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Gebeyehu TF, Harrop CM, Barbieri L, Thalheimer S, Harrop J. Do Postsurgical Follow-Up Calls Reduce Unplanned 30-Day Readmissions in Neurosurgery Patients? A Quality Improvement Project in a University Hospital. World Neurosurg 2024:S1878-8750(24)00834-9. [PMID: 38763460 DOI: 10.1016/j.wneu.2024.05.078] [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: 04/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Unplanned 30-day readmissions after surgery are a source of patient dissatisfaction, monitored by the Centers for Medicare and Medicaid Services, have financial penalties for hospitals, and are publicly reported. Neurosurgical operations have a higher 30-day unplanned readmission rate after the index discharge than other specialties. After a simple initiative for a 48-72-hour postdischarge telephone call, there was an observed significant decrease in readmission rates from 17% to 8% in 7 months at Thomas Jefferson University. To better understand the role of postoperative telephone calls in this reduction, a retrospective evaluation over a longer period was performed. METHODS A quality improvement initiative was assessed using patient records between August 2018 and May 2023. The primary observed subject is the 30-day unplanned readmission rate and secondarily a change in Physician Communication Score. Thirty-day unplanned readmission rate and Physician Communication Scores before and after the telephone call initiative were compared, checking for difference, variance, and correlation. RESULTS 874 readmissions (average, 28/month; 95% confidence interval [CI], 25.3-29.3), 12.9% (95% CI, 11.9-13.9) were reported before the telephone call; of 673 readmissions (average, 26/month; 95% CI, 23-28.8), 12.9% (95% CI, 11.6-14.1) were reported after the telephone call. No significant difference, variance of scores or rates, or correlation of rate with communication score were noted before and after the initiative. CONCLUSIONS Telephone calls and peridischarge efficient communication are needed after neurologic surgery. This approach decreased unplanned readmissions in certain instances without having a significant impact on neurosurgical patients.
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Affiliation(s)
- Teleale F Gebeyehu
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
| | - Catriona M Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Lauren Barbieri
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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El Naamani K, Hunt A, Jain P, Lawall CL, Yudkoff CJ, El Fadel O, Ghanem M, Mastorakos P, Momin AA, Alhussein A, Alhussein R, Atallah E, Abbas R, Zakar R, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study. Neurosurgery 2023; 93:1415-1424. [PMID: 37681971 DOI: 10.1227/neu.0000000000002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms. METHODS This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission. RESULTS The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission. CONCLUSION In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Charles L Lawall
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- Gilbert and Rose-Marie Chaghoury School of Medicine, Lebanese American University, Byblos , Lebanon
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rida Zakar
- School of Medicine, Saint Joseph University, Beirut , Lebanon
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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Rumalla K, Catapano JS, Mahadevan V, Sorkhi SR, Koester SW, Winkler EA, Graffeo CS, Srinivasan VM, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Socioeconomic Drivers of Outcomes After Aneurysmal Subarachnoid Hemorrhage Treatment at a Large Comprehensive Stroke Center. World Neurosurg 2023; 173:e109-e120. [PMID: 36775240 DOI: 10.1016/j.wneu.2023.02.018] [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: 11/04/2022] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Sparse data exist on socioeconomic disparities among patients treated for aneurysmal subarachnoid hemorrhage (aSAH). The authors analyzed factors possibly influencing patient outcomes, including having a primary care physician (PCP) at admission, family/caregiver support, a foreign language barrier, primary payer status, and race. METHODS Socioeconomic data were abstracted for patients treated endovascularly or microsurgically for aSAH at a single center (January 1, 2014-July 31, 2019). Binary logistic regression analyses were used to identify independent predictors of an unfavorable outcome (modified Rankin Scale [mRS] score >2) and for predictive modeling. RESULTS Among 422 patients, the median (interquartile range) follow-up was 2 (1-23) months. Lack of caregiver support was the only socioeconomic factor associated with an unfavorable outcome at discharge. Independent predictors of mRS score >2 at last follow-up included baseline markers of disease severity (P ≤ 0.03), nonwhite race (OR, 1.69; P = 0.047), lack of caregiver support (OR, 5.55; P = 0.007), and lack of a PCP (OR, 1.96; P = 0.007). Adjusting for follow-up mediated the effects of race and PCP, although caregiver support remained significant and PCP was associated with a lower mortality risk independent of follow-up (OR, 0.51; P = 0.047). Predischarge socioeconomic factors, alongside disease severity, predicted a follow-up mRS score >2 with excellent discrimination (area under the receiver operating curve, 0.81; 95% CI, 0.77-0.86). CONCLUSIONS At a large, urban, comprehensive stroke center, patients with PCPs, caregiver support, and white race had significantly better long-term outcomes after aSAH. These results reflect disparities in access to healthcare after aSAH for vulnerable populations with extensive lifetime needs.
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Affiliation(s)
- Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Varun Mahadevan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Samuel R Sorkhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Spille DC, Lohmann S, Schwake M, Spille J, Alsofy SZ, Stummer W, Brokinkel B, Schipmann S. Can Currently Suggested Quality Indicators Be Transferred to Meningioma Surgery?-A Single-Center Pilot Study. J Neurol Surg A Cent Eur Neurosurg 2022. [PMID: 35901814 DOI: 10.1055/a-1911-8678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Risk stratification based on standardized quality measures has become crucial in neurosurgery. Contemporary quality indicators have often been developed for a wide range of neurosurgical procedures collectively. The accuracy of tumor-inherent characteristics of patients diagnosed with meningioma remains questionable. The objective of this study was the analysis of currently applied quality indicators in meningioma surgery and the identification of potential new measures. METHODS Data of 133 patients who were operated on due to intracranial meningiomas were subjected to a retrospective analysis. The primary outcomes of interest were classical quality indicators such as the 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and the 30-day surgical site infection rate. Uni- and multivariate analyses were performed. The occurrence of a new postoperative neurologic deficit was analyzed as a potential new quality indicator. RESULTS The overall unplanned readmission rate was 3.8%; 13 patients were reoperated within 30 days (9.8%). The 30-day nosocomial infection and surgical site infection rates were 6.8 and 1.5%, respectively. A postoperative new neurologic deficit or neurologic deterioration as a currently assessed quality feature was observed in 12 patients (9.2%). The edema volume on preoperative scans proved to have a significant impact on the occurrence of a new postoperative neurologic deficit (p = 0.023). CONCLUSIONS Classical quality indicators in neurosurgery have proved to correlate with considerable deterioration of the patient's health in meningioma surgery and thus should be taken into consideration for application in meningioma patients. The occurrence of a new postoperative neurologic deficit is common and procedure specific. Thus, this should be elucidated for application as a complementary quality indicator in meningioma surgery.
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Affiliation(s)
- Dorothee C Spille
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Johannes Spille
- Department of Oral and Maxillofacial Surgery, Christian Albrechts University, UKSH, Kiel, Germany
| | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
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Posri N, Srisatidnarakul B, Hickman RL. Development of a Readiness for Hospital Discharge assessment tool in Thai patients with stroke. BELITUNG NURSING JOURNAL 2022; 8:75-83. [PMID: 37521078 PMCID: PMC10386804 DOI: 10.33546/bnj.1968] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/12/2021] [Accepted: 01/08/2022] [Indexed: 08/01/2023] Open
Abstract
Background The transition from hospital to home among patients with stroke is quite challenging. If the patients are not ready for hospital discharge, their condition may worsen, which also causes a high rate of readmission. Although instruments to measure readiness for hospital discharge exist, none of them fit with the Thailand context. Objective This study aimed to develop a Readiness for Hospital Discharge assessment tool in Thai patients with stroke. Methods The study was conducted from February to September 2020, which consisted of several steps: 1) conducting an extensive literature review, 2) content validity with five experts, 3) pilot testing with 30 samples, and 4) field testing with 348 participants. Content validity index (CVI) was used to measure the content validity, Cronbach's alpha and inter-item correlation to evaluate reliability, and multiple logistic regression analysis to measure the construct validity. Results The findings showed good validity and reliability, with I-CVI of 0.85, Cronbach's alpha of 0.94, and corrected item-total correlation ranging from 0.43 to 0.86. The construct validity was demonstrated through the results of regression analysis showing that the nine variables include level of consciousness (OR = 0.544; CI 95% = 0.311 - 0.951), verbal response (OR = 0.445; 95% CI 0.272- 0.729), motor power right leg (OR = 0.165; 95% CI 0.56- 0.485), visual field (OR = 0.188; 95% CI 0.60-0.587), dysphagia (OR = 0.618; 95% CI 0.410-0.932), mobility (OR = 0.376; 95% CI 0.190 - 0.741), self-feeding (OR = 0.098; 95% CI 0.036 -0.265), bathing (OR = 0.099; 95% CI 0.026-0.378), and bladder control (OR = 0.589; 95% CI 0.355-0.977) that significantly influenced the hospital readmission within 30 days in patients with stroke. Conclusion The Readiness for Hospital Discharge assessment tool is valid and reliable. Healthcare providers, especially nurses, can use this tool to assess discharge conditions for patients with stroke with greater accuracy in predicting hospital readmission.
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Affiliation(s)
| | | | - Ronald L. Hickman
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
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6
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Schipmann S, Lohmann S, Al Barim B, Suero Molina E, Schwake M, Toksöz ÖA, Stummer W. Applicability of contemporary quality indicators in vestibular surgery-do they accurately measure tumor inherent postoperative complications of vestibular schwannomas? Acta Neurochir (Wien) 2022; 164:359-372. [PMID: 34859305 PMCID: PMC8854327 DOI: 10.1007/s00701-021-05044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/28/2021] [Indexed: 12/01/2022]
Abstract
Background Due to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators. Methods One hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. Results Thirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026). Conclusions Our data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Sebastian Lohmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Bilal Al Barim
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Özer Altan Toksöz
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Comorbidities and Medical Complications in Hospitalized Subarachnoid Hemorrhage Patients. Can J Neurol Sci 2021; 49:569-578. [PMID: 34275514 DOI: 10.1017/cjn.2021.176] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) remains a devastating condition with a case fatality of 36% at 30 days. Risk factors for mortality in SAH patients include patient demographics and the severity of the neurological injury. Pre-existing conditions and non-neurological medical complications occurring during the index hospitalization are also risk factors for mortality in SAH. The magnitude of the effect on mortality of pre-existing conditions and medical complications, however, is less well understood. In this study, we aim to determine the effect of pre-existing conditions and medical complications on SAH mortality. METHODS For a 25% random sample of the Greater Montreal Region, we used discharge abstracts, physician billings, and death certificate records, to identify adult patients with a new diagnosis of non-traumatic SAH who underwent cerebral angiography or surgical clipping of an aneurysm between 1997 and 2014. RESULTS The one-year mortality rate was 14.76% (94/637). Having ≥3 pre-existing conditions was associated with increased one-year mortality OR 3.74, 95% CI [1.25, 9.57]. Having 2, or ≥3 medical complications was associated with increased one-year mortality OR, 2.42 [95% CI 1.25-4.69] and OR, 2.69 [95% CI 1.43-5.07], respectively. Sepsis, respiratory failure, and cardiac arrhythmias were associated with increased one-year mortality. Having 1, 2, or ≥3 pre-existing conditions was associated with increased odds of having medical complications in hospital. CONCLUSIONS Pre-existing conditions and in-hospital non-neurological medical complications are associated with increased one-year mortality in SAH. Pre-existing conditions are associated with increased medical complications.
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Schipmann S, Suero Molina E, Windheuser J, Doods J, Schwake M, Wilbers E, Alsofy SZ, Warneke N, Stummer W. The 30-day readmission rate in neurosurgery-a useful indicator for quality assessment? Acta Neurochir (Wien) 2020; 162:2659-2669. [PMID: 32495079 DOI: 10.1007/s00701-020-04382-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND A shift in how we evaluate healthcare outcomes has driven the introduction of quality indicators as potential parameters to evaluate value-based healthcare delivery. So far, only few studies have been performed evaluating quality indicators in the context of neurosurgery, especially in the European region. The purpose of this study was to evaluate the 30-day readmission rate, identify reasons for readmission regarding the various neurosurgical diagnoses, and discuss the usefulness of this rate as a potential quality indicator. METHODS During a 6-year period, a total of 8878 hospitalized patients in our neurosurgical department were retrospectively analyzed and included in this study. Reasons for readmission were identified. Patients' diagnoses and baseline characteristics were obtained in order to identify possible risk factors for readmission. RESULTS The 30-day readmission rate was 2.9%. The most common reason for unplanned readmissions were surgical site infections. The reasons for readmissions varied significantly between the different underlying neurosurgical diseases (p < 0.001). Multivariate logistic regression revealed hydrocephalus (OR, 4) and shorter length of stay during index admission (OR, 0.9) as risk factors for readmission. CONCLUSIONS We provided an analysis of reasons for readmission for various neurosurgical diseases in a large patient spectrum in Germany. Although readmission rates are easy to track and an attractive tool for quality assessment, the rate alone cannot be seen as an adequate measure for quality in neurosurgery as it lacks a homogenous definition and depends on the underlying health care system. In addition, strategies for risk adjustment are required.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Julia Windheuser
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Justin Doods
- Institute of Medical Informatics, University Hospital Münster, Münster, Germany
| | - Michael Schwake
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Eike Wilbers
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westphalian Wilhelm-University Münster, Hamm, Germany
| | - Samer Zawy Alsofy
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westphalian Wilhelm-University Münster, Hamm, Germany
- Department of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Nils Warneke
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Jarvis CA, Lin M, Ding L, Julian A, Giannotta SL, Zada G, Mack WJ, Attenello FJ. Comorbid depression associated with non-routine discharge following craniotomy for low-grade gliomas and benign tumors - a nationwide readmission database analysis. Acta Neurochir (Wien) 2020; 162:2671-2681. [PMID: 32876766 DOI: 10.1007/s00701-020-04559-4] [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: 06/08/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Prior studies have demonstrated elevated rates of depression in patients with malignant brain tumor; however, the prevalence and effect on surgical outcomes in patients with low-grade gliomas (LGG) and benign brain tumors (BBT) remain unknown. Readmission and non-routine discharge, which includes discharge to skilled nursing, rehabilitative, and other inpatient facilities, are well-established quality of care indicators. We sought to analyze the association between comorbid depression and non-routine discharge, readmission, and other post-operative inpatient outcomes in patients with LGG and BBT. METHODS The Nationwide Readmissions Database from 2010 to 2014 was retrospectively queried to select for surgically treated patients with LGG and BBT. Multivariable logistic regression models adjusting for patient and hospital characteristics were used to determine the effects of comorbid depression on post-operative outcomes. Interaction of gender and depression on non-routine disposition was analyzed. RESULTS We identified 31,654 craniotomies for resection of BBT and LGG (2010-2014). The majority of patients (64.1%) were female. The rate of depression comorbid with BBT and LGG was 11.9%. Depression was associated with non-routine discharge after surgery (OR 1.19, p 0.0002*), but was not associated with increased morbidity, mortality, or readmission at 30 or 90 days. The rate of comorbid depression was higher among female than male patients (14.0 vs. 8.0%). Depression in males was associated with a 38% increased likelihood of non-routine disposition (p = 0.0002*), while depression in females was associated with a 13% increased likelihood of non-routine disposition (p = 0.03*). CONCLUSION Depression is prevalent in patients with LGG and BBT and is associated with increased risk of non-routine discharge following surgical intervention. The increased likelihood of non-routine disposition is greater for males than that for females. Awareness of the risk factors for depression may aid in early screening and intervention and improve overall patient outcomes.
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Affiliation(s)
- Casey A Jarvis
- Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA.
| | - Michelle Lin
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alex Julian
- Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA
| | - Steven L Giannotta
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Ye F, Garton HJL, Hua Y, Keep RF, Xi G. The Role of Thrombin in Brain Injury After Hemorrhagic and Ischemic Stroke. Transl Stroke Res 2020; 12:496-511. [PMID: 32989665 DOI: 10.1007/s12975-020-00855-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023]
Abstract
Thrombin is increased in the brain after hemorrhagic and ischemic stroke primarily due to the prothrombin entry from blood either with a hemorrhage or following blood-brain barrier disruption. Increasing evidence indicates that thrombin and its receptors (protease-activated receptors (PARs)) play a major role in brain pathology following ischemic and hemorrhagic stroke (including intracerebral, intraventricular, and subarachnoid hemorrhage). Thrombin and PARs affect brain injury via multiple mechanisms that can be detrimental or protective. The cleavage of prothrombin into thrombin is the key step of hemostasis and thrombosis which takes place in every stroke and subsequent brain injury. The extravascular effects and direct cellular interactions of thrombin are mediated by PARs (PAR-1, PAR-3, and PAR-4) and their downstream signaling in multiple brain cell types. Such effects include inducing blood-brain-barrier disruption, brain edema, neuroinflammation, and neuronal death, although low thrombin concentrations can promote cell survival. Also, thrombin directly links the coagulation system to the immune system by activating interleukin-1α. Such effects of thrombin can result in both short-term brain injury and long-term functional deficits, making extravascular thrombin an understudied therapeutic target for stroke. This review examines the role of thrombin and PARs in brain injury following hemorrhagic and ischemic stroke and the potential treatment strategies which are complicated by their role in both hemostasis and brain.
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Affiliation(s)
- Fenghui Ye
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, R5018 Biomedical Science Research Building, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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11
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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12
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Martini ML, Neifert SN, Yaeger KA, Hardigan T, Ladner TR, Nistal DA, Lamb C, Kellner CP, Macdonald RL, Mocco J, Oermann EK. Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes. World Neurosurg 2020; 141:e195-e203. [DOI: 10.1016/j.wneu.2020.05.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 12/15/2022]
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13
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Chatrath A, Soldozy S, Sokolowski JD, Burke RM, Schultz JG, Rannigan ZC, Park MS. Endovascular and Surgical Treatment Is Predictive of Readmission Risk After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 142:e494-e501. [PMID: 32693223 DOI: 10.1016/j.wneu.2020.07.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating disease process accounting for 5% of strokes. Although improvements in care have reduced the case-fatality rates, patients have an increased risk of neurological and medical complications after discharge. Additionally, the readmission rates have been increasingly used as a metric for patient care quality. METHODS In the present study, we reviewed the medical records of 206 patients who had been treated for aSAH at the University of Virginia from 2011 to 2018 to identify the causes and predictors of readmission. RESULTS The all-cause readmission rate was 9.8%, 15.3%, and 21.3% within 30, 60, and 180 days, respectively. The readmission rate for neurologic causes was 7.7%, 12.6%, and 18.0% within 30, 60, and 180 days, respectively. The neurologic causes of readmission included aneurysm retreatment, cranioplasty, a fall, hydrocephalus, stroke symptoms, and syncope. Surgical treatment (odds ratio [OR], 4.11-6.30) and endovascular treatment (OR, 3.79-8.33) of vasospasm were associated with an increased risk of all-cause readmission. Endovascular aneurysm treatment (OR, 0.22) was associated with a decreased risk of all-cause readmission. The average interval to the first follow-up appointment at our institution was 55.3 ± 63.3 days. Of the patients who had been readmitted from the emergency room, 65% had not had follow-up contact with physicians at our institution until their readmission. CONCLUSIONS To the best of our knowledge, the present study is the first to have examined the readmission rates for subarachnoid hemorrhage >90 days after treatment. Our results have suggested that the readmission rates >90 days after treatment could still be predicted by the hospital and treatment course during admission and that follow-up appointments with patients earlier in the clinic could identify those patients with a greater risk of readmission.
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Affiliation(s)
- Ajay Chatrath
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Sauson Soldozy
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer D Sokolowski
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Rebecca M Burke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Julianne G Schultz
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zuseen C Rannigan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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14
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Gerner ST, Reichl J, Custal C, Brandner S, Eyüpoglu IY, Lücking H, Hölter P, Kallmünzer B, Huttner HB. Long-Term Complications and Influence on Outcome in Patients Surviving Spontaneous Subarachnoid Hemorrhage. Cerebrovasc Dis 2020; 49:307-315. [DOI: 10.1159/000508577] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/06/2020] [Indexed: 11/19/2022] Open
Abstract
Background: While the short-term clinical outcome of patients with subarachnoid hemorrhage (SAH) is well described, there are limited data on long-term complications and their impact on social reintegration. This study aimed to assess the frequency of complications post-SAH and to investigate whether these complications attribute to functional and self-reported outcomes as well as the ability to return to work in these patients. Methods: This retrospective single-center study included patients with atraumatic SAH over a 5-year period at a tertiary care center. Patients received a clinical follow-up for 12 months. In addition to demographics, imaging data, and parameters of acute treatment, the rate and extent of long-term complications after SAH were recorded. The functional outcome was assessed using the modified Rankin Scale (mRS; favorable outcome defined as mRS = 0–2). Further outcomes comprised self-reported subjective health measured by the EQ-5D and return to work for SAH patients with appropriate age. Multivariable analyses including in-hospital parameters and long-term complications were conducted to identify parameters independently associated with outcomes in SAH survivors. Results: This study cohort consisted of 505 SAH patients of whom 405 survived the follow-up period of 12 months (i.e., mortality rate of 19.8%). Outcome data were available in 359/405 (88.6%) patients surviving SAH. At 12 months, a favorable functional outcome was achieved in 287/359 (79.9%) and 145/251 (57.8%) SAH patients returned to work. The rates of post-acute complications were headache (32.3%), chronic hydrocephalus requiring permanent ventriculoperitoneal shunting (VP shunt 25.4%) and epileptic seizures (9.5%). Despite patient’s and clinical characteristics, both presence of epilepsy and need for VP shunt were independently and negatively associated with a favorable functional outcome (epilepsy: adjusted odds ratio [aOR] (95% confidence interval [95% CI]): 0.125 [0.050–0.315]; VP shunt: 0.279 [0.132–0.588]; both p < 0.001) as well as with return to work (aOR [95% CI]: epilepsy 0.195 [0.065–0.584], p = 0.003; VP shunt 0.412 [0.188–0.903], p = 0.027). Multivariable analyses revealed presence of headache, VP shunt, or epilepsy to be significantly related to subjective health impairment (aOR [95% CI]: headache 0.248 [0.143–0.430]; epilepsy 0.223 [0.085–0.585]; VP shunt 0.434 [0.231–0.816]; all p < 0.01). Conclusions: Long-term complications occur frequently after SAH and are associated with an impairment of functional and social outcomes. Further studies are warranted to investigate if treatment strategies specifically targeting these complications, including preventive aspects, may improve the outcomes after SAH.
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15
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Lohmann S, Brix T, Varghese J, Warneke N, Schwake M, Suero Molina E, Holling M, Stummer W, Schipmann S. Development and validation of prediction scores for nosocomial infections, reoperations, and adverse events in the daily clinical setting of neurosurgical patients with cerebral and spinal tumors. J Neurosurg 2020; 134:1226-1236. [PMID: 32197255 DOI: 10.3171/2020.1.jns193186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 01/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various quality indicators are currently under investigation, aiming at measuring the quality of care in neurosurgery; however, the discipline currently lacks practical scoring systems for accurately assessing risk. The aim of this study was to develop three accurate, easy-to-use risk scoring systems for nosocomial infections, reoperations, and adverse events for patients with cerebral and spinal tumors. METHODS The authors developed a semiautomatic registry with administrative and clinical data and included all patients with spinal or cerebral tumors treated between September 2017 and May 2019. Patients were further divided into development and validation cohorts. Multivariable logistic regression models were used to develop risk scores by assigning points based on β coefficients, and internal validation of the scores was performed. RESULTS In total, 1000 patients were included. An unplanned 30-day reoperation was observed in 6.8% of patients. Nosocomial infections were documented in 7.4% of cases and any adverse event in 14.5%. The risk scores comprise variables such as emergency admission, nursing care level, ECOG performance status, and inflammatory markers on admission. Three scoring systems, NoInfECT for predicting the incidence of nosocomial infections (low risk, 1.8%; intermediate risk, 8.1%; and high risk, 26.0% [p < 0.001]), LEUCut for 30-day unplanned reoperations (low risk, 2.2%; intermediate risk, 6.8%; and high risk, 13.5% [p < 0.001]), and LINC for any adverse events (low risk, 7.6%; intermediate risk, 15.7%; and high risk, 49.5% [p < 0.001]), showed satisfactory discrimination between the different outcome groups in receiver operating characteristic curve analysis (AUC ≥ 0.7). CONCLUSIONS The proposed risk scores allow efficient prediction of the likelihood of adverse events, to compare quality of care between different providers, and further provide guidance to surgeons on how to allocate preoperative care.
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Affiliation(s)
| | - Tobias Brix
- 2Institute of Medical Informatics, University Hospital Münster, Germany
| | - Julian Varghese
- 2Institute of Medical Informatics, University Hospital Münster, Germany
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16
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A Propensity Score-Matched Comparison of Readmission Rates Associated With Microsurgical Clipping and Endovascular Treatment of Ruptured Intracranial Aneurysms. J Stroke Cerebrovasc Dis 2020; 29:104696. [PMID: 32089437 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104696] [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: 12/28/2019] [Revised: 01/08/2020] [Accepted: 01/25/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the treatment of aneurysmal subarachnoid hemorrhage (aSAH), microsurgical clipping, and endovascular therapy (EVT) with coiling are modalities for securing the ruptured aneurysm. Little data is available regarding associated readmission rates. We sought to determine whether readmission rates differed according to treatment modality for ruptured intracranial aneurysms. METHODS The Nationwide Readmissions Database (NRD) was used to identify adults who experienced aSAH and underwent clipping or EVT. Primary outcomes of interest were the incidences of 30- and 90-day readmissions (30dRA, 90dRA). Propensity score matching was used to generate matched pairs based on age, comorbidities, hospital volume, and hemorrhage severity. RESULTS We identified 13,623 and 11,160 patients who were eligible for 30dRA and 90dRA analyses, respectively. Among the patients eligible for 30dRA and 90dRA, we created 4282 and 3518 propensity score-matched pairs, respectively. There was no difference in the incidence of 30dRA (12.4% for clipping versus 11.2% for EVT; P = .094). However, 90dRA occurred more frequently after clipping (22.5%) compared to EVT (19.7%; P = .003). Clipping was associated with poor outcome after 30dRA (odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.21-1.88, P < .001) and after 90dRA (OR = 1.60, 95% CI 1.34-1.91, P = .001). Mean duration to readmission and cost of readmission did not vary, but clipping was associated with longer lengths of stay during readmission. CONCLUSIONS Microsurgical clipping of ruptured aneurysms is associated with a greater incidence of 90dRA, but not 30dRA, compared to EVT. Poor outcomes after readmission are more common following clipping.
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17
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Hoffman H, Furst T, Jalal MS, Chin LS. Annual incidences and predictors of 30-day readmissions following spontaneous intracerebral hemorrhage from 2010 to 2014 in the United States: A retrospective Nationwide analysis. Heliyon 2020; 6:e03109. [PMID: 31909273 PMCID: PMC6938885 DOI: 10.1016/j.heliyon.2019.e03109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/17/2019] [Accepted: 12/19/2019] [Indexed: 11/17/2022] Open
Abstract
Objective 30-day readmission rate is a quality metric often employed to represent hospital and provider performance. Currently, little is known regarding 30-day readmissions (30dRA) following spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to use a national database to identify risk factors and trends in 30dRAs following sICH. Patients and methods 64,909 cases with a primary diagnosis of sICH were identified within the Nationwide Readmission Database (NRD) from 2010 through 2014. Charlson Comorbidity Index (CCI) was used to adjust for the severity of each patient's comorbidities. A binary logistic regression model was constructed to identify predictors of 30-day readmission. Cochran-Mantel-Haenszel test was used to generate a pooled odd ratio (OR) describing the likelihood of experiencing a 30dRA according to year. Results The 30dRA rate following sICH decreased from 13.9% in 2010 to 12.5% in 2014 (pooled OR = 0.90, 95% CI 0.87–0.94). Cerebrovascular and cardiovascular etiologies accounted for the greatest number of admissions (36.1%). Sodium abnormality, healthcare-associated infection, gastrostomy, venous thromboembolism, and ischemic stroke during the index admission were associated with 30-day readmission. Furthermore, patients who underwent ventriculostomy (OR = 1.20, 95% CI 1.03–1.38) and craniotomy (OR = 1.20, 95% CI 1.09–1.31) were more likely to be readmitted within 30 days. Hospital volume, hospital teaching status, mechanical ventilation, and tracheostomy did not affect 30dRAs. Median readmission costs increased from $9,875 in 2012 to $11,028 in 2014 (p = 0.040). Conclusion The overall U.S. 30dRA rate after sICH from 2010 to 2014 was 12.9% and decreased slightly during this time period, but associated costs increased. Prospective studies are required to confirm the risk factors described in this study and to identify methods for preventing readmissions.
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18
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Liang JW, Cifrese L, Ostojic LV, Shah SO, Dhamoon MS. Preventable Readmissions and Predictors of Readmission After Subarachnoid Hemorrhage. Neurocrit Care 2019; 29:336-343. [PMID: 29949004 DOI: 10.1007/s12028-018-0557-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To estimate rates of all-cause and potentially preventable readmissions up to 90 days after discharge for aneurysmal subarachnoid hemorrhage (SAH) and medical comorbidities associated with readmissions BACKGROUND: Readmission rate is a common metric linked to compensation and used as a proxy to quality of care. Prior studies in SAH have reported 30-day readmission rates of 7-17% with a higher readmission risk among those with the higher SAH severity, ≥ 3 comorbidities, and non-home discharge. Intermediate-term rates, up to 90-days, and the proportion of these readmissions that are potentially preventable are unknown. Furthermore, the specific medical comorbidities associated with readmissions are unknown. METHODS Index SAH admissions were identified from the 2013 Nationwide Readmissions Database. All-cause readmissions were defined as any readmission during the 30-, 60-, and 90-day post-discharge period. Potentially preventable readmissions were identified using Prevention Quality Indicators developed by the US Agency for Healthcare Research and Quality. Unadjusted and adjusted Poisson models were used to identify factors associated with increased readmission rates. RESULTS Out of 9987 index admissions for SAH, 7949 (79%) survived to discharge. The percentage of 30-, 60-, and 90-day all-cause readmissions were 7.8, 16.6, and 26%, respectively. Up to 14% of readmissions in the first 30 days were considered potentially preventable and acute conditions (dehydration, bacterial pneumonia, and urinary tract infections) accounted for over half, whereas acute cerebrovascular disease was the most common cause for neurological return. In multivariable analysis, significant predictors of a higher readmission rate included diabetes (rate ratio [RR] 1.09, 95% confidence interval [CI] 1.03-1.15), congestive heart failure (RR 1.09, 1.003-1.18), and renal impairment (RR 1.35, 1.13-1.61). Only discharge home was associated with a lower readmission rate (RR 0.89, 0.85-0.93). CONCLUSIONS SAH has a 30-day readmission rate of 7.8% which continues to rise into the intermediate-term. A low but constant proportion of readmissions are potentially preventable. Several chronic medical comorbidities were associated with readmissions. Prospective studies are warranted to clarify causal relationships.
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Affiliation(s)
- John W Liang
- Divisions of Cerebrovascular Disease, Critical Care, and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA. .,Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Department of Neurology, Mount Sinai Downtown, New York, NY, USA.
| | - Laura Cifrese
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Syed O Shah
- Divisions of Cerebrovascular Disease, Critical Care, and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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19
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Gong Y, Du MY, Yu HL, Yang ZY, Li YJ, Zhou L, Mei R, Yang L, Wang F. Increased TRPM4 Activity in Cerebral Artery Myocytes Contributes to Cerebral Blood Flow Reduction After Subarachnoid Hemorrhage in Rats. Neurotherapeutics 2019; 16:901-911. [PMID: 31073979 PMCID: PMC6694375 DOI: 10.1007/s13311-019-00741-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Cerebral blood flow (CBF) reduction underlies unfavorable outcomes after subarachnoid hemorrhage (SAH). Transient receptor potential melastatin-4 (TRPM4) has a pivotal role in cerebral artery myogenic tone maintenance and CBF regulation under physiological conditions. However, the role of TRPM4 in CBF reduction after SAH is unclear. In this study, we aimed at testing whether TRPM4 would contribute to CBF reduction after SAH in vivo and determining underlying mechanisms. Rat SAH model was established by stereotaxic injection of autologous nonheparinized arterial blood at the suprasellar cistern. A TRPM4 blocker, 9-phenanthrol (9-Phe), was infused through an intraventricular catheter connected to a programmed subcutaneous pump to evaluate the contribution of TRPM4 to SAH outcomes. TRPM4 expression and translocation in cerebral artery myocytes were detected by immunoblotting. Macroscopic currents in cerebral artery myocytes were determined by whole-cell patch clamp. Myogenic tone of cerebral arteries was studied by pressurized myography. Cortical and global CBFs were measured via laser Doppler flowmetry and fluorescent microspheres, respectively. After SAH, TRPM4 translocation and macroscopic current density increased significantly. Furthermore, TRPM4 accounted for a greater proportion of myogenic tone after SAH, suggesting an upregulation of TRPM4 activity in response to SAH. Cortical and global CBFs were reduced after SAH, but were restored significantly by 9-Phe, implying that TRPM4 contributed to CBF reduction after SAH. Collectively, these discoveries show that increased TRPM4 activity has a pivotal role in CBF reduction after SAH, and provide a novel target for the management of cerebral perfusion dysfunction following SAH.
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Affiliation(s)
- Yi Gong
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, 650032 China
- Yunnan Key Laboratory of Laboratory Medicine, Kunming, 650032 China
- Department of Neurosurgery, The Third People’s Hospital of Yunnan Province, Kunming, 650011 China
| | - Ming-yue Du
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, 650032 China
| | - Hua-lin Yu
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, 650032 China
| | - Zhi-yong Yang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, 650032 China
| | - Yu-jin Li
- Department of Anesthesiology, The First People’s Hospital of Yunnan Province, Kunming, 650032 China
| | - Lei Zhou
- The Key Laboratory of Stem Cell and Regenerative Medicine of Yunnan Province, Institute of Molecular and Clinical Medicine, Kunming Medical University, Kunming, 650500 China
| | - Rong Mei
- Department of Neurology, The First People’s Hospital of Yunnan Province, Kunming, 650500 China
| | - Li Yang
- Department of Anatomy, Histology and Embryology, Kunming Medical University, Kunming, 650500 China
| | - Fei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, 295 Xichang Road, Kunming, 650032 China
- Yunnan Key Laboratory of Laboratory Medicine, Kunming, 650032 China
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Healthcare Economics of Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage in the United States. Transl Stroke Res 2019; 10:650-663. [PMID: 30864050 DOI: 10.1007/s12975-019-00697-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Hydrocephalus is one of the most common sequelae after aneurysmal subarachnoid hemorrhage (aSAH), and it is a large contributor to the condition's high rates of readmission and mortality. Our objective was to quantify the healthcare resource utilization (HCRU) and health economic burden incurred by the US health system due to post-aSAH hydrocephalus. The Truven Health MarketScan® Research database was used to retrospectively quantify the prevalence and HCRU associated with hydrocephalus in aSAH patients undergoing surgical clipping or endovascular coiling from 2008 to 2015. Multivariable longitudinal analysis was conducted to model the relationship between annual cost and hydrocephalus status. In total, 2374 patients were included; hydrocephalus was diagnosed in 959 (40.4%). Those with hydrocephalus had significantly longer initial lengths of stay (median 19.0 days vs. 12.0 days, p < .001) and higher 30-day readmission rates (20.5% vs. 10.4%, p < .001). With other covariates held fixed, in the first 90 days after aSAH diagnosis, the average cost multiplier relative to annual baseline for hydrocephalus patients was 24.60 (95% CI, 20.13 to 30.06; p < .001) whereas for non-hydrocephalus patients, it was 11.52 (95% CI, 9.89 to 13.41; p < .001). The 5-year cumulative median total cost for the hydrocephalus group was $230,282.38 (IQR, 166,023.65 to 318,962.35) versus $174,897.72 (IQR, 110,474.24 to 271,404.80) for those without hydrocephalus. We characterize one of the largest cohorts of post-aSAH hydrocephalus patients in the USA. Importantly, the substantial health economic impact and long-term morbidity and costs from this condition are quantified and reviewed.
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21
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Ng I, Du R. Thirty-day readmissions in aneurysmal subarachnoid hemorrhage: A good metric for hospital quality? J Neurosci Res 2019; 98:219-226. [PMID: 30742320 DOI: 10.1002/jnr.24398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/24/2018] [Accepted: 01/23/2019] [Indexed: 11/12/2022]
Abstract
Thirty-day readmission rates has been increasingly used by clinicians, hospital administrators, and policy makers as a metric for the quality of care. However, the 30-day readmission rates may be affected by other factors intrinsic to the patient and may not be a good measure of the quality of care provided by the hospital. In this review, we examined the quality of the 30-day readmissions rate as a quality metric for the quality of care provided to patients with aneurysmal subarachnoid hemorrhage (SAH). It has been shown that in this patient population, 30-day readmission rate primarily captures values, such as the number of comorbidities, disease severity, and discharge dispositions. There is little association between SAH 30-day readmission rates and mortality. However, 30-day readmissions may be reduced by increasing early discharge surveillance, providing readmission reduction programs to patients discharged to medical facilities as well as to home, and identifying patients most at risk for readmission.
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Affiliation(s)
- Isaac Ng
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
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22
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Liu J, Gormley N, Dasenbrock HH, Aglio LS, Smith TR, Gormley WB, Robertson FC. Cost-Benefit Analysis of Transitional Care in Neurosurgery. Neurosurgery 2018; 85:672-679. [DOI: 10.1093/neuros/nyy424] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/09/2018] [Indexed: 11/12/2022] Open
Abstract
AbstractBACKGROUNDTransitional care programs (TCPs) coordinate care to improve safety and efficiency surrounding hospital discharge. While TCPs have the potential to reduce hospital length of stay and readmissions, their financial implications are less well understood.OBJECTIVETo perform a cost-benefit analysis of a previously published neurosurgical TCP implemented at an urban academic hospital from 2013 to 2015.METHODSPatients received intensive preoperative education and framing of expectations for hospitalization, in-hospital discharge planning and medication reconciliation with a nurse educator, and a follow-up phone call postdischarge. The cost-benefit analysis involved program costs (nurse educator salary) and total direct hospital costs within the 30-d perioperative window including readmission costs.RESULTSThe average cost of the TCP was $435 per patient. The TCP was associated with an average total cost reduction of 17.2% (95% confidence interval [CI]: 7.3%-26.7%, P = .001). This decrease was driven by a 14.3% reduction in the average initial admission cost (95% CI: 6.2%-23.7%, P = .001), largely attributable to the 16.3% decrease in length of stay (95% CI: 9.93%-23.49%, P < .001). Thirty-day readmissions were significantly decreased in the TCP group, with a 5.5% readmission rate for controls and 2.4% for TCP enrollees (P = .04). The average cost of readmission was decreased by 71.3% (95% CI: 58.7%-74.7%, P < .01).CONCLUSIONThis neurosurgical TCP was associated with decreased costs of initial admissions, 30-d readmissions, and total costs of hospitalization alongside previously published decreased length of stay and reduced 30-d readmission rates. These results underscore the clinical and financial feasibility and impact of transitional care in a surgical setting.
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Affiliation(s)
- Jingyi Liu
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Natalia Gormley
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Hormuzdiyar H Dasenbrock
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Linda S Aglio
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain, Brigham and Women's Hospital, Boston, Massachusetts
| | - Timothy R Smith
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Neurological Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Faith C Robertson
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, Massachusetts
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23
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Chen CJ, Turnage C, Sokolowski JD, Kumar JS, Kalani MY, Park MS. Dangers of outpatient nimodipine use after spontaneous subarachnoid hemorrhage in accordance with the Comprehensive Stroke Center guidelines. J Clin Neurosci 2018; 52:151-152. [DOI: 10.1016/j.jocn.2018.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/12/2018] [Accepted: 04/02/2018] [Indexed: 11/30/2022]
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