Causes for 30-Day Readmission following Transsphenoidal Surgery

The impact of obesity on rates of post-operative CSF leak following endoscopic skull base surgery: results from a prospective international multi-centre cohort study

Aims

Post-operative CSF leak is the major source of morbidity following transsphenoidal approaches (TSA) and expanded endonasal approaches (EEA) to lesions of the sella turcica and the ventral skull base. There are conflicting reports in the literature as to whether obesity (BMI ≥30) is a risk factor for this complication. We aimed to evaluate data collected as part of prospective multi-centre cohort study to address this question.

Methods

The CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) study database was reviewed and patients were divided into obese and non-obese cohorts. Data on patient demographics, underlying pathology, intra-operative findings and skull base repair techniques were analysed.

Results

TSA were performed on 726 patients, of whom 210 were obese and 516 were non-obese. The rate of post-operative CSF leak in the obese cohort was 11/210 (5%), compared to 17/516 (3%) in the non-obese cohort, which was not statistically significant (χ2 = 1.520, p=0.217). EEA were performed on 140 patients, of whom 28 were obese and 112 were non-obese. The rate of post-operative CSF leak in the obese cohort was 2/28 (7%), which was identical to the rate observed in the non-obese cohort 8/112 (7%) Fisher's Exact Test, p=1.000). These results persisted following adjustment for inter-institutional variation and baseline risk of post-operative CSF leak.

Conclusion

CSF leak rates following TSA and EEA, in association with modern skull base repair techniques, were found to be low in both obese and non-obese patients. However, due to the low rate of post-operative CSF leak, we were unable to fully exclude a small contributory effect of obesity to the risk of this complication.

Gender potentially affects early postoperative hyponatremia in pituitary adenoma: XGBoost-based predictive modeling

Purpose

The occurrence of hyponatremia is a prevalent complication following transnasal transsphenoidal surgery for pituitary adenoma surgery, which adversely affects patient prognosis, hospitalization duration, and rehospitalization risk. The primary objective of this study is to strengthen the correlation between clinical factors associated with pituitary adenoma and postoperative hyponatremia. Additionally, the study aims to develop a predictive model for postoperative hyponatremia in patients with pituitary adenoma, with the ultimate goal of establishing a basis for reducing the occurrence of postoperative hyponatremia following surgical interventions.

Methods

The chi-square test or Fisher test was employed for nominal data, while the t-test or Mann-Whitney test was utilized for continuous data analysis. In cases where the data exhibited statistical differences, binary logistic analysis was conducted to examine the risk and protective factors associated with postoperative hyponatremia. XGBoost was employed to construct predictive models for hyponatremia in this study. The patients were partitioned into training and test sets, and the most suitable parameters were determined through five-fold cross-validation and subsequently utilized for training on the training set. The discriminatory capability was assessed on the internal validation set.

Results and conclusions

Out of the total 280 patients included in this investigation, 82 patients experienced early postoperative hyponatremia. Among these individuals, male gender (P = 0.02, odds ratio = 1.98) was identified as a risk factor for early postoperative hyponatremia, while preoperative chloride levels (P = 0.021, odds ratio = 0.866) and surgery time (P = 0.039, odds ratio = 0.990) were identified as protective factors against postoperative hyponatremia. The XGBoost model exhibited a sensitivity of 94.2%, a specificity of 61.5%, a positive predictive value of 51.6%, a negative predictive value of 96%, and identified male gender, preoperative sodium, and preoperative cortisol as the most significant predictors. Our findings indicate that gender may have influence in the development of early postoperative hyponatremia in patients with pituitary adenomas.

Emergency department visits following endoscopic skull base surgery: An opportunity for improvement

BACKGROUND

Readmissions are major healthcare expenditures, key hospital metrics, and are often preceded by an evaluation in the emergency department (ED). The purpose of this study was to analyze ED visits within 30 days of endoscopic skull base surgery (ESBS), risk factors for readmission once in the ED, and ED-related evaluation and outcomes.

METHODS

Retrospective review from January 2017 to December 2022 at a high-volume center of all ESBS patients who presented to the ED within 30 days of surgery.

RESULTS

Of 593 ESBS cases, 104 patients (17.5%) presented to the ED following surgery within 30 days, with a median presentation of 6 days post-discharge (IQR 5-14); 54 (51.9%) patients were discharged while 50 (48.1%) were readmitted. Readmitted patients were significantly older than discharged patients (median 60 years, IQR 50-68 vs. 48 years, 33-56; p < 0.01). Extent of ESBS was not associated with readmission or discharge from the ED. The most common discharge diagnoses were headache (n = 13, 24.1%) and epistaxis (n = 10, 18.5%); the most common readmitting diagnoses were serum abnormality (n = 15, 30.0%) and altered mental status (n = 5, 10.0%). Readmitted patients underwent significantly more laboratory testing than discharged patients (median 6, IQR 3-9 vs. 4, 1-6; p < 0.01).

CONCLUSIONS

Approximately half of patients who presented to the ED following ESBS were discharged home but underwent significant workup. Follow-up within 7 days of discharge, risk-stratified endocrine care pathways, and efforts to address the social determinants of health may be considered to optimize postoperative ESBS care.

Intraoperative prevention of nasal mucosal injury and surgical field contamination during single-nostril transnasal endoscopic pituitary adenomas resection

BACKGROUND

The common complications of transnasal endoscopic pituitary adenomas resection include nasal hemorrhage, olfactory disorder, nasal adhesion, and intracranial infection. Consequently, the protection of nasal mucosa and the prevention of surgical field contamination are critical.

METHOD

We presented a step-by-step description of the methods of the disinfection and protection of nasal mucosa and the prevention of surgical field contamination during transnasal endoscopic pituitary adenomas resection, and these comprehensive measures to prevent these complications have not been documented.

CONCLUSION

These measures effectively reduce the risk of nasal mucosal injury and surgical field contamination, and are easy to perform.

Risk Factors Associated with Postoperative CSF Leak in Extrasellar Tumors

Objective  While postoperative cerebrospinal fluid (CSF) leak rates of pituitary tumors have been frequently studied, there are fewer studies examining postoperative CSF leak rates for extrasellar tumors. The purpose of this study was to identify risk factors for the development of postoperative CSF leak in patients undergoing endoscopic surgery for extrasellar tumors. Methods  A retrospective chart review was done for patients who underwent endoscopic resection for extrasellar tumors between 2008 and 2020. Age, gender, tumor type, tumor location, tumor size, reconstruction technique, medical comorbidities, and other potential risk factors were identified. Data was analyzed to identify significant risk factors for development of postoperative CSF leak. Results  There were 100 patients with extrasellar tumors who developed intraoperative CSF leaks. Seventeen patients (17%) developed postoperative CSF leaks. Leaks occurred at a median of 2 days following surgery (range 0-34 days). Clival tumors had a significantly higher incidence of postoperative leak than those in other sites ( p  < 0.05). There were no significant differences in other locations, body mass index, tumor size, reconstruction technique, medical comorbidities, or other factors. There were nearly twice as many intraoperative grade III leaks in those who developed postoperative CSF leak, but this was not statistically significant ( p  = 0.12). Conclusion  Extrasellar tumors, particularly clival tumors, have a higher rate of postoperative CSF leak than pituitary tumors. Prophylactic lumbar drains can be considered for patients at high risk for developing postoperative CSF leak.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery

BACKGROUND

We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications.

METHODS

We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions.

RESULTS

One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021).

CONCLUSIONS

A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Time taken to resume activities of daily living after transsphenoidal surgery for pituitary tumors

Postoperative management after transsphenoidal surgery (TSS) is important; however, the guidelines for resuming daily activities after TSS are insufficient. This study aimed to examine the time to return to activities of daily living (ADL) after TSS for pituitary tumors. A 4-month prospective data collection was completed for 114 of 117 patients who underwent TSS for pituitary tumors from April to July 2021. The time when the patient returned to ADL after surgery was measured using the self-recording sheet. More than 97% and 92% of the patients returned within 1 month (median: within 7 days) for the elements of basic ADL and within 2 months (median: within 15 days) for the elements of instrumental ADL, excluding a few. Notably, 73.3% of patients returned to work within 4 months. The median time for the activities included 64 days for washing hair head down, 44 days for blowing nose, 59 days for lifting heavy objects, and 102 days for sexual activity. For patients who received extended-TSS or had postoperative problems, the time to return was delayed. Based on these results, it will be possible to provide practical information and guidelines on the time to return to ADL after TSS in pituitary tumor patients.

Multidisciplinary Postoperative Care Pathway to Reduce Readmissions following Endoscopic Transsphenoidal Pituitary Surgery: Improving Quality of Patient Care

Background  Thirty-day unplanned readmission following endoscopic transsphenoidal pituitary surgery (ETPS) occurs in up to 14% of patients. Delayed hyponatremia is one of the most common causes, accounting for 30% of readmissions and often occurs within 1 week of surgery. The authors' prior retrospective review identified endocrinology follow-up as protective factor. Objectives  Implementation of a multidisciplinary postoperative care (POC) pathway: (1) to reduce 30-day hospital readmissions following ETPS and (2) improve inpatient and outpatient coordination of care with endocrinologist. Methods  This study is a single institution temporal cohort study of patients prior to (control cohort) and after implementation of the POC pathway (intervention cohort). The POC pathway utilized postdischarge 1 to 1.5 L/d fluid restriction, postoperative days 5 to 7 serum sodium, and endocrinology follow-up within 1 week of discharge to stratify patients into tiered hyponatremia regimens. Results  A total of 542 patients were included in the study, 409 (75%) in the control cohort and 133 (25%) in the intervention cohort. All-cause readmission was significantly reduced following implementation of the POC pathway (14 vs. 6%, p  = 0.015). Coordination with endocrinologist significantly increased in the inpatient (96 vs. 83%, p  < 0.001) and outpatient (77 vs. 68%, p  = 0.042) settings. Patients who were not in the POC pathway had the highest risk of readmission (odds ratio: 2.5; 95% confidence interval: 1.1-5.5). Conclusion  A multidisciplinary POC pathway incorporating endocrinologist in conjunction with postdischarge weight-based fluid restriction and postoperative serum sodium levels can safely be used to reduce 30-day readmissions following ETPS.

Factors Influencing Cerebrospinal Fluid Leaking following Pituitary Adenoma Transsphenoidal Surgery: A Meta-Analysis and Comprehensive Review

Background

Surgical resection is the main method to treat pituitary adenoma. Cerebrospinal fluid leakage (CSF Leak) is the main complication after transsphenoidal surgery. The impact of postoperative CSF Leak can be predicted in advance, and preventive measures can be taken in time. Clinically, a variety of factors may affect the occurrence of postoperative CSF Leak. In this study, meta-analysis was used to investigate the risk factors of postoperative CSF Leak as a clinical reference.

Methods

The databases PubMed, Medline, Embrase, Cochrane library, CNKI, and CBM were searched for all studies on the risk factors of postoperative CSF Leak. Studies were screened and finally included. The quality of the included studies was assessed by the Newcastle-Ottawa scale. We used Revman 5.4 software to conduct the pooled effect size of every potential statistically significant factor.

Results

13 articles with a total of 5967 patients with pituitary adenoma and 405 cases of postoperative CSF Leak were finally included, accounting for 6.79%. All of the 13 articles had a quality score > 5, indicating good quality. Meta-analysis showed that patient age (OR = 0.71, 95% CI (0.41, 1.20), P = 0.20) was not a factor influencing postoperative CSF Leak, while BMI (MD = 2.26, 95% CI (1.31, 3.20), P < 0.00001), tumor size (MD = 1.35, 95% CI (0.22, 2.49), P = 0.02), whether a second operation was performed (OR = 2.20, 95% CI (1.45, 3.33), P = 0.0002), and intraoperative CSF Leak (OR = 8.88, 95% CI (3.64, 21.69), P < 0.00001) were risk factors for postoperative CSF Leak in patients. Discussion. BMI, tumor size, reoperation, and intraoperative CSF Leak are the risk factors of postoperative CSF Leak. However, not all the factors were covered in this study, it is still worth continuing to deeply investigate in this topic.

Effects of a transsphenoidal surgery quality improvement program on patient outcomes and hospital financial performance

OBJECTIVE

A comprehensive quality improvement (QI) program aimed at all aspects of patient care after pituitary surgery was initiated at a single center. This initiative was guided by standard quality principles to improve patient outcomes and optimize healthcare value. The programmatic goal was to discharge most elective patients within 1 day after surgery, improve patient safety, and limit unplanned readmissions. The program is described, and its effect on patient outcomes and hospital financial performance over a 5-year period are investigated.

METHODS

Details of the patient care pathway are presented. Foundational elements of the QI program include evidence-based care pathways (e.g., for hyponatremia and pain), an in-house research program designed to fortify care pathways, patient education, expectation setting, multidisciplinary team care, standard order sets, high-touch postdischarge care, outcomes auditing, and a patient navigator, among other elements. Length of stay (LOS), outcome variability, 30-day unplanned readmissions, and hospital financial performance were identified as surrogate endpoints for healthcare value for the surgical epoch. To assess the effect of these protocols, all patients undergoing elective transsphenoidal surgery for pituitary tumors and Rathke's cleft cysts between January 2015 and December 2019 were reviewed.

RESULTS

A total of 609 adult patients who underwent elective surgery by experienced pituitary surgeons were identified. Patient demographics, comorbidities, and payer mix did not change significantly over the study period (p ≥ 0.10). The mean LOS was significantly shorter in 2019 versus 2015 (1.6 ± 1.0 vs 2.9 ± 2.2 midnights, p < 0.001). The percentage of patients discharged after 1 midnight was significantly higher in 2019 versus 2015 (75.4% vs 15.6%, p < 0.001). The 30-day unplanned hospital readmission rate decreased to 2.8% in 2019 from 8.3% in 2015. Per-patient hospital profit increased 71.3% ($10,613 ± $19,321 in 2015; $18,180 ± $21,930 in 2019), and the contribution margin increased 42.3% ($18,925 ± $19,236 in 2015; $26,939 ± $22,057 in 2019), while costs increased by only 3.4% ($18,829 ± $6611 in 2015; $19,469 ± $4291 in 2019).

CONCLUSIONS

After implementation of a comprehensive pituitary surgery QI program, patient outcomes significantly improved, outcome variability decreased, and hospital financial performance was enhanced. Future studies designed to evaluate disease remission, patient satisfaction, and how the surgeon learning curve may synergize with other quality efforts may provide additional context.

Audit of postoperative readmissions and patient messages following endoscopic transnasal transsphenoidal surgery

Objectives:To identify the reasons for patient messages, phone calls and Emergency Department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design: Retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020-August 2021. Patient, tumor, and surgical characteristics were collected, along with post-operative, post-discharge, and readmission information. Regression analyses were performed to investigate risk factors associated with post-discharge phone calls, messages, ED visits, and readmissions. Main Outcome Measures: Number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient’s discharge instructions. Results: A total of 98 patients underwent eTNTS during the study period. Median length of hospital stay was 2-days (Interquartile range [IQR] 1-4days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9-days after discharge (IQR 7-10days). Within that time, 54% of patients made/sent at least one phone call or electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, symptom and medication questions. Conclusions: Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection

OBJECTIVE

While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS.

METHODS

A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery.

RESULTS

A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge.

CONCLUSIONS

This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.

Machine Learning-Based Analysis and Prediction of Unplanned 30-Day Readmissions After Pituitary Adenoma Resection: A Multi-Institutional Retrospective Study With External Validation

BACKGROUND

Unplanned readmission after transsphenoidal resection of pituitary adenoma can occur in up to 10% of patients but is unpredictable.

OBJECTIVE

To develop a reliable system for predicting unplanned readmission and create a validated method for stratifying patients by risk.

METHODS

Data sets were retrospectively collected from the National Surgical Quality Improvement Program and 2 tertiary academic medical centers. Eight machine learning classifiers were fit to the National Surgical Quality Improvement Program data, optimized using Bayesian parameter optimization and evaluated on the external data. Permutation analysis identified the relative importance of predictive variables, and a risk stratification system was built using the trained machine learning models.

RESULTS

Readmissions were accurately predicted by several classification models with an area under the receiving operator characteristic curve of 0.76 (95% CI 0.68-0.83) on the external data set. Permutation analysis identified the most important variables for predicting readmission as preoperative sodium level, returning to the operating room, and total operation time. High-risk and medium-risk patients, as identified by the proposed risk stratification system, were more likely to be readmitted than low-risk patients, with relative risks of 12.2 (95% CI 5.9-26.5) and 4.2 (95% CI 2.3-8.7), respectively. Overall risk stratification showed high discriminative capability with a C-statistic of 0.73.

CONCLUSION

In this multi-institutional study with outside validation, unplanned readmissions after pituitary adenoma resection were accurately predicted using machine learning techniques. The features identified in this study and the risk stratification system developed could guide clinical and surgical decision making, reduce healthcare costs, and improve the quality of patient care by better identifying high-risk patients for closer perioperative management.

Costs and Its Determinants in Pituitary Tumour Surgery

PURPOSE

Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.

METHODS

We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.

RESULTS

271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).

CONCLUSIONS

Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

Diabetes insipidus after endoscopic transsphenoidal surgery: multicenter experience and development of the SALT score

OBJECTIVE

To identify risk factors for the development of postoperative diabetes insipidus (DI) in a modern cohort of endoscopic endonasal transsphenoidal surgery.

METHODS

Analysis of prospectively collected data of 449 consecutive patients operated on for anterior skull base pathology. DI was defined as a polyuria (> 250 ml/h for ≥ 2 consecutive hours) polydipsia syndrome associated with hypotonic urine with or without hypernatraemia. Multivariate logistic regression was used to identify predictors of postoperative DI. A simple scoring system was then created.

RESULTS

Postoperative DI occurred in 46 (10.2%) patients. The development of DI did not affect quality of life. Predictors of DI on multivariate analysis included suprasellar extension (OR 2.2; p = 0.04), age < 50 years (OR 2.8; p = 0.003), craniopharyngioma histology (OR 6.7; p = 0.002), and Kelly grade 3 intraoperative CSF leak (OR 2.1; p = 0.04). The SALT score was created based on these characteristics, with one point awarded for each feature present, and predicted DI with fair to good predictive value in our cohort (AUROC 0.735 (95%CI 0.65-0.82)). The rates of postoperative DI were 4.0%, 6.5%, 15.0%. 36.8% and 85.7% for SALT scores of zero, one, two, three, and four, respectively.

CONCLUSIONS

The SALT score predicts postoperative DI with fair to good accuracy, and now requires prospective external validation. Improved prediction of DI could optimize resource allocation and facilitate individualised preoperative patient counselling. We also provide our algorithm for diagnosis and treatment of DI.

30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients

Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions.

Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center.

Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88).

Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS.

Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.

Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery

OBJECTIVE

To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery.

METHODS

All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software.

RESULTS

The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant.

CONCLUSIONS

Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:760-764, 2021.

Feasibility, safety, and outcomes of a stratified fast-track care trajectory in pituitary surgery

OBJECTIVE

Discharge policies concerning hospitalization after endoscopic pituitary tumor surgery are highly variable. A few studies support fast-track discharge; however, this is not commonplace. Our goal was to report the transition to and evaluate the feasibility, safety, clinical- and patient-reported outcomes and costs of fast-track care in pituitary surgery.

METHODS

This observational study included 155 patients undergoing pituitary surgery between December 2016 and December 2018. Fast-track care consisted of planned discharge 2-3 days after surgery, followed by daily surveillance by a case manager. All outcomes were compared with patients not eligible for fast-track discharge. The total group (fast-track and non-fast-track) was compared with historic controls (N = 307).

RESULTS

A total of 79/155 patients (51%) were considered eligible for fast-track discharge, of whom 69 (87%) were discharged within 3 days. The total group was discharged more often within 3 days compared with historic controls (49 vs. 20%, p < 0.001), the total length of stay did not differ (5.3 vs. 5.7 days, p = 0.363). Although the total group had more readmissions compared with historic controls (17 vs. 10%, p = 0.002), no life-threatening complications occurred after discharge. On average, clinical- and patient-reported outcomes improved over time, both in the fast-track and non-fast-track groups. The mean overall costs within 30 days after surgery did not differ between the total group € 9992 (SD € 4562) and historic controls € 9818 (SD € 3488) (p = 0.649).

CONCLUSION

A stratified fast-track care trajectory with enhanced postoperative outpatient surveillance after pituitary tumor surgery is safe and feasible. As expected, costs of the fast-track were lower than the non-fast-track group, however we could not prove overall cost-effectiveness compared with the historic controls.

Analysis of modifiable and nonmodifiable risk factors in patients undergoing pituitary surgery

OBJECTIVE

Pituitary adenomas (PAs) are among the most common intracranial tumors. Understanding the clinical effects of various modifiable risk factors (MRFs) and nonmodifiable risk factors (NMRFs) is important in guiding proper treatment, yet there is limited evidence outlining the influence of MRFs and NMRFs on outcomes of PA resection. The aim of this study was to analyze MRFs and NMRFs in patients undergoing resection for PAs.

METHODS

Using the 2016 and 2017 National Readmission Database, the authors identified a cohort of 9472 patients undergoing microscopic or endoscopic resection of a PA. Patients with nonoverlapping MRFs and NMRFs were analyzed for length of stay (LOS), hospital cost, readmission rates, and postoperative complications. From the original cohort, a subset of 373 frail patients (as defined by the Johns Hopkins Frailty Index) were identified and propensity matched to nonfrail patients. Statistical analysis included 1-way ANOVA, Tukey multiple comparisons of means, odds ratios, Wald testing, and unpaired Welch 2-sample t-tests to compare complications, outcomes, and costs between each cohort. Perioperative outcomes and hospital readmission rates were tracked, and predictive algorithms were developed to establish precise relationships between relevant risk factors and neurosurgical outcomes.

RESULTS

Malnourished patients had significantly longer LOSs when compared to nonmalnourished patients (p < 0.001). There was a significant positive correlation between the number of MRFs and readmission at 90 days (p = 0.012) and 180 days (p = 0.020). Obese patients had higher rates of postoperative neurological injury at the 30-day follow-up (p = 0.048) compared to patients with normal BMI. Within this NMRF cohort, frail patients were found to have significantly increased hospital LOS (p < 0.001) and total inpatient costs compared to nonfrail patients (p < 0.001). Predictive analytics showed that frail patients had significantly higher readmission rates at both 90-day (p < 0.001) and 180-day follow-ups (p < 0.001). Lastly, rates of acute postsurgical infection were higher in frail patients compared to nonfrail patients (p < 0.001).

CONCLUSIONS

These findings suggest that both MRFs and NMRFs negatively affect the perioperative outcomes following PA resection. Notable risk factors including malnutrition, obesity, elevated lipid panels, and frailty make patients more prone to prolonged LOS, higher inpatient costs, and readmission. Further prospective research with longitudinal data is required to precisely pinpoint the effects of various risk factors on the outcomes of pituitary surgery.

Preoperative radiographic and clinical factors associated with the visualization of intraoperative cerebrospinal fluid during endoscopic transsphenoidal resection of pituitary adenomas

Background:

Intraoperative visualization of cerebrospinal fluid (CSF) during endoscopic endonasal resection of skull base tumors is the most common factor contributing to the development of postoperative CSF leaks. No previous studies have solely evaluated preoperative factors contributing to intraoperative CSF visualization. The purpose of this study was to identify preoperative factors predictive of intraoperative CSF visualization.

Methods:

Retrospective review of patients who underwent transsphenoidal resection of pituitary adenomas was conducted. Clinical and radiographic variables were compared for those who had CSF visualized to those who did not. Nominal logistic regression models were built to determine predictive variables.

Results:

Two hundred and sixty patients were included in the study. All significant demographic and radiographic variables on univariate analysis were included in multivariate analysis. Two multivariate models were built, as tumor height and supraclinoid extension were collinear. The first model, which considered tumor height, found that extension into the third ventricle carried a 4.60-fold greater risk of CSF visualization (P = 0.005). Increasing tumor height showed a stepwise, linear increase in risk; tumors >3 cm carried a 19.02-fold greater risk of CSF visualization (P = 0.003). The second model, which considered supraclinoid tumor extension, demonstrated that extension into the third ventricle carried a 4.38-fold increase in risk for CSF visualization (P = 0.010). Supraclinoid extension showed a stepwise, linear increase in intraoperative CSF risk; tumors with >2 cm of extension carried a 9.26-fold increase in risk (P = 0.017).

Conclusion:

Our findings demonstrate that tumor height, extension into the third ventricle, and extension above the clinoids are predictive of intraoperative CSF visualization.

National trends in hospital readmission following transsphenoidal surgery for pituitary lesions

PURPOSE

Several institutions recently published their experiences with unplanned readmissions rates after transsphenoidal surgery for pituitary lesions. Readmission rates on a national level, however, have not been explored in depth. We investigated nationwide trends in this procedure and associated independent predictors, costs, and causes of 30-day readmission.

METHODS

The Nationwide Readmissions Database was queried to identify patients 18 and older who underwent transsphenoidal surgery for pituitary lesion resection (2010-2015). National trends and statistical variances were calculated based on weighted, clustered, and stratified sample means.

RESULTS

Of the weighted total of 44,759 patients treated over the 6-year period, 4658 (10.4%) were readmitted within 30 days. Readmission rates did not change across the survey period (P = 0.71). Patients readmitted had a higher prevalence of comorbidities than those not readmitted (82.5% vs. 78.4%, respectively, P < 0.001), experienced more postoperative complications (47.2% vs. 31.8%, P < 0.001), and had a longer length of stay (6.59 vs. 4.23 days, P < 0.001) during index admission. The most common causes for readmission were SIADH (17.5%) and other hyponatremia (16.4%). Average total readmission cost was $12,080 with no significant trend across the study period (P = 0.25). Predictors for readmission identified included diabetes mellitus, psychological disorders, renal failure, and experiencing diabetes insipidus during the index admission.

CONCLUSION

Unplanned readmission is an important quality metric. While transsphenoidal pituitary surgery is a relatively safe procedure, 30-day readmission rates and costs have not declined. Future studies on institutional protocols targeting these identified predictors to prevent readmission are necessary to decrease readmission rates on a national scale.

Multidisciplinary Team Care in the Surgical Management of Pituitary Adenoma

Objective  Despite multidisciplinary care being commonly recommended, there remains limited evidence supporting its benefits in pituitary disease management. This study aimed to assess the impact of multidisciplinary care in pituitary surgery. Methods  A retrospective cohort study was performed comparing pituitary surgery outcomes among consecutive patients within a quaternary referral center in 5 years before and after introduction of a multidisciplinary team (MDT). Primary outcomes were endocrine (transient diabetes insipidus [DI], syndrome of inappropriate antidiuretic hormone [SIADH], and new hypopituitarism) and surgical (cerebrospinal fluid [CSF] leak, epistaxis, intracranial hemorrhage, and meningitis) complications, length of hospital stay, and intrasellar residual tumor. Results  279 patients (89 pre-MDT vs. 190 post-MDT) were assessed (age 54 ± 17 years, 48% female). Nonfunctioning adenomas were most common (54%). In the post-MDT era, more clinically functioning tumors (42 vs. 28%, p  = 0.03) were treated. Transient DI and SIADH occurred less often post-MDT (20 vs. 36%, p  < 0.01 and 18 vs. 39%, p  < 0.01), as well as new hypothyroidism (5 vs. 15, p  < 0.01). Hospital stay was shorter post-MDT (5[3] vs. 7[5] days, p  < 0.001) and intrasellar residuals were less common (8 vs. 35%, p  < 0.001). Complications were more frequent pre-MDT independent of tumor size, hormone status, and surgical technique (odds ratio [OR] = 2.14 [1.05-4.32], p  = 0.04). Conclusion  Outcomes of pituitary surgery improved after the introduction of an MDT. Pituitary MDTs may benefit both patients and the health system by improving quality of care and reducing hospital stays.

30-day unplanned readmission rate in otolaryngology patients: A population-based study in Thuringia, Germany

Purpose

Analyze associations between patients’ characteristics and treatment factors with 30-day unplanned readmissions in hospitalized otolaryngology patients in the German Diagnosis Related Group (D-DRG) system.

Methods

A retrospective cohort study was performed on 15.271 otolaryngology admissions of 12.859 patients in 2015 in Thuringia, Germany. The medical records of the 1173 cases (7.6%) with readmission within 30-days were analyzed in detail.

Results

The 30-day readmission was planned in 747 cases (4.9%) and was unplanned in 422 cases (2.8%). The median interval between primary and next inpatient treatment was 11 days. The principal diagnosis was the same as during the primary index treatment in 72% of the cases. The most frequent reasons for readmission were: Need for non-surgical therapy (31.2%), need for further surgery (26.3%), post-surgical complaints (16.9%), and recurrence of primary complaints (10.7%). The multivariate analysis revealed that discharge due to patient’s request against medical advice was a strong independent factor with high risk for unplanned readmission (Odds Ratio [OR] = 9.62]; confidence interval [CI] = 2.69–34.48). Surgery at index admission (OR = 3.33; CI = 1.86–5.96) was the second important independent risk factor for unplanned readmission. Unplanned readmission had more frequently a non-surgical treatment at readmission than a surgical treatment (OR = 3.92; CI = 2.24–6.84) and needed more frequently further diagnostics (OR = 2.34; CI = 1.34–4.11). The following index International Classification of Diseases (ICD) categories had the highest risk for unplanned readmission: Injury, poisoning and certain other consequences of external causes, ICD: S00-T98 (OR = 66.67; CI = 15.87–333.33), symptoms, signs, abnormal findings, ill-defined causes, not otherwise classified, ICD: R00-R99 (OR = 62.5; CI = 11.76–333.33), blood forming organ diseases, ICD: D50-D90 (OR = 21.276; CI = 3.508–125), and eye/ ear diseases, ICD: H00-H95 (OR = 12.66; CI = 4.29–37.03).

Conclusions

The causes of unplanned 30-day readmission in German otolaryngology inpatients are multifactorial. Specific patient and treatment characteristics were identified to be targeted with health care interventions to decrease unplanned readmissions.

Readmissions after endoscopic skull base surgery: associated risk factors and prevention

BACKGROUND

Unplanned readmissions within 30 days of discharge is a quality measure introduced by the Centers for Medicare Services. This measure has been used to rate hospital quality and also to penalize hospitals for excess readmissions. It has been hypothesized that shorter hospital stays and fewer readmissions are associated with endoscopic skull base procedures. In this study we analyze endoscopic skull base procedures performed at our institution over a 10-year period to identify rates and factors associated with readmissions after endoscopic skull base surgery.

METHODS

A retrospective chart review was performed at a tertiary care academic medical center identifying patients who underwent endoscopic skull base surgery over the past 10 years. Data on patient demographics and tumor variables, as well as patient variables such as body mass index (BMI), revision surgery, history of skull base radiation, medical comorbidities, intraoperative cerebrospinal fluid (CSF) leaks, and postoperative CSF leaks, were recorded.

RESULTS

Eight hundred thirty-three patients were included in our study. Sixty-one patients (7.3%) were readmitted a total of 66 times within 30 days. The most common reasons were as follows: hyponatremia (n = 18); CSF leak (n = 17); epistaxis (n = 3); diabetes insipidus (n = 3); rhinorrhea (n = 3); as well as other reasons. Statistical analysis revealed that the presence of intraoperative CSF leak was the only statistically significant variable associated with increased rate of readmissions within 30 days of discharge (p < 0.001).

CONCLUSION

Presence of intraoperative CSF leak was the only statistically significant variable associated with an increased risk for readmission after surgery. Other tumor and patient variables were not associated with an increased risk of readmission within 30 days.

Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases

OBJECTIVE

Hospital readmission is a key component in value-based healthcare models but there are limited data about the 30-day readmission rate after endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma. The objective of this study was to determine the incidence and identify factors associated with 30-day readmission after EETS for pituitary adenoma.

METHODS

The authors analyzed a prospectively acquired database of patients who underwent EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. Clinical, socioeconomic, and radiographic data were reviewed for cases of unplanned readmission within 30 days of surgery and, as a control group, for all other patients in the series who were not readmitted. Statistical significance was determined with an alpha < 0.05 using Pearson's chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables.

RESULTS

Of 584 patients undergoing EETS for pituitary adenoma, 27 (4.6%) had unplanned readmission within 30 days. Most readmissions occurred within the first week after surgery, with a mean time to readmission of 6.6 ± 3.9 days. The majority of readmissions (59%) were for hyponatremia. These patients had a mean sodium level of 120.6 ± 4.6 mEq/L at presentation. Other causes of readmission were epistaxis (11%), spinal headache (11%), sellar hematoma (7.4%), CSF leak (3.7%), nonspecific headache (3.7%), and pulmonary embolism (3.7%). The postoperative length of stay was significantly shorter for patients who were readmitted than for the controls (2.7 ± 1.0 days vs 3.9 ± 3.2 days; p < 0.05). Patients readmitted for hyponatremia had an initial length of stay of 2.6 ± 0.9 days, the shortest of any cause for readmission. The mean BMI was significantly lower for readmitted patients than for the controls (26.4 ± 3.9 kg/m2 vs 29.3 ± 6.1 kg/m2; p < 0.05).

CONCLUSIONS

Readmission after EETS for pituitary adenoma is a relatively rare phenomenon, with delayed hyponatremia being the primary cause. The study results demonstrate that shorter postoperative length of stay and lower BMI were associated with 30-day readmission.

Recurrent Pneumococcal Meningitis in Children: A Multicenter Case-control Study

BACKGROUND

Pneumococcal meningitis (PM) is a serious disease that can rarely recur at a later time after the initial episode.

METHODS

A retrospective multicenter case-control study was conducted with data for children 18 years of age or younger obtained from the National Observatory of Bacterial Meningitis in Children between January 2001 and September 2015. Cases were all patients with RPM. Each case was matched with 2 randomized controls with a single PM episode in the year of the first episode of PM in the case and born the same year. Case and control data were compared.

RESULTS

Among the 1634 PM episodes in children 18 years of age or younger, 24 (1.5%) children had RPM. RPM cases were significantly less frequent than single PM cases in winter (27% vs. 48%; P=0.03) and showed significantly less concomitant ear, nose and throat infections when considering the first episode (30% vs. 56%, P = 0.04) and all episodes (28% vs. 56%, P < 0.01). Cerebrospinal fluid leakage was frequent in RPM cases versus controls (83% vs. 10%, P < 0.01), including 25% discovered after the third PM episode. Immune deficiency was absent in cases and present in 15% of controls. Cases and controls did not differ in death rate or neurologic outcome.

CONCLUSIONS

RPM is rare in children. Cerebrospinal fluid leakage must be considered.

Sodium Perturbations After Pituitary Surgery

Sodium perturbations are a common complication after pituitary surgery, with hyponatremia being the most frequent. Postoperative assessments should be tailored to the early and late periods, and monitoring sodium perturbations is recommended. Cerebral salt wasting is rare after pituitary surgery, and diagnosis and management can be challenging. Providing patient counseling and close postoperative follow-up is important to effectively manage diabetes insipidus and reduce hospital readmissions due to sodium perturbations.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center

BACKGROUND

Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population.

METHODS

We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program.

RESULTS

Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia.

CONCLUSION

Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Predictive Factors for Delayed Hyponatremia After Endoscopic Transsphenoidal Surgery in Patients with Nonfunctioning Pituitary Tumors: A Retrospective Observational Study

OBJECTIVE

Delayed hyponatremia can occur after transsphenoidal pituitary tumor surgery, resulting in unexpected readmission. Predictive factors for delayed hyponatremia after this type of surgery are not well established. In this retrospective study, predictive factors for delayed hyponatremia were investigated in patients undergoing transsphenoidal pituitary tumor surgery.

METHODS

Preoperative data (demographics, comorbidities, and hormonal assessment), preoperative, intraoperative, and immediate postoperative sodium concentrations, the nadir sodium concentration on postoperative day (POD) 1-2, characteristics of pituitary tumor (size, cell type, optic chiasm compression, and cavernous sinus invasion), and intraoperative data (operation time and fluid balance) were retrospectively collected from 234 patients undergoing endoscopic transsphenoidal surgery for removal of nonfunctioning pituitary tumors. Delayed hyponatremia was defined as serum sodium concentration <135 mEq/L on POD 3 or later, and after discharge, postoperative sodium concentration was measured on POD 7-10.

RESULTS

Delayed hyponatremia was observed in 53 patients (22.6%). Of these patients, 5 (9.4%) were readmitted because of delayed hyponatremia. In binary logistic regression analysis, age >60 years (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.16-4.26; P = 0.017), the nadir sodium concentration on POD 1-2 (OR, 0.88; 95% CI, 0.77-0.99; P = 0.034), and operation time (OR, 1.01; 95% CI, 1.00-1.02; P = 0.018) were independent risk factors for delayed hyponatremia after endoscopic transsphenoidal pituitary surgery.

CONCLUSIONS

The incidence of delayed hyponatremia in patients with nonfunctioning pituitary tumor who underwent endoscopic transsphenoidal surgery was 22.6%. Old age, low sodium concentration on POD 1-2, and long operation time were associated with the development of delayed hyponatremia in such patients.

Strategies to reduce readmissions for hyponatremia after transsphenoidal surgery for pituitary adenomas

PURPOSE

Disorders of water balance, particularly hyponatremia from altered antidiuretic hormone (ADH) secretion, are a common post-operative complication of transsphenoidal surgery (TSS). We present our results from implementation of a 2-week 1.5 liter/daily fluid restriction on readmission rates for hyponatremia.

METHODS

A retrospective chart review was performed on 295 patients that underwent TSS for pituitary adenomas at the University of Colorado, between March 2014 and March 2017. Groups were divided into those before and after the implementation of a two-week, 1.5 liter daily fluid restriction and measurement of a serum sodium level 7 days (+/- 2 days) after discharge. A standard-of-care approach for variable degrees of hyponatremia was also utilized to guide hyponatremia management. Patient demographics, hospital course, post-operative complication rates, and rates of hospital admissions for hyponatremia were then evaluated.

RESULTS

Readmissions for symptomatic hyponatremia within 30 days of TSS occurred in 9 of 118 (7.6%) of patients prior to fluid restriction implementation and in four of 169 (2.4%) of patients in the post-implementation, fluid-restricted group (p-value = 0.04): a 70% reduction in hospitalizations. The two groups were similarly matched for pituitary tumor sub-type, age and gender. None of these factors were predictive for hyponatremia. Importantly, the mild fluid restriction did not result in any hospital readmissions for hypernatremia.

CONCLUSIONS

Mild fluid restriction (to 1.5 liters daily), in addition to a single post-operative serum sodium level, is an effective approach to preventing readmission for hyponatremia after TSS for pituitary adenomas.

The socioeconomic determinants for transsphenoidal pituitary surgery: a review of New York State from 1995 to 2015

BACKGROUND

Prolonged length of stay (pLOS), disease-related complications, and 30-day readmissions are important quality metrics under the Affordable Care Act. The purpose of our study was to investigate the effect of patient-level and hospital-level factors on these outcomes for patients admitted for transsphenoidal pituitary surgery.

METHODS

The Statewide Planning and Research Cooperative System (SPARCS) database was queried to investigate 30-day readmissions and pLOS for transsphenoidal pituitary surgery in New York from 1995 to 2015. Multivariate logistic regression, adjusting for patient and hospital characteristics, was performed to assess the effect of these variables on the outcomes of interest.

RESULTS

A total of 9950 patients underwent transsphenoidal pituitary surgery; 7122 (72%), 2394 (24%), and 434 (4%) patients were treated at high-volume, medium-volume, and low-volume centers, respectively. Patient factors associated with treatment at high-volume centers (HVCs) included: top income quartile, private insurance, urban residence, and white or Asian race (p < 0.05). Patient variables associated with treatment at low-volume centers (LVCs) included: age >65 years, elevated Charlson comorbidity index (CCI) scores, bottom income quartile, Medicaid and Medicare insurance, rural residence, black race, and Hispanic ethnicity (p < 0.05). Variables predictive of prolonged hospitalizations in our multivariable model included black race, Hispanic ethnicity, Medicaid insurance, low income, female gender, LVC, and comorbidities (panhypopituitarism, hypothyroidism, diabetes insipidus [DI], visual disturbances, CCI) while predictors of readmissions included Asian race, female gender, and comorbidities (Cushing syndrome, DI, CCI).

CONCLUSION

Patients undergoing transsphenoidal pituitary surgery at HVCs have shorter hospitalizations, fewer postoperative electrolyte abnormalities, and lower charges; however, socioeconomic factors may influence access to quality care.

Implementation of a Postoperative Outpatient Care Pathway for Delayed Hyponatremia Following Transsphenoidal Surgery

BACKGROUND

After transsphenoidal surgery, delayed hyponatremia (DH) is the leading cause of 30-d unplanned hospital readmissions.

OBJECTIVE

To determine the impact of a DH care pathway on 30-d readmissions after transsphenoidal surgery.

METHODS

Data from before and after DH care pathway implementation were retrospectively reviewed. Patient demographics and clinical characteristics were compared. Readmission causes, clinical pathway failures, sodium trends, and symptoms were evaluated.

RESULTS

Before the DH care pathway implementation, 229 (55%) patients were treated (group 1); afterward, 188 (45%) were treated (group 2). Baseline characteristics were equivalent between groups, except for glucocorticoid supplementation, which was higher in group 2. The incidence of detected DH was significantly lower in group 1 (16/229, 7%) than group 2 (29/188, 15%) (P = .006) likely due to the impact of routine screening in group 2. Ten group 1 patients (4%) were readmitted for hyponatremia and 6 (3%) were managed as outpatients. Eleven group 2 patients (6%) were readmitted and 17 (9%) were managed as outpatients. Readmission rates between groups were similar (P = .49). Patients readmitted with severe hyponatremia experienced symptoms ≥24 h before presentation. The protocol failed to prevent readmission because outpatient management for mild or moderate DH (n = 4) failed, sodium levels precipitously declined after normal screening (n = 3), and severe hyponatremia developed after scheduled screenings were missed (n = 3).

CONCLUSION

Although more DH patients were identified after care pathway implementation, readmission rates were not reduced and clinical outcomes were not changed. Because DH onset timing varies, some patients have highly acute presentation, and most readmitted patients develop symptoms before reaching their sodium nadir, close symptom monitoring may be a reasonable alternative to routine screening.

A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery

INTRODUCTION

Patients undergoing transsphenoidal pituitary surgery (TSS) are at risk for several serious complications, including the syndrome of inappropriate antidiuretic hormone and subsequent hyponatremia.

OBJECTIVE

In this study, we examined the effect of 1 week of post-discharge fluid restriction to 1.0 L daily on rates of post-operative readmission for hyponatremia.

METHODS

We retrospectively analyzed all patients undergoing TSS from 2008 to 2014 and prospectively recorded patient data from 2015 to 2017. Patients were divided into a control cohort (2008-2014), who were discharged with instructions to drink to thirst; and an intervention cohort (2015-2017) who were instructed to drink less than 1.0 L daily for 1 week post-operatively.

RESULTS

This study included 788 patients; 585 (74.2%) in the control cohort and 203 (25.8%) in the intervention cohort. Overall, 436 (55.3%) were women, the median age was 47 (range 15-89), and average BMI was 29.4 kg/m² (range 17.7-101.7). Patients were relatively well matched. Of patients in the intervention group, none was readmitted for hyponatremia (0/203), compared to 3.41% (20/585) in the control group (p = 0.003). Patients in the intervention group also had significantly higher post-operative week one sodium levels (140.1 vs 137.5 mEq/L; p = 0.002). No fluid balance complications occurred in patients who followed this protocol.

CONCLUSION

Hyponatremia can be a life-threatening complication of TSS, and prevention of readmission for hyponatremia can help improve patient safety and decrease costs. Mandatory post-discharge fluid restriction is a simple and inexpensive intervention associated with decreased rates of readmission for hyponatremia and normal post-operative sodium levels.

Primary Dural Closure for Retrosigmoid Approaches

Object  Primary closure of posterior fossa dura can be challenging, and postoperative cerebrospinal fluid (CSF) leaks continue to represent a common complication of the retrosigmoid approach. We describe a simple technique to allow for primary closure of the dura following retrosigmoid approaches. The incidence of CSF leaks using this method is reported.

Methods  A retrospective chart review was conducted on all cases of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The primary outcome was development of postoperative CSF leak or pseudomeningocele. Length of stay, lesion type, and other surgical complications were also reported.

Results  Eighty-six patients underwent a retrosigmoid craniotomy during the study period. The most common indications for retrosigmoid craniotomy were microvascular decompression (58%) and tumor resection (36%). No allo- or autografts to repair the dural defect were needed, and no lumbar drains were used. No patients developed CSF otorrhea, rhinorrhea, or incisional leak postoperatively.

Conclusion  Primary dural closure is possible in retrosigmoid approaches without the use of allo- or autografts and may prevent postoperative CSF leaks when combined with other posterior fossa closure techniques. Careful attention to the handling of the dural flap is necessary to achieve this.

Thirty-Day Hospital Revisit Rates and Factors Associated With Revisits in Patients Undergoing Septorhinoplasty

Importance

Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies.

Objective

To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits.

Design, Setting, and Participants

A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015.

Main Outcomes and Measures

Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure.

Results

In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02-1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06-1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16-1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32-1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33-2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20-6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33-3.20), anxiety (aOR, 1.79; 99% CI, 1.55-2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35-2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29-3.14).

Conclusions and Relevance

The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties.

Level of Evidence

3.

Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Readmission and Other Adverse Events after Transsphenoidal Surgery: Prevalence, Timing, and Predictive Factors

BACKGROUND

Transsphenoidal surgery is a common neurosurgical procedure for accessing the pituitary and anterior skull base, yet few multicenter analyses have evaluated outcomes after this procedure.

STUDY DESIGN

Patients undergoing transsphenoidal surgery from 2006 to 2015 were extracted from the American College of Surgeons NSQIP database. Logistic regression was used to identify predictors of 30-day complications.

RESULTS

Of 1,240 patients included in this analysis, 6.9% experienced a major complication, and 9.4% experienced any complication within 30 days. Other adverse events included death in 0.7% and nonroutine hospital discharge in 5.3%. Most adverse events occurred within the first 2 weeks postoperatively; 82.9% of patients experienced their first complication during the initial hospital stay. Multivariable analysis demonstrated that predictors of hospital stay longer than 4 days included American Society of Anesthesiologists classification III to V (p = 0.015), insulin-dependent diabetes mellitus (p < 0.001), and operative time in the third and fourth quartiles (both p < 0.001). American Society of Anesthesiologists classification III to V and operative time in the fourth quartile were also predictors of any adverse event (p = 0.01 and p = 0.005, respectively). Among these patients, 3.7% underwent reoperation, the most common reason for which was postoperative cerebrospinal fluid leak (63.6%). Readmission occurred after 8.5% of cases at a median of 11.0 days post-discharge. The most common cause of readmission was hyponatremia (29.5%), followed by delayed postoperative cerebrospinal fluid leak (16.0%).

CONCLUSIONS

Overall rates of adverse events in patients undergoing transsphenoidal surgery are relatively low, and most occur before discharge from the hospital. Post-discharge complications associated with transsphenoidal surgery include deep vein thrombosis, pulmonary embolism, and urinary tract infection. Delayed postoperative cerebrospinal fluid leak is the major cause of reoperation, and hyponatremia is the major cause of readmission.

Incidence and Risk Factors for Prolonged Hospitalization and Readmission after Transsphenoidal Pituitary Surgery

Objective

To evaluate the incidence and factors associated with 30-day readmission and to analyze risk factors for prolonged hospital length of stay following transsphenoidal pituitary surgery.

Study Design

Retrospective longitudinal claims analysis.

Setting

American College of Surgeons National Surgical Quality Improvement Program.

Subjects and Methods

The database of the American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent transsphenoidal pituitary surgery ( Current Procedural Terminology code 61548 or 62165) between 2005 and 2014. Patient demographic information, indications for surgery, and incidence of hospital readmission and length of stay were reviewed. Risk factors for readmission and prolonged length of stay, defined as >75th percentile for the cohort, were identified through logistic regression modeling.

Results

A total of 1006 patients were included for analysis. Mean hospital length of stay after surgery was 4.1 ± 0.2 days. Predictors of prolonged length of stay were operative time ( P < .001, odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 1.5-2.0), bleeding disorder ( P = .049, OR = 3.1, 95% CI = 1.0-9.5), insulin-dependent diabetes ( P = .007, OR = 2.4, 95% CI = 1.3-4.4), and reoperation ( P < .001, OR = 10.3, 95% CI = 4.7-23.9). In a subset analysis of 529 patients who had surgery between 2012 and 2014, 7.2% (n = 38) required hospital readmission. History of congestive heart failure (CHF) was a predictor of hospital readmission ( P = 0.03, OR = 12.7, 95% CI = 1.1-144.0).

Conclusion

This review of a large validated surgical database demonstrates that CHF is an independent predictor of hospital readmission after transsphenoidal surgery. Although CHF is a known risk factor for postoperative complications, it poses unique challenges to patients with potential postoperative pituitary dysfunction.