Variations in the intensive use of head CT for elderly patients with hemorrhagic stroke

Neuroradiology of acute pathologies in adults with hematologic malignancies: a pictorial review

Hematopoietic and lymphoid tumors are a heterogeneous group of diseases including lymphomas, multiple myeloma (MM), and leukemias. These diseases are associated with systemic involvement and various clinical presentations including acute neurological deficits. Adult patients with hematologic malignancies (HM) are at risk for developing a wide array of acute conditions involving the nervous system. HM in adults may present as tumoral masses responsible for mass effect, possibly resulting in acute neurological signs and symptoms caused by tumor growth with compression of central nervous system (CNS) structures. Moreover, as result of the hematologic disease itself or due to systemic treatments, hematologic patients are at risk for vascular pathologies, such as ischemic, thrombotic, and hemorrhagic disorders due to the abnormal coagulation status. The onset of these disorders is often with acute neurologic signs or symptoms. Lastly, it is well known that patients with HM can have impaired function of the immune system. Thus, CNS involvement due to immune-related diseases such as mycotic, parasitic, bacterial, and viral infections linked to immunodeficiency, together with immune reconstitution inflammatory syndrome, are frequently seen in hematologic patients. Knowledge of the etiology and expected CNS imaging findings in patients with HM is of great importance to reach a fast and correct diagnosis and guide treatment choices. In this manuscript, we review the computed tomography (CT) and magnetic resonance findings of these conditions which can be related to the disease itself and/or to their treatments.

Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State

OBJECTIVE

Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.

METHODS

A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.

RESULTS

Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Carotid Endarterectomy in the Southern California Vascular Outcomes Improvement Collaborative

BACKGROUND

The objective of this study was to examine the variation in practice patterns and associated outcomes for carotid endarterectomy (CEA) within the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe), a regional quality group of the Vascular Quality Initiative.

METHODS

All cases entered in the CEA registry by the So Cal VOICe were included in the study.

RESULTS

From September 2010 through September 2015, 1,110 CEA cases were entered by 9 centers in the So Cal VOICe. Six hundred seventy-seven patients (61%) were male with mean age of 73 years. Nine hundred eighty-eight (89%) were hypertensive, 655 (59%) were prior or current smokers, 389 (35%) were diabetics, and 233 (21%) had coronary artery disease. Eight hundred twenty-one (74%) patients were asymptomatic (no history of ipsilateral neurologic event). The percentage of asymptomatic patients varied across the 9 centers from 57% to 91%. Preoperatively, 344 (31%) underwent cardiac stress test, center variation 13-75%, 500 (45%) underwent only duplex, center variation 11-72%. Intraoperatively, 600 (54%) underwent routine shunting, whereas 67 (6%) were shunted for an indication, and 444 (40%) were not shunted. Wound drainage was used in 422 (38%) cases, center variation 2-98%. Completion imaging by duplex and/or angiogram was performed in 766 (69%) cases, center variation 0-100%. Postoperatively, 11 (1%) patients had a new ipsilateral postoperative neurologic event, center variation 0-1.3%, 6 (0.5%) had a postoperative myocardial infarction, center variation 0-1.3%, and 8 (0.7%) required return to operating room for bleeding, center variation 0-1.3%.

CONCLUSIONS

Despite wide variation in practice patterns surrounding CEA in the So Cal VOICe, postoperative complications were uniformly low. Further work will focus on identifying practices that can be modified to improve cost-effectiveness while maintaining excellent outcomes.

Does the ranking of surgeons in a publicly available online platform correlate with objective outcomes?

OBJECTIVE The accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion. METHODS The authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons. RESULTS During the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72-1.31), length of stay (adjusted difference -0.1, 95% CI -0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49-1.55), and hospitalization charges (adjusted difference $18,735, 95% CI -$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score-adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients. CONCLUSIONS After merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.

Does the ranking of surgeons in a publicly available online platform correlate with objective outcomes?

OBJECTIVE The accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion. METHODS The authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons. RESULTS During the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72-1.31), length of stay (adjusted difference -0.1, 95% CI -0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49-1.55), and hospitalization charges (adjusted difference $18,735, 95% CI -$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score-adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients. CONCLUSIONS After merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.

Outpatient continuity of care and 30-day readmission after spine surgery

BACKGROUND CONTEXT

The value of continuity of care in preventing 30-day readmissions after surgical procedures remains an issue of debate.

PURPOSE

This study aimed to investigate the association of being evaluated in the emergency room (ER) of the hospital where the original procedure was performed with 30-day readmissions for spine surgery patients.

STUDY DESIGN/SETTING

This is a cohort study.

PATIENT SAMPLE

A total of 16,483 spine surgery patients were evaluated in the emergency department within 30-days postoperatively.

OUTCOME MEASURES

A 30-day post-discharge readmission was the outcome measure.

METHODS

We performed a cohort study involving patients who were evaluated in the ER within 30-days after discharge following spine surgery from 2009 to 2013, and were registered in the Statewide Planning and Research Cooperative System database. A propensity score adjusted model was used to control for confounding.

RESULTS

From our patients, 11,638 (70.6%) were seen in a hospital different from the one where the original procedure was performed (12.0% readmitted), and 4,845 (29.4%) were evaluated at the original hospital (10.9% readmitted). In a multivariable analysis, we demonstrated that being evaluated in the original hospital was associated with decreased rate of 30-day readmission (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.77-0.97). We found similar associations in a propensity score adjusted model (OR, 0.87; 95% CI, 0.78-0.97). This corresponded to seven patients who needed to be evaluated in the hospital where the original procedure was performed to prevent one readmission.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ER after spine surgery, we identified an association of assessment in the hospital where the original procedure was performed with lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Early Physician Follow-Up and Out-of-Hospital Outcomes After Cerebral Aneurysm Treatment in Elderly Patients

BACKGROUND

The impact of early physician follow-up on out-of-hospital outcomes after cerebral aneurysm treatment has not been studied previously. We investigated the association of early physician follow-up (within 30 days of discharge) with mortality and readmissions for elderly patients undergoing treatment for cerebral aneurysms.

METHODS

We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent treatment for cerebral aneurysms from 2007 to 2012. To control for confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the Hospital Referral Region level.

RESULTS

Of 8703 patients presenting with unruptured aneurysms, 5673 (65.2%) had early physician follow-up, and 3030 (34.8%) did not. Of 3211 patients with subarachnoid hemorrhage, 1504 (46.8%) had early physician follow-up, and 1707 (53.2%) did not. Propensity score-adjusted analysis demonstrated that patients with unruptured aneurysms who visited a physician within 30 days of discharge had lower 3-month mortality (odds ratio [OR] 0.52; 95% confidence interval [95% CI] 0.36-0.74) but a greater rate of 90-day readmissions (OR 1.14; 95% CI 1.03-1.28). Similarly, early follow-up was associated with lower 3-month mortality (OR, 0.33; 95% CI, 0.24-0.46), and a greater rate of 90-day readmissions (OR 1.79; 95% CI 1.02-3.14) for patients presenting with subarachnoid hemorrhage.

CONCLUSIONS

In a cohort of Medicare patients undergoing treatment for cerebral aneurysms, we identified an association of early physician follow-up with decreased short-term post-discharge mortality, but increased 90-day readmissions. More studies on the impact of strengthening the post-discharge network on the outcomes of this population are warranted.

Negative spot sign in primary intracerebral hemorrhage: potential impact in reducing imaging

Intracerebral hemorrhage (ICH) is one of the most devastating and costly diagnoses in the USA. ICH is a common diagnosis, accounting for 10-15 % of all strokes and affecting 20 out of 100,000 people. The CT angiography (CTA) spot sign, or contrast extravasation into the hematoma, is a reliable predictor of hematoma expansion, clinical deterioration, and increased mortality. Multiple studies have demonstrated a high negative predictive value (NPV) for ICH expansion in patients without spot sign. Our aim is to determine the absolute NPV of the spot sign and clinical characteristics of patients who had ICH expansion despite the absence of a spot sign. This information may be helpful in the development of a cost effective imaging protocol of patients with ICH. During a 3-year period, 204 patients with a CTA with primary intracerebral hemorrhage were evaluated for subsequent hematoma expansion during their hospitalization. Patients with intraventricular hemorrhage were excluded. Clinical characteristics and antithrombotic treatment on admission were noted. The number of follow-up NCCT was recorded. Of the resulting 123 patients, 108 had a negative spot sign and 7 of those patients subsequently had significant hematoma expansion, 6 of which were on antithrombotic therapy. The NPV of the CTA spot sign was calculated at 0.93. In patients without antithrombotic therapy, the NPV was 0.98. In summary, the negative predictive value of the CTA spot sign for expansion of ICH, in the absence of antithrombotic therapy and intraventricular hemorrhage (IVH) on admission, is very high. These results have the potential to redirect follow-up imaging protocols and reduce cost.

Continuity of care and 30-day readmission for patients evaluated in the emergency room after cerebral aneurysm treatment

Background

The association between continuity of care and the rate of 30-day readmissions after surgical procedures continues to be debated.

Objective

To investigate the association of 30-day readmissions with evaluation in the hospital where the original procedure was performed for patients presenting to the emergency department (ED) after cerebral aneurysm treatment.

Methods

We performed a cohort study of patients with cerebral aneurysms, who were evaluated in the ED within 30 days after discharge following surgical clipping or endovascular coiling between 2009 and 2013, and were registered in the Statewide Planning and Research Cooperative System database. A propensity score adjusted model was used to control for confounding, whereas mixed effects accounted for clustering at the hospital level.

Results

Of the 452 patients presenting to the ED, 218 (48.2%) were evaluated in a different hospital from that in which the original procedure was performed (7.7% readmitted), and 234 (51.8%) were evaluated at the original hospital (18.4% readmitted). In a multivariable analysis, we showed that evaluation in the ED of the original hospital was associated with decreased rate of 30-day readmission (OR=0.41; 95% CI 0.22 to 0.78). We found similar associations in a mixed-effects logistic regression model (OR=0.46; 95% CI 0.35 to 0.84) and a propensity score adjusted model (OR=0.41; 95% CI 0.22 to 0.77). This corresponds to10 patients needing to be evaluated in the hospital at which the original procedure was performed to prevent one readmission.

Conclusions

Using a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ED after cerebral aneurysm treatment, we identified an association between assessment in the hospital at which the original procedure was performed and a lower rate of 30-day readmissions. This underlines the potential importance of continuity of care for surgical patients to prevent readmission.