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Vessell M, Willett A, Ugiliweneza B, Sharma M, Mutchnick I, Boakye M, Chern J, Weiner H, Neimat J. National 22-year epilepsy surgery landscape shows increasing open and minimally invasive pediatric epilepsy surgery. Epilepsia 2024. [PMID: 38943543 DOI: 10.1111/epi.18030] [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: 01/16/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES A surgical "treatment gap" in pediatric epilepsy persists despite the demonstrated safety and effectiveness of surgery. For this reason, the national surgical landscape should be investigated such that an updated assessment may more appropriately guide health care efforts. METHODS In our retrospective cross-sectional observational study, the National Inpatient Sample (NIS) database was queried for individuals 0 to <18 years of age who had an International Classification of Diseases (ICD) code for drug-resistant epilepsy (DRE). This cohort was then split into a medical group and a surgical group. The former was defined by ICD codes for -DRE without an accompanying surgical code, and the latter was defined by DRE and one of the following epilepsy surgeries: any open surgery; laser interstitial thermal therapy (LITT); vagus nerve stimulation; or responsive neurostimulation (RNS) from 1998 to 2020. Demographic variables of age, gender, race, insurance type, hospital charge, and hospital characteristics were analyzed between surgical options. Continuous variables were analyzed with weight-adjusted quantile regression analysis, and categorical variables were analyzed by weight-adjusted counts with percentages and compared with weight-adjusted chi-square test results. RESULTS These data indicate an increase in epilepsy surgeries over a 22-year period, primarily due to a statistically significant increase in open surgery and a non-significant increase in minimally invasive techniques, such as LITT and RNS. There are significant differences in age, race, gender, insurance type, median household income, Elixhauser index, hospital setting, and size between the medical and surgical groups, as well as the procedure performed. SIGNIFICANCE An increase in open surgery and minimally invasive surgeries (LITT and RNS) account for the overall rise in pediatric epilepsy surgery over the last 22 years. A positive inflection point in open surgery is seen in 2005. Socioeconomic disparities exist between medical and surgical groups. Patient and hospital sociodemographics show significant differences between the procedure performed. Further efforts are required to close the surgical "treatment gap."
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Affiliation(s)
- Meena Vessell
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Austin, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew Willett
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Mayur Sharma
- Department of Neurological Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ian Mutchnick
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Pediatric Neurosurgery, Norton Neuroscience Institute, Louisville, Kentucky, USA
| | - Maxwell Boakye
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Chern
- Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Howard Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Austin, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Neimat
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Lau HL, Patel SD, Garg N. Causes and Predictors of 30-Day Readmission in Elderly Patients With Delirium. Neurol Clin Pract 2021; 11:e251-e260. [PMID: 34484899 DOI: 10.1212/cpj.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/18/2020] [Indexed: 11/15/2022]
Abstract
Objective To study 30-day readmission (30-DR) rate and predictors for readmission among elderly patients with delirium. Methods This was a retrospective observational cohort study of patients aged ≥65 years with discharge diagnosis of delirium identified from the Nationwide Readmission Database using common International Classification of Diseases, Ninth Revision, and Clinical Modification codes linked to delirium diagnosis. Multivariate logistic regression analyses were performed adjusting for stratified cluster design to identify patient/system-specific factors associated with 30-DR. Results Overall, the 30-DR rate was 17% (7,140 of 42,655 weighted index admissions). The common causes of readmission were systemic diseases (43%), infections (27%), and neurologic diseases (18%). Compared with initial hospitalization, readmission costs were higher ($11,442 vs $10,350, p < 0.0001) with a longer length of stay (6.6 vs 6.1 days, p < 0.0001). Independent predictors of readmission included discharge against medical advice (odds ratio [OR] 1.8, p < 0.0034), length of stay (OR 1.3, p < 0.0001), and chronic systemic diseases (anemia, OR 2.4, p < 0.0001, chronic renal failure OR 1.4, p < 0.0001, congestive heart failure OR 1.3, p < 0.0001, lung disease OR 1.2, p < 0.0004, and liver disease OR 1.2, p < 0.03). Private insurance was associated with a lower risk of readmission (OR 0.78, p < 0.02). Conclusions The main predictors of readmission were chronic systemic diseases and discharge against medical advice. These data may help design directed clinical care pathways to optimize medical management and postdischarge care to reduce readmission rates.
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Affiliation(s)
- H Lee Lau
- Department of Neurology (HLL, NG), Miller School of Medicine University of Miami, FL; and Department of Neurology (SDP), University of Connecticut, Hartford
| | - Smit D Patel
- Department of Neurology (HLL, NG), Miller School of Medicine University of Miami, FL; and Department of Neurology (SDP), University of Connecticut, Hartford
| | - Neeta Garg
- Department of Neurology (HLL, NG), Miller School of Medicine University of Miami, FL; and Department of Neurology (SDP), University of Connecticut, Hartford
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Rumalla K, Srinivasan VM, Gaddis M, Kvint S, Patel AJ, Kan P, Lawton MT, Burkhardt JK. Cavernous Malformation Surgery in the United States: Validation of a Novel International Classification of Disease, 10th Edition, Clinical Modification Code Search Algorithm and Volume-Driven Surgical Outcomes. World Neurosurg 2021; 150:e66-e73. [PMID: 33640531 DOI: 10.1016/j.wneu.2021.02.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The surgical decision-making process for cavernous malformation (CM) must weigh the risks of surgery against the burden of patient symptoms/hemorrhage and anticipated natural history. Here, we sought to internally validate an International Classification of Disease (ICD)-10 search algorithm for CM surgery to use to analyze a nationwide administrative database. METHODS Institutional records were accessed to test the validity of a novel ICD-10 search algorithm for CM surgery. The algorithm identified patients with positive predictive value (92%), specificity (100%), and sensitivity of 55%. The algorithm was applied to extract our target population from the Nationwide Readmissions Database. Univariate and multivariable analyses were used to identify factors influencing patient outcomes. RESULTS We identified 1235 operations for supratentorial (87%) or infratentorial (13%) CM surgery from the Nationwide Readmissions Database (2016-2017). The overall rate of adverse disposition and 30-day readmission were 19.7% and 7.5%, respectively. The rate of adverse disposition was significantly higher for infratentorial (vs. supratentorial cases) (34.3% vs. 17.6%, P = 0.001) and brainstem (vs. cerebellar) cases (55% vs. 28%, P = 0.03). Hospital case-volume percentile was associated with decreasing rates of adverse disposition (1-74th: 22%, 75th: 16%, 90th: 13%, 95th: 7%). Treatment at HVCs was also associated with shorter average length of stay (4.6 vs. 7.3 days, P < 0.001) without significant changes to average cost of hospitalization (P = 0.60). CONCLUSIONS Our ICD-10 coding algorithm reliably identifies CM surgery with minimal false positives. Outcomes were influenced by patient age, clinical presentation, location of CM, and experience of institution. Centralization of care may improve outcomes and warrants further investigation.
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Affiliation(s)
- Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Monica Gaddis
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA; Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA; Jan and Dan Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
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Rumalla K, Srinivasan VM, Gaddis M, Kan P, Lawton MT, Burkhardt JK. Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes. J Neurosurg 2020; 135:431-439. [PMID: 33157529 DOI: 10.3171/2020.6.jns202117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms. METHODS The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes. RESULTS In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction). CONCLUSIONS Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.
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Affiliation(s)
- Kavelin Rumalla
- 1School of Medicine, University of Missouri-Kansas City, Missouri
| | | | - Monica Gaddis
- 1School of Medicine, University of Missouri-Kansas City, Missouri
| | - Peter Kan
- 3Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas
| | - Michael T Lawton
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Jan-Karl Burkhardt
- 5Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Landazuri P, Shih J, Leuthardt E, Ben-Haim S, Neimat J, Tovar-Spinoza Z, Chiang V, Spencer D, Sun D, Fecci P, Baumgartner J. A prospective multicenter study of laser ablation for drug resistant epilepsy – One year outcomes. Epilepsy Res 2020; 167:106473. [DOI: 10.1016/j.eplepsyres.2020.106473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/21/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
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Sharma M, Ball T, Alhourani A, Ugiliweneza B, Wang D, Boakye M, Neimat JS. Inverse national trends of laser interstitial thermal therapy and open surgical procedures for refractory epilepsy: a Nationwide Inpatient Sample–based propensity score matching analysis. Neurosurg Focus 2020; 48:E11. [DOI: 10.3171/2020.1.focus19935] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVESurgery for medically refractory epilepsy (RE) is an underutilized treatment modality, despite its efficacy. Laser interstitial thermal therapy (LITT), which is minimally invasive, is increasingly being utilized for a variety of brain lesions and offers comparable seizure outcomes. The aim of this study was to report the national trends of open surgical procedures for RE with the advent of LITT.METHODSData were extracted using the ICD-9/10 codes from the Nationwide Inpatient Sample (NIS, 2012–2016) in this retrospective study. Patients with a primary diagnosis of RE who underwent either open surgeries (lobectomy, partial lobectomy, and amygdalohippocampectomy) or LITT were included. Patient demographics, complications, hospital length of stay (LOS), discharge disposition, and index hospitalization costs were analyzed. Propensity score matching (PSM) was used to analyze outcomes.RESULTSA cohort of 128,525 in-hospital patients with RE was included and 5.5% (n = 7045) of these patients underwent either open surgical procedures (94.3%) or LITT (5.7%). LITT is increasingly being performed at a rate of 1.09 per 1000 epilepsy admissions/year, while open surgical procedures are decreasing at a rate of 10.4/1000 cases/year. The majority of procedures were elective (92%) and were performed at large-bed-size hospitals (86%). All LITT procedures were performed at teaching facilities and the majority were performed in the South (37%) and West (30%) regions. The median LOS was 1 day for the LITT cohort and 4 days for the open cohort. Index hospitalization charges were significantly lower following LITT compared to open procedures ($108,332 for LITT vs $124,012 for open surgery, p < 0.0001). LITT was associated with shorter median LOS, high likelihood of discharge home, and lower median index hospitalization charges compared to open procedures for RE on PSM analysis.CONCLUSIONSLITT is increasingly being performed in favor of open surgical procedures. LITT is associated with a shorter LOS, a higher likelihood of being discharged home, and lower index hospitalization charges compared to open procedures. LITT is a safe treatment modality in carefully selected patients with RE and offers an opportunity to increase the utilization of surgical treatment in patients who may be opposed to open surgery or have contraindications that preclude open surgery.
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Kwon CS, Agarwal P, Subramaniam V, Dhamoon M, Mazumdar M, Yeshokumar A, Panov F, Ghatan S, Jetté N. Readmission after neurosurgical intervention in epilepsy: A nationwide cohort analysis. Epilepsia 2019; 61:61-69. [PMID: 31792965 DOI: 10.1111/epi.16401] [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: 08/29/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hospital readmissions result in increased health care costs and are associated with worse outcomes after neurosurgical intervention. Understanding factors associated with readmissions will inform future studies aimed at improving quality of care in those with epilepsy. METHODS Patients of all ages with epilepsy who underwent a neurosurgical intervention were identified in the 2014 Nationwide Readmissions Database, a nationally representative dataset containing data from roughly 17 million US hospital discharges. Diagnosis of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based case definitions. Neurosurgical interventions for epilepsy: resective/disconnective surgery, responsive neurostimulation/deep brain stimulation, vagus nerve stimulation, radiosurgery, and intracranial electroencephalography were identified using ICD-9-CM procedure codes. Primary outcome was all-cause 30-day readmission following discharge from the index hospitalization. RESULTS There were a total of 2284 index surgical admissions. Overall, 10.83% (n = 251) of patients following an index epilepsy surgery admission were readmitted within 30 days. Factors independently associated with 30-day readmission for all epilepsy surgery admissions were: Medicare insurance (P < .01), discharge disposition that was not home (P < .01), higher Elixhauser comorbidity indexes (P < .01), longer length of stay (P < .01), and adverse events of surgical and medical care during index stay (P = .04). In the multivariate model, Medicare insurance (hazard ratio [HR] 1.81 [1.29-2.53], P < .01) and length of stay (HR 1.02 [1.01-1.04], P < .01) remained significant independent predictors for 30-day readmission. The most common primary reason for readmissions was epilepsy/convulsions accounting for 22.85%. SIGNIFICANCE Our results suggest that careful management of postoperative seizures and discharge planning after epilepsy surgery may be important to optimize outcomes and reduce the risk of readmission, particularly for patients on Medicare.
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Affiliation(s)
- Churl-Su Kwon
- Department of Neurology, Icahn school of Medicine at Mount Sinai, New York, NY, USA.,Division of Health Outcomes & Knowledge Translation Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parul Agarwal
- Institute for Healthcare Delivery Service, Department of Population Health Science and Policy, Medicine, and Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varsha Subramaniam
- Department of Neurology, Icahn school of Medicine at Mount Sinai, New York, NY, USA
| | - Mandip Dhamoon
- Department of Neurology, Icahn school of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Service, Department of Population Health Science and Policy, Medicine, and Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anusha Yeshokumar
- Department of Neurology, Icahn school of Medicine at Mount Sinai, New York, NY, USA
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathalie Jetté
- Department of Neurology, Icahn school of Medicine at Mount Sinai, New York, NY, USA.,Division of Health Outcomes & Knowledge Translation Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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