1
|
Lehrich BM, Birkenbeuel JL, Roman K, Mahmoodi A, Goshtasbi K, Sahyouni R, Hsu FP, Kuan EC. Treatment selection towards active surveillance over definitive treatment for pituitary adenomas is influenced by sociodemographic factors. Clin Neurol Neurosurg 2022; 222:107455. [DOI: 10.1016/j.clineuro.2022.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/11/2022] [Accepted: 09/25/2022] [Indexed: 11/03/2022]
|
2
|
Yu S, Taghvaei M, Collopy S, Piper K, Karsy M, Lavergne P, Barton B, Chitguppi C, D'Souza G, Rosen MR, Nyquist GG, Rabinowitz M, Farrell CJ, Evans JJ. Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection. J Neurosurg 2022; 136:1337-1346. [PMID: 34653980 DOI: 10.3171/2021.5.jns2185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. METHODS A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. RESULTS A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge. CONCLUSIONS This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.
Collapse
Affiliation(s)
- Siyuan Yu
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Mohammad Taghvaei
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Sarah Collopy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Keenan Piper
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Michael Karsy
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Pascal Lavergne
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - Blair Barton
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Chandala Chitguppi
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Glen D'Souza
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Marc R Rosen
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gurston G Nyquist
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mindy Rabinowitz
- 2Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Christopher J Farrell
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| | - James J Evans
- 1Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia; and
| |
Collapse
|
3
|
Thakur JD, Corlin A, Mallari RJ, Yawitz S, Eisenberg A, Sivakumar W, Griffiths C, Carrau RL, Rettinger S, Cohan P, Krauss H, Araque KA, Barkhoudarian G, Kelly DF. Complication avoidance protocols in endoscopic pituitary adenoma surgery: a retrospective cohort study in 514 patients. Pituitary 2021; 24:930-942. [PMID: 34215990 PMCID: PMC8252985 DOI: 10.1007/s11102-021-01167-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE To evaluate the impact of using consistent complication-avoidance protocols in patients undergoing endoscopic pituitary adenoma surgery including techniques for avoiding anosmia, epistaxis, carotid artery injury, hypopituitarism, cerebrospinal fluid leaks and meningitis. METHODS All patients undergoing endoscopic adenoma resection from 2010 to 2020 were included. Primary outcomes included 90-day complication rates, gland function outcomes, reoperations, readmissions and length of stay. Secondary outcomes were extent of resection, short-term endocrine remission, vision recovery. RESULTS Of 514 patients, (mean age 51 ± 16 years; 78% macroadenomas, 19% prior surgery) major complications occurred in 18(3.5%) patients, most commonly CSF leak (9, 1.7%) and meningitis (4, 0.8%). In 14 of 18 patients, complications were deemed preventable. Four (0.8%) had complications with permanent sequelae (3 before 2016): one unexplained mortality, one stroke, one oculomotor nerve palsy, one oculoparesis. There were no internal carotid artery injuries, permanent visual worsening or permanent anosmia. New hypopituitarism occurred in 23/485(4.7%). Partial or complete hypopituitarism resolution occurred in 102/193(52.8%) patients. Median LOS was 2 days; 98.3% of patients were discharged home. Comparing 18 patients with major complications versus 496 without, median LOS was 7 versus 2 days, respectively p < 0.001. Readmissions occurred in 6%(31/535), mostly for hyponatremia (18/31). Gross total resection was achieved in 214/312(69%) endocrine-inactive adenomas; biochemical remission was achieved in 148/209(71%) endocrine-active adenomas. Visual field or acuity defects improved in 126/138(91.3%) patients. CONCLUSION This study suggests that conformance to established protocols for endoscopic pituitary surgery may minimize complications, re-admissions and LOS while enhancing the likelihood of preserving gland function, although there remains opportunity for further improvements.
Collapse
Affiliation(s)
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Samantha Yawitz
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | | | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel F Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave, Santa Monica, CA, 90404, USA.
- Saint John's Cancer Institute (Formerly John Wayne Cancer Institute), Providence Saint John's Health Center, Santa Monica, CA, USA.
| |
Collapse
|
4
|
Tao C, Cheng G, Chen Y, Gu P, Hu W. Early outcomes of endoscopic endonasal approach pituitary adenomas resection with minimal nasal injury. Medicine (Baltimore) 2021; 100:e27843. [PMID: 34797319 PMCID: PMC8601292 DOI: 10.1097/md.0000000000027843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 11/01/2021] [Indexed: 01/05/2023] Open
Abstract
To report the results of a consecutive series of pituitary adenomas resected through endoscopic endonasal approach (EEA) with minimal nasal injury.Retrospectively review tumor characteristics and surgical outcomes of a consecutive series of EEA pituitary adenomas resection performed mainly by a single author between March 2018 and June 2019.A total of 75 endoscopic endonasal approach pituitary adenoma resections were performed by the authors' team. Of the 75 patients, 28 through mononostril EEA, 47 through Binonostril EEA. Hadad-Bassagasteguy vascularized nasoseptal flap was harvested in only 4 (5.3%) patients with a high risk of postoperative cerebrospinal fluid leak, and one side middle turbinate only been resected in 2 (2.7%) patients, other patients preserved bilateral middle turbinate. Of the 75 patients, gross total resection is 74.7%, near-total resection is 16.0%. Endocrinological remission was achieved in 76.9% of GH-secreting adenomas, 61.5% of prolactin-secreting adenomas. The postoperative cerebrospinal fluid leak rate was 2.7%. Two patients had suprasellar hemorrhage, 1 patient had perioperative stroke, 2 patients had permanent diabetes insipidus, no cranial nerve deficits, internal carotid artery injury, anosmia, and death. The sino-nasal function was measured with the Sino-Nasal Outcome Test-22 and visual analog scale for olfaction preoperatively and postoperatively, and there was no statistically significant difference.The EEA is an effective approach to resect pituitary adenomas, the gross total resection and near-total resection rate and endocrinological remission rate are satisfactory. The EEA is a safe approach, as the complication rate is acceptable compared with those reported in the previous series of microscopic and endoscopic approaches. These results can be achieved with minimal nasal injury.
Collapse
|
5
|
Farooqi AS, Detchou DKE, Glauser G, Strouz K, McClintock SD, Malhotra NR. Overlapping single-level lumbar fusion and adverse short-term outcomes. J Neurosurg Spine 2021; 35:571-582. [PMID: 34359028 DOI: 10.3171/2020.12.spine201861] [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: 10/17/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a paucity of research on the safety of overlapping surgery. The purpose of this study was to evaluate the impact of overlapping surgery on a homogenous population of exactly matched patients undergoing single-level, posterior-only lumbar fusion. METHODS The authors retrospectively analyzed case data of 3799 consecutive adult patients who underwent single-level, posterior-only lumbar fusion during a 6-year period (June 7, 2013, to April 29, 2019) at a multihospital university health system. Outcomes included 30-day emergency department (ED) visit, readmission, reoperation, and morbidity and mortality following surgery. Thereafter, coarsened exact matching was used to match patients with and without overlap on key demographic factors, including American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index (CCI) score, sex, and body mass index (BMI), among others. Patients were subsequently matched by both demographic data and by the specific surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographically matched cohort, and the surgeon-matched cohort, with significance set at a p value < 0.05. RESULTS There was no significant difference in morbidity or any short-term outcome, including readmission, reoperation, ED evaluation, and mortality. Among the demographically matched cohort and surgeon-matched cohort, there was no significant difference in age, sex, history of prior surgery, ASA class, or CCI score. Overlapping surgery patients in both the demographically matched cohort and the matched cohort limited by surgeon had longer durations of surgery (p < 0.01), but no increased morbidity or mortality was noted. Patients selected for overlap had fewer prior surgeries and lower ASA class and CCI score (p < 0.01). Patients with overlap also had a longer duration of surgery (p < 0.01) but not duration of closure. CONCLUSIONS Exactly matched patients undergoing overlapping single-level lumbar fusion procedures had no increased short-term morbidity or mortality; however, duration of surgery was 20 minutes longer on average for overlapping operations. Further studies should assess long-term patient outcomes and the impact of overlap in this and other surgical procedures.
Collapse
Affiliation(s)
- Ali S Farooqi
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Donald K E Detchou
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Gregory Glauser
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| | - Krista Strouz
- 2McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia; and
- 3West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania
| | - Scott D McClintock
- 3West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, Pennsylvania
| | - Neil R Malhotra
- 1Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, and
| |
Collapse
|
6
|
Hunsaker JC, Khan M, Gamblin A, Karsy M, Couldwell WT. Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series. World Neurosurg 2021; 152:e476-e483. [PMID: 34098141 DOI: 10.1016/j.wneu.2021.05.126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. METHODS In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. RESULTS Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. CONCLUSIONS These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.
Collapse
Affiliation(s)
| | - Majid Khan
- Reno School of Medicine, University of Nevada, Reno, NV, USA
| | - Austin Gamblin
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | | |
Collapse
|
7
|
Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study. PLoS One 2021; 16:e0254958. [PMID: 34324519 PMCID: PMC8321144 DOI: 10.1371/journal.pone.0254958] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/06/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic forced a reconsideration of surgical patient management in the setting of scarce resources and risk of viral transmission. Herein we assess the impact of implementing a protocol of more rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication for patients undergoing brain tumor surgery. METHODS A case-control retrospective review was undertaken at a community hospital with a dedicated neurosurgery and otolaryngology team using minimally invasive surgical techniques, total intravenous anesthesia (TIVA) and early post-operative imaging protocols. All patients undergoing craniotomy or endoscopic endonasal removal of a brain, skull base or pituitary tumor were included during two non-overlapping periods: March 2019-January 2020 (pre-pandemic epoch) versus March 2020-January 2021 (pandemic epoch with streamlined care protocol implemented). Data collection included demographics, preoperative American Society of Anesthesiologists (ASA) status, tumor pathology, and tumor resection and remission rates. Primary outcomes were ICU utilization and hospital length of stay (LOS). Secondary outcomes were complications, readmissions and reoperations. FINDINGS Of 295 patients, 163 patients were treated pre-pandemic (58% women, mean age 53.2±16 years) and 132 were treated during the pandemic (52% women, mean age 52.3±17 years). From pre-pandemic to pandemic, ICU utilization decreased from 92(54%) to 43(29%) of operations (p<0.001) and hospital LOS≤1 day increased from 21(12.2%) to 60(41.4%), p<0.001, respectively. For craniotomy cohort, median LOS was 2 days for both epochs; median ICU LOS decreased from 1 to 0 days (p<0.001), ICU use decreased from 73(80%) to 29(33%),(p<0.001). For endonasal cohort, median LOS decreased from 2 to 1 days; median ICU LOS was 0 days for both epochs; (p<0.001). There were no differences pre-pandemic versus pandemic in ASA scores, resection/remission rates, readmissions or reoperations. CONCLUSION This experience suggests the COVID-19 pandemic provided an opportunity for implementing a brain tumor care protocol to facilitate safely decreasing ICU utilization and accelerating discharge home without an increase in complications, readmission or reoperations. More rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication, layered upon a foundation of minimally invasive surgery, TIVA anesthesia and early post-operative imaging are possible contributors to these favorable trends.
Collapse
|
8
|
Farooqi AS, Borja AJ, Detchou DKE, Glauser G, Strouz K, McClintock SD, Malhotra NR. Duration of overlap during lumbar fusion does not predict outcomes. Clin Neurol Neurosurg 2021; 205:106610. [PMID: 33845404 DOI: 10.1016/j.clineuro.2021.106610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The relationship between degree of surgical overlap and adverse postoperative outcomes remains poorly defined. This study aims to evaluate the impact of increasing duration of overlap on lumbar fusion outcomes. PATIENTS AND METHODS 1302 adult patients undergoing overlapping surgery during single-level, posterior-only lumbar fusion at a multi-hospital, university health system were retrospectively assessed. Amount of overlap was calculated as a percentage of total overlap time. Patients were separated into groups with the most (top 10% of patients) and least amounts of overlap (bottom 40% of patients). Using Coarsened Exact Matching, patients with the most and least amounts of overlap were matched on demographics alone, then on both demographics and attending surgeon. Univariate analysis was performed for the whole population and both matched cohorts to compare amount of overlap to risk of adverse postsurgical events. Significance for all analyses was p-value < 0.05. RESULTS Duration of overlap was not associated with outcomes in the whole population, demographic-matched, or surgeon-matched analyses. Before exact matching, patients with the most amount of overlap had a significantly higher CCI score (p = 0.031) and shorter length of surgery (p = 0.006). In the demographic matched cohort, patients with increased overlap had a significantly shorter length of surgery (p = 0.001) only. In the surgeon matched cohort, there were no differences in length of surgery or CCI score. CONCLUSIONS Duration of surgical overlap does not predict adverse outcomes following lumbar fusion. These results suggest that overlapping surgery is a safe practice within this common neurosurgical indication.
Collapse
Affiliation(s)
- Ali S Farooqi
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Donald K E Detchou
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Krista Strouz
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, PA, USA; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, USA
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, USA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
9
|
Farooqi AS, Detchou DK, Glauser G, Strouz K, McClintock SD, Malhotra NR. Patients undergoing overlapping posterior single-level lumbar fusion are not at greater risk for adverse 90-day outcomes. Clin Neurol Neurosurg 2021; 203:106584. [PMID: 33684676 DOI: 10.1016/j.clineuro.2021.106584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/16/2021] [Accepted: 02/27/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This study evaluated overlapping surgery on long-term outcomes following elective, single-level lumbar fusion on exact matched patients undergoing surgery with or without overlap. PATIENTS AND METHODS 3799 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a six-year period at a multi-hospital university health system were retrospectively followed. Reported outcomes included reoperation, emergency department (ED) visit, readmission, overall morbidity and mortality in the 90 days following surgery. Coarsened Exact Matching was used to match patients with and without overlap on key demographic factors. Patients were subsequently matched by both demographic data and by the attending surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographic matched cohort, and demographic and surgeon matched cohort, with significance set at a p-value < 0.05. RESULTS Patients with overlap had a longer duration of surgery and were less likely to have an ED visit within 90 days of surgery (p < 0.03) but had no other significant differences. Within the demographic matched cohort and demographic/surgeon matched cohort, there was no significant difference in age, gender, history of prior surgery, ASA score, or CCI score, but patients with overlap had a longer duration of surgery (p < 0.01). Patients did not have significant differences with respect to any morbidity or mortality outcome in either the demographic or surgeon matched cohort. CONCLUSIONS Patients undergoing overlapping, single-level lumbar fusion were not at greater risk of long-term morbidity or mortality, despite having a significantly longer duration of surgery.
Collapse
Affiliation(s)
- Ali S Farooqi
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Donald K Detchou
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Krista Strouz
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, PA, United States; West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, United States
| | - Scott D McClintock
- West Chester University, The West Chester Statistical Institute and Department of Mathematics, West Chester, PA, United States
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| |
Collapse
|
10
|
Zhang X, Wang J, Liu F, Zhao Y. Comparison of Patient Outcomes and Safety between Overlapping and Nonoverlapping Surgeries in Patients Undergoing Laparoscopic Common Bile Duct Exploration. J INVEST SURG 2021; 35:496-501. [PMID: 33541168 DOI: 10.1080/08941939.2020.1867674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Overlapping surgery or double-booking is a vital yet disputed issue in healthcare field. However, safety of the overlapping surgery during laparoscopic common bile duct exploration (LCBDE) remains unclear. This study aimed to assess the clinical outcomes and safety of overlapping surgery during laparoscopic cholecystectomy and LCBDE for gallbladder and common bile duct stones (CBDS). MATERIAL AND METHODS This study retrospectively reviewed 2736 laparoscopic cholecystectomy and LCBDE surgeries during 2013-2020. One thousand, two hundred eighty patients underwent LCBDE through cystic duct, including 867 receiving overlapping procedures, while 1456 underwent LCBDE through laparoscopic choledochotomy (LC), including 981 who underwent overlapping procedures. Data regarding patient sex, age, body mass index, the American Society of Anesthesiology grade, comorbidities, preoperative liver function test, previous upper abdominal surgery, presence of acute cholecystitis, cholangitis, pancreatitis, or jaundice, common bile duct (CBD) or CBDS diameter, CBDS number, LCBDE operation time, procedure duration, length of stay, stone clearance, CBD closure methods, conversion to open surgery, and complications were collected. RESULTS Differences in demographics and clinical variables between both groups were not significant, and the unadjusted outcomes were comparable, except for the total procedure duration (transcystic: p < .001; LC: p < .001). After adjusting for demographics and clinical variables, overlapping surgery showed an extended total surgical procedure duration (transcystic: standardized coefficient = 0.084, p = .004; LC: standardized coefficient = 0.072, p = .015). Other effects of overlapping surgery were also comparable. CONCLUSIONS Overlapping surgery in laparoscopic cholecystectomy and LCBDE was safe at our institution. However, the association of patient outcomes with overlapping laparoscopic cholecystectomy and LCBDE should be further investigated.
Collapse
Affiliation(s)
- Xue Zhang
- Department of Surgical Oncology, Lu 'an Hospital Affiliated to Anhui Medical University, Lu 'an, China
| | - Jinhui Wang
- Department of Cardiothoracic Surgery, Lu 'an Hospital Affiliated to Anhui Medical University, Lu 'an, China
| | - Fubao Liu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yong Zhao
- Department of Surgical Oncology, Lu 'an Hospital Affiliated to Anhui Medical University, Lu 'an, China
| |
Collapse
|
11
|
Thakur JD, Corlin A, Mallari RJ, Huang W, Eisenberg A, Sivakumar W, Krauss H, Griffiths C, Rettinger S, Cohan P, Barkhoudarian G, Araque KA, Kelly D. Pituitary adenomas in older adults (≥ 65 years): 90-day outcomes and readmissions: a 10-year endoscopic endonasal surgical experience. Pituitary 2021; 24:14-26. [PMID: 32936381 DOI: 10.1007/s11102-020-01081-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Longer lifespan and newer imaging protocols have led to more older adults being diagnosed with pituitary adenomas. Herein, we describe outcomes of patients ≥ 65 years undergoing endoscopic adenoma removal. To address selection criteria, we also assess a conservatively managed cohort. METHODS A retrospective analysis of 90-day outcomes of patients undergoing endoscopic pituitary adenomectomy from 2010 to 2019 by a neurosurgical/ENT team was performed. Tumor subtype, cavernous sinus invasion, extent of resection/early remission, endocrinology outcomes, complications, re-operations and readmissions were analyzed. A comparator cohort ≥ 65 years undergoing clinical surveillance without surgery was also analyzed. RESULTS Of 468 patients operated on for pituitary adenoma, 123 (26%) were ≥ 65 years (range 65-93 years); 106 (86.2%) had endocrine-inactive adenomas; 18 (14.6%) had prior surgery. Of 106 patients with endocrine-inactive adenomas, GTR was achieved in 70/106 (66%). Of 17 patients with endocrine-active adenomas, early biochemical remission was: Cushing's 6/8; acromegaly 1/4; prolactinomas 1/5. Gland function recovery occurred in 28/58 (48.3%) patients with various degrees of preoperative hypopituitarism. New anterior hypopituitarism occurred in 3/110 (2.4%) patients; permanent DI in none. Major complications in 123 patients were: CSF leak 2 (1.6%), meningitis 1 (0.8%), vision decline 1 (0.8%). There were no vascular injuries, operative hematomas, anosmia, deaths, MIs, or thromboembolic events. Median length of stay was 2 days. Readmissions occurred in 14/123 (11.3%) patients, 57% for delayed hyponatremia. Intra-cohort analysis by age (65-69, 70-74, 75-79, ≥ 80 years) revealed no outcome differences. Cavernous sinus invasion (OR 7.7, CI 1.37-44.8; p = 0.02) and redo-surgery (OR 8.5, CI 1.7-42.8; p = 0.009) were negative predictors for GTR/NTR. Of 105 patients evaluated for presumed pituitary adenoma beginning in 2015, 72 (69%) underwent surgery, 8 (7%) had prolactinomas treated with cabergoline and 25 (24%) continue clinical surveillance without surgery, including two on new hormone replacement. CONCLUSION This study suggests that elderly patients carefully selected for endoscopic adenoma removal can have excellent short-term outcomes including high resection rates, low complication rates and short length of stay. Our experience supports a multidisciplinary approach and the concept of pituitary centers of excellence. Based on our observations, approximately 25% of elderly patients with pituitary adenomas referred for possible surgery can be monitored closely without surgery.
Collapse
Affiliation(s)
- Jai Deep Thakur
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
- Department of Neurosurgery, University of South Alabama, Mobile, AL, USA
| | - Alex Corlin
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Regin Jay Mallari
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Weichao Huang
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Amalia Eisenberg
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Walavan Sivakumar
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Howard Krauss
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Chester Griffiths
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Sarah Rettinger
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Pejman Cohan
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Katherine A Araque
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Daniel Kelly
- Pacific Neuroscience Institute, 2125 Arizona Ave., Santa Monica, CA, 90404, USA.
- John Wayne Cancer Institute, Providence Saint John's Health Center, Santa Monica, CA, USA.
| |
Collapse
|
12
|
Glauser G, Osiemo B, Goodrich S, McClintock SD, Weber KL, Levin LS, Malhotra NR. Assessment of Short-Term Patient Outcomes Following Overlapping Orthopaedic Surgery at a Large Academic Medical Center. J Bone Joint Surg Am 2020; 102:654-663. [PMID: 32058352 DOI: 10.2106/jbjs.19.00554] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Overlapping surgery is a long-standing practice that has not been well studied. The aim of this study was to assess whether overlapping surgery is associated with untoward outcomes for orthopaedic patients. METHODS Coarsened exact matching was used to assess the impact of overlap on outcomes among elective orthopaedic surgical interventions (n = 18,316) over 2 years (2014 and 2015) at 1 health-care system. Overlap was categorized as any overlap, and subcategories of exclusively beginning overlap and exclusively end overlap. Study subjects were matched on the Charlson comorbidity index score, duration of surgery, surgical costs, body mass index, length of stay, payer, and race, among others. Serious unanticipated events were studied. RESULTS A total of 3,395 patients had any overlap and were matched (a match rate of 90.8% of 3,738). For beginning and end overlap, matched groups were created, with a match rate of 95.2% of 1043 and 94.7% of 863, respectively. Among matched patients, any overlap did not predict an unanticipated return to surgery at 30 days (8.2% for any overlap and 8.3% for no overlap; p = 0.922) or 90 days (14.1% and 14.1%, respectively; p = 1.000). Patients who had surgery with any overlap demonstrated no difference compared with controls with respect to reoperation, readmission, or emergency room (ER) visits at 30 or 90 days (a reoperation rate of 3.1% and 3.2%, respectively [p = 0.884] at 30 days and 4.2% and 3.5% [p = 0.173] at 90 days; a readmission rate of 10.3% and 11.0% [p = 0.352] at 30 days and 5.5% and 5.2% [p = 0.570] at 90 days; and an ER visit rate of 5.2% and 4.6% [p = 0.276] at 30 days and 4.8% and 4.3% [p = 0.304] at 90 days). Patients with surgical overlap showed reduced mortality compared with controls during follow-up (1.8% and 2.6%, respectively; p = 0.029). Patients with beginning and/or end overlap had a similar lack of association with serious unanticipated events; however, patients with end overlap showed an increased unexpected rate of return to the operating room after reoperation at 90 days (13.3% versus 9.7%; p = 0.015). CONCLUSIONS Nonconcurrent overlapping surgery was not associated with adverse outcomes in a large, matched orthopaedic surgery population across 1 academic health system. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Gregory Glauser
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- McKenna EpiLog Program in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania.,The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Stephen Goodrich
- McKenna EpiLog Program in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania.,The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Kristy L Weber
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - L Scott Levin
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Departments of Neurosurgery (G.G. and N.R.M.) and Orthopedic Surgery (K.L.W. and L.S.L.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Glauser G, Goodrich S, McClintock SD, Szeto WY, Atluri P, Acker MA, Malhotra NR. Association of overlapping cardiac surgery with short-term patient outcomes. J Thorac Cardiovasc Surg 2020; 162:155-164.e2. [PMID: 32014329 DOI: 10.1016/j.jtcvs.2019.11.136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 11/14/2019] [Accepted: 11/29/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study seeks to assess the safety of overlap in cardiac surgery. METHODS Coarsened exact matching was used to assess the impact of overlap on outcomes among cardiac surgical interventions (n = 4463) over 2 years (2014-2016). Overlap was categorized as any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables, including Charlson comorbidity score, surgical costs, body mass index, length of postoperative hospitalization, and race, among others. Serious unanticipated events were studied, including readmission, unplanned return to the operating room, and mortality. RESULTS A total of 984 patients had any overlap and were matched to similar patients without overlap (n = 1501). For beginning/end overlap, separate matched groups were created (n = 462, n = 329 patients, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap did not predict increased readmission, reoperation, or emergency department visits at 30 or 90 days. Overlap did not predict higher rates of death over follow-up. Beginning/end overlap had results similar to any overlap. CONCLUSIONS Nonconcurrent, overlapping surgery is not associated with an increase in adverse outcomes in a large, matched cardiac surgery population.
Collapse
Affiliation(s)
- Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health at the University of Pennsylvania, Philadelphia, Pa; The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pa
| | - Scott D McClintock
- The West Chester Statistical Institute and Department of Mathematics, West Chester University, West Chester, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| |
Collapse
|
14
|
Wilde H, Twitchell S, Reese J, Guan J, Eli IM, Karsy M, Taussky P, Grandhi R, Schmidt RH, Couldwell WT. Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms. Acta Neurochir (Wien) 2020; 162:157-167. [PMID: 31811467 DOI: 10.1007/s00701-019-04153-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. METHODS The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. RESULTS One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. CONCLUSIONS These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.
Collapse
Affiliation(s)
- Herschel Wilde
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jared Reese
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ilyas M Eli
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - Richard H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.
| |
Collapse
|
15
|
Association of Overlapping, Nonconcurrent, Surgery With Patient Outcomes at a Large Academic Medical Center. Ann Surg 2019; 270:620-629. [DOI: 10.1097/sla.0000000000003494] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
16
|
Murphy WS, Harris S, Pahalyants V, Zaki MM, Lin B, Cheng T, Talmo C, Murphy SB. Alternating operating theatre utilization is not associated with differences in clinical or economic outcome measures in primary elective knee arthroplasty. Bone Joint J 2019; 101-B:1081-1086. [DOI: 10.1302/0301-620x.101b9.bjj-2018-1485.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon’s cases and the total time spent in the operating theatre per day. Materials and Methods A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared. Results A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days. Conclusion The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081–1086.
Collapse
Affiliation(s)
- William S. Murphy
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
| | - Samantha Harris
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
| | - Vartan Pahalyants
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
| | - Mark M. Zaki
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Business School, Boston, Massachusetts, USA
| | - Ben Lin
- Archway Health, Watertown, Massachusetts, USA
| | - Tony Cheng
- Archway Health, Watertown, Massachusetts, USA
| | - Carl Talmo
- New England Baptist Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
17
|
Agarwal P, Ramayya AG, Osiemo B, Goodrich S, Glauser G, McClintock SD, Chen HI, Schuster JM, Grady MS, Malhotra NR. Association of Overlapping Neurosurgery With Patient Outcomes at a Large Academic Medical Center. Neurosurgery 2019; 85:E1050-E1058. [DOI: 10.1093/neuros/nyz243] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/27/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Limited data exist on the safety of overlapping surgery, a practice that has recently received widespread attention.
OBJECTIVE
To examine the association of overlapping neurosurgery with patient outcomes.
METHODS
A total of 3038 routinely scheduled, elective neurosurgical procedures were retrospectively reviewed at a single, multihospital academic medical center. Procedures were categorized into any overlap or no overlap and further subcategorized into beginning overlap (first 50% of procedure only), end overlap (last 50% of procedure only), and middle overlap (overlap at the midpoint).
RESULTS
A total of 1030 (33.9%) procedures had any overlap, whereas 278 (9.2%) had beginning overlap, 190 (6.3%) had end overlap, and 476 (15.7%) had middle overlap. Compared with no overlap patients, patients with any overlap had lower American Society of Anesthesiologists scores (P = .0018), less prior surgery (P < .0001), and less prior neurosurgery (P < .0001), though they tended to be older (P < .0001) and more likely in-patients (P = .0038). Any-overlap patients had decreased overall mortality (2.8% vs 4.5%; P = .025), 30- to 90-d readmission rate (3.1% vs 5.5%; P = .0034), 30- to 90-d reoperation rate (1.0% vs 2.0%; P = .03), 30- to 90-d emergency room (ER) visit rate (2.1% vs 3.7%; P = .018), and future surgery on index admission (2.8% vs 7.3%; P < .0001). Multiple regression analysis validated noninferior outcomes for overlapping surgery, except for the association of increased future surgery on index admission with middle overlap (odds ratio 3.99; 95% confidence interval [1.91, 8.33]).
CONCLUSION
Overlapping neurosurgery is associated with noninferior patient outcomes that may be driven by surgeon selection of healthier patients, regardless of specific overlap timing.
Collapse
Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Osiemo
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania
- Statistics Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Stephen Goodrich
- McKenna EpiLog Fellowship in Population Health, University of Pennsylvania, Philadelphia, Pennsylvania
- Statistics Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Gregory Glauser
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott D McClintock
- Statistics Institute, Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - H Isaac Chen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Schuster
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
18
|
Theriault B, Pazniokas J, Mittal A, Schmidt M, Cole C, Gandhi C, Anderson P, Bowers C. What Does it Mean for a Surgeon to “Run Two Rooms”? A Comprehensive Literature Review of Overlapping and Concurrent Surgery Policies. Am Surg 2019. [DOI: 10.1177/000313481908500435] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to review and analyze all of the “concurrent surgery” (CS) and “overlapping surgery” (OS) literature with the goal of: standardizing terminology, defining discrepancies in the literature and proposing solutions for the current challenges of regulating surgery to achieve maximal safety and efficiency. The CS and OS literature has grown exponentially over the past two years. Before this, there were no significant publications addressing this topic. There is an extremely wide variance on how “running two rooms” is defined and whether it should be permitted. These differences affect our patients’ perception of this practice. The literature lacks any comprehensive review of the topic and terminology. We performed a PubMed search to identify studies that considered the issue of OS. The terms “overlapping surgery”, “concurrent surgery”, and “simultaneous surgery” (SS) were used in the query. We then analyzed the publications identified. The literature contained 18 published studies analyzing OS safety between November 2016 and June 2018. Eight were neurosurgical studies, three were orthopedic, and the remaining seven articles were in other surgical specialties. A total of 1,207,155 surgical cases (range 250–>500,000 patients) were analyzed among the 18 studies. There were 57,880 (5.04%) OS cases. The OS rates in the individual studies ranged from 1.2 to 68 per cent (Table 1). Neurosurgical studies had the highest average OS rate of 54 per cent (range 37–68%), whereas the average OS rate in orthopedic surgery was 43 per cent (range 2.7–68%). Approximately one-third of the studies were multicenter investigations (27.7%). The studies measured more than 20 distinct outcomes, but there were only five outcomes that were included in the majority of the studies: mortality rates, reoperation rates, procedure length of time, readmission rates, and hospital length of stay. The current body of literature repeatedly demonstrates that OS is a safe and effective option when undertaken by experienced surgeons who practice it frequently. For successful OS, the Mandatory Attending Portion for two surgeries must not overlap and Unnecessary Anesthesia Time must be prohibited. Hospitals and surgical specialty organizations must implement policies to assure the safe practice of OS.
Collapse
Affiliation(s)
| | - Julia Pazniokas
- New York Medical College, Valhalla, New York; Departments of
| | - Abhiniti Mittal
- New York Medical College, Valhalla, New York; Departments of
| | - Meic Schmidt
- Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Chad Cole
- Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Chirag Gandhi
- Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Patrice Anderson
- Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Christian Bowers
- Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| |
Collapse
|
19
|
Azab MA, O'Hagan M, Abou-Al-Shaar H, Karsy M, Guan J, Couldwell WT. Safety and Outcome of Transsphenoidal Pituitary Adenoma Resection in Elderly Patients. World Neurosurg 2019; 122:e1252-e1258. [DOI: 10.1016/j.wneu.2018.11.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/30/2022]
|