is low. Patient perspectives are often erroneous. Patient informational needs are often unmet. Written patient educational materials are written at a level too complex for the average patients. Videos are mostly of poor quality. Multimodal audiovisual interventions, eBooks, models, and virtual reality are shown to be effective methods for promoting recall. CONCLUSIONS Studies examining health literacy in neurosurgery primarily focus on the topic indirectly, most often via written educational materials and recall after educational interventions. Increasing awareness of health literacy among neurosurgeons, assessing health literacy, and incorporating health literacy-informed counseling approaches are warranted to improve patient care.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Jonathan Huang
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA.
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Manuel SP, Chia ZK, Raygor KP, Fernández A. Association of Language Barriers With Process Outcomes After Craniotomy for Brain Tumor. Neurosurgery 2022; 91:590-595. [PMID: 35857019 PMCID: PMC10552977 DOI: 10.1227/neu.0000000000002080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Little is known about the independent association of language barriers on postoperative process outcomes after craniotomies. OBJECTIVE To evaluate the association of limited English proficiency (LEP) with length of stay (LOS), discharge disposition, hospitalization costs, and rate of 30-day readmission after craniotomy for brain tumor. METHODS This is a retrospective cohort study of adult patients who underwent craniotomies for brain tumor from 2015 to 2019 at a high-volume neurosurgical center. Multivariable logistic regression was used to evaluate the association of LEP with discharge disposition and 30-day readmission. Negative binomial regression was used to evaluate the association of LEP with LOS and hospitalization cost. RESULTS Of the 2232 patients included, 7% had LEP. LEP patients had longer LOS (median [IQR] 5 [3-8] days vs 3 [2-5] days, P < .001), higher costs of hospitalization (median [IQR] $27 000 [$21 000-$36 000] vs $23 000 [$19 000-$30 000], P < .001), and were more likely to be discharged to skilled care facilities (37% vs 21%, P < .001) compared with English proficient patients. In multivariable models, the association between LEP and longer LOS (incidence rate ratio 1.11, 95% CI 1.00-1.24), higher hospitalization costs (incidence rate ratio 1.13, 95% CI 1.05-1.20), and discharge to skilled care (OR 1.76, 95% CI 1.13-2.72) remained after adjusting for confounders. There was no difference in 30-day readmission rates by language status. CONCLUSION LEP is an independent risk factor for extended LOS, higher hospitalization cost, and discharge to skilled care in neurosurgical patients who undergo craniotomy for brain tumor. Future research should seek to understand mediators of these observed disparities.
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Affiliation(s)
- Solmaz P. Manuel
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Zer Keen Chia
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Kunal P. Raygor
- Department of Neurological Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Alicia Fernández
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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13
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Wang A, Shlobin NA, DiCesare JAT, Holly LT, Liau LM. Diversity in Neurosurgical Recruitment and Training in the United States: A Systematic Review. World Neurosurg 2022; 162:111-117.e1. [PMID: 35339710 DOI: 10.1016/j.wneu.2022.03.086] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The benefits of diversity are particularly salient in neurosurgical training because of treatment of varied patient populations and the importance of close collaboration between trainees and attending neurosurgeons of different backgrounds. However, there is a paucity of literature that comprehensively examines diversity in neurosurgical recruitment and training. The aim of this study is to systematically review the scope of diversity in neurosurgical recruitment and training. METHODS PudMed, Embase, and Scopus were searched since inception to October 31, 2021. Inclusion consisted of 1) on neurosurgery training; 2) sample was medical student, resident, fellows or attending; 3) discussed diversity variable(s). This study followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS Of 1578 articles, 15 studies were included. Studies largely reported gender (n = 14) underrepresentation in neurosurgery compared with racial/ethnic diversity (n = 2) and socioeconomic status (n = 1). From studies focusing on residency match (n = 4), women medical students placed greater emphasis on mentorship, earlier clinical exposure, and program camaraderie and reputation as most important. From studies (n = 4) reporting retention and attrition, although women residents and attendings representation has increased, black, indigenous and people of color groups continue to represent <15% of studies on neurosurgical training. Studies (n = 4) discussing research suggested that women residents were more likely to have lower h-indices with fewer research grants. Studies (n = 4) describing workforce employment further showed that women and racial/ethnic minority groups were less likely to hold high academic and leadership positions. In studies (n = 4) on work-life balance, 18.5% women attendings found less career fulfillment and 20.4% would not choose to pursue neurosurgery again because of lack of protected personal time. CONCLUSIONS This systematic review shows the scope of studies of diversity within neurosurgery and provides impetus for efforts to expand our understanding of diversity within the field.
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Affiliation(s)
- Andrew Wang
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA; College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, Los Angeles, California, USA.
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jasmine A T DiCesare
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Langston T Holly
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Linda M Liau
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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Singh R, Richter KR, Pollock JR, Haglin JM, Richter RA, Meyer FB. In Reply to the Letter to the Editor Regarding "An Analysis of Political Contributions from Neurosurgeons in the United States". World Neurosurg 2021; 155:213. [PMID: 34724746 DOI: 10.1016/j.wneu.2021.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Rohin Singh
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA.
| | - Kent R Richter
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA; Geisinger Health System Department of Neurosurgery, Danville, Pennsylvania, USA
| | | | - Jack M Haglin
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA; Mayo Clinic Department of Orthopedic Surgery, Scottsdale, Arizona, USA
| | | | - Fredric B Meyer
- Mayo Clinic Department of Neurological Surgery, Rochester, Minnesota, USA
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