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Turner EM, Olsen E, Duvall S. Neurocognition in Pediatric Temporal Lobe Tumor-Related Epilepsy. Dev Neuropsychol 2024; 49:178-189. [PMID: 38753032 DOI: 10.1080/87565641.2024.2354745] [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: 10/31/2023] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
Tumor-related epilepsy is a common and understudied neurological comorbidity among pediatric temporal lobe tumor patients that poses risk for neurocognitive impairment (NCI). Forty-one youth with either TLT+ (n = 23) or nonneoplastic temporal lobe epilepsy (n = 18) ages 6-20 years completed routine neuropsychological evaluations. Rates of NCI were similar across groups; however, NCI was more common in nonneoplastic participants on a task of phonemic fluency, p = .047. Younger age of seizure onset and greater number of antiseizure medications were associated with NCI among TLT+ participants only. Preliminary findings suggest separate prognostic models of cognitive outcomes between TLT+ and nonneoplastic epilepsy populations may be needed.
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Affiliation(s)
- Elise M Turner
- Section of Neurology, Department of Pediatrics, Children's Hospital Colorado/University of Colorado School of Medicine, Portland, Oregon, USA
| | - Emily Olsen
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Susanne Duvall
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
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2
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Sayeed S, Theriault BC, Hengartner AC, Ahsan N, Sadeghzadeh S, Elsamadicy EA, DiLuna M, Elsamadicy AA. Insurance Disparities in Patient Outcomes and Healthcare Resource Utilization Following Neonatal Intraventricular Hemorrhage. World Neurosurg 2024:S1878-8750(24)00899-4. [PMID: 38815926 DOI: 10.1016/j.wneu.2024.05.136] [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: 04/03/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Within the field of pediatric neurosurgery, insurance status has been shown to be associated with surgical delay, longer time to referral, and longer hospitalization in epilepsy treatment, myelomeningocele repair, and spasticity surgery.1,2 The aim of this study was to investigate the association of insurance status with inpatient adverse events (AEs), length of stay (LOS), and costs for newborns diagnosed with intraventricular hemorrhage (IVH). METHODS A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. Patients with a primary diagnosis of intraventricular hemorrhage were identified using ICD-10-CM diagnostic and procedural codes. Patients were categorized based on insurance status: Medicaid or Private Insurance (PI). Multivariate logistic regression analyses were used to identify the impact of insurance status on extended LOS (defined as >75th percentile of LOS) and exorbitant cost (defined as >75th percentile of cost). RESULTS Demographics differed significantly between groups, with the majority of newborns in the PI cohort being White (Medicaid: 35.8% vs. PI: 60.3%, P < 0.001) and the majority of Medicaid patients being in the 0-25th quartile of household income (Medicaid: 40.9% vs. PI: 12.9%, P < 0.001). While insurance status was not independently associated with increased odds of extended LOS or exorbitant cost, Medicaid patients had a greater mean LOS and total cost of admission than PI patients. CONCLUSIONS Demographic characteristics, mean LOS, and mean total cost differed significantly between Medicaid and PI patients, indicating potential disparities based on insurance status. However, insurance status was not independently associated with increased healthcare utilization, necessitating further research in this area of study.
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Affiliation(s)
- Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Brianna C Theriault
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nabihah Ahsan
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sina Sadeghzadeh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Emad A Elsamadicy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Vanderbilt University, Nashville, Tennessee, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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3
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Bushong EE, Patmon D, Pfershy H, Huffman C, Carlson A, Girotto J. Timing of Alveolar Bone Graft and Barriers to Care. Cleft Palate Craniofac J 2024:10556656241242695. [PMID: 38576319 DOI: 10.1177/10556656241242695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG. DESIGN A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates. SETTING Single-institution, primary cleft care center. PATIENTS 202 patients with cleft palates who underwent ABG. INTERVENTIONS ABG. MAIN OUTCOME MEASURES Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years). RESULTS Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p = .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p = .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p = .0001). CONCLUSION Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.
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Affiliation(s)
| | - Darin Patmon
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Corewell Health, Grand Rapids, MI, USA
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
| | - Hanna Pfershy
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | | | - Anna Carlson
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
- Pediatric Plastic and Craniofacial Surgery, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - John Girotto
- Corewell Health/Michigan State University Plastic Surgery Residency, Grand Rapids, MI, USA
- Pediatric Plastic and Craniofacial Surgery, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
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Patel N, Rock M, Dowlati E, Phan T, Sanchez CE, Myseros JS, Oluigbo C, Syed HR, Donoho DA, Keating RF. Socioeconomic Disparities Affecting the Presentation and Outcomes in Pediatric Subdural Empyema Patients. Neurosurgery 2024; 94:764-770. [PMID: 37878410 DOI: 10.1227/neu.0000000000002741] [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: 02/01/2023] [Accepted: 06/12/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric subdural empyemas (SDE) carry significant morbidity and mortality, and prompt diagnosis and treatment are essential to ensure optimal outcomes. Nonclinical factors affect presentation, time to diagnosis, and outcomes in several neurosurgical conditions and are potential causes of delay in presentation and treatment for patients with SDE. To evaluate whether socioeconomic status, race, and insurance status affect presentation, time to diagnosis, and outcomes for children with subdural empyema. METHODS We conducted a retrospective cohort study with patients diagnosed with SDE between 2005 and 2020 at our institution. Information regarding demographics (age, sex, zip code, insurance status, race/ethnicity) and presentation (symptoms, number of prior visits, duration of symptoms) was collected. Outcome measures included mortality, postoperative complications, length of stay, and discharge disposition. RESULTS 42 patients were diagnosed with SDE with a mean age of 9.5 years. Most (85.7%) (n = 36) were male ( P = .0004), and a majority, 28/42 (66.7%), were African American ( P < .0001). There was no significant difference in socioeconomic status based on zip codes, although a significantly higher number of patients were on public insurance ( P = .015). African American patients had a significantly longer duration of symptoms than their Caucasian counterparts (8.4 days vs 1.8 days P = .0316). In total, 41/42 underwent surgery for the SDE, most within 24 hours of initial neurosurgical evaluation. There were no significant differences in the average length of stay. The average length of antibiotic duration was 57.2 days and was similar for all patients. There were no significant differences in discharge disposition based on any of the factors identified with most of the patients (52.4%) being discharged to home. There was 1 mortality (2.4%). CONCLUSION Although there were no differences in outcomes based on nonclinical factors, African American men on public insurance bear a disproportionately high burden of SDE. Further investigation into the causes of this is warranted.
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Affiliation(s)
- Nirali Patel
- Department of Neurosurgery, Children's National Hospital, Washington , District of Columbia , USA
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Hatoum R, Nathoo-Khedri N, Shlobin NA, Wang A, Weil AG, Fallah A. Barriers to Epilepsy Surgery in Pediatric Patients: A Scoping Review. Seizure 2022; 102:83-95. [DOI: 10.1016/j.seizure.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/05/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
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6
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Alayon AL, Hagerty V, Hospedales E, Botros J, Levene T, Samuels S, Spader H. Impact of insurance status, hospital ownership type, and children's hospital designation on outcomes for pediatric neurosurgery patients following spasticity procedures in the USA. Childs Nerv Syst 2021; 37:3881-3889. [PMID: 34467419 DOI: 10.1007/s00381-021-05317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aims to examine the relationship between insurance status, hospital ownership type, and children's hospital designation with outcomes for pediatric patients undergoing neurosurgical treatment for spasticity. METHODS This retrospective cohort study utilized the Healthcare Cost and Utilization Project Kids' Inpatient Database and included 11,916 pediatric patients (≤ 17 years of age) who underwent neurosurgical treatment for spasticity between 2006 and 2012 using ICD-9-CM procedure codes. RESULTS Uninsured patients had a significantly shorter hospital length of stay compared to Medicaid patients (-1.42 days, P = 0.030) as did privately insured patients (-0.74 days; P = 0.035). Discharge disposition and inpatient mortality rate were not associated with insurance status. There were no significant associations with hospital ownership type. Free-standing children's hospitals retained patients significantly longer compared to non-children's hospitals (+1.48 days; P = 0.012) and had a significantly higher likelihood of favorable discharge disposition (P = 0.004). Mortality rate was not associated with children's hospital designation. CONCLUSION Pediatric patients undergoing neurosurgical treatment for spasticity were more likely to stay in the hospital longer if they were insured by Medicaid or treated in a free-standing children's hospital. In addition, patients in free standing children's hospitals were more likely to be discharged with a favorable disposition.
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Affiliation(s)
- Amaris L Alayon
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
| | - Vivian Hagerty
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
| | - Emilio Hospedales
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
| | - James Botros
- Department of Neurosurgery, School of Medicine, University of New Mexico, NM, 87131, Albuquerque, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, 1150 N 35th Ave, Hollywood, FL, 33021, USA
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, 4411 Sheridan St, Hollywood, FL, 33021, USA
| | - Heather Spader
- Department of Neurosurgery, School of Medicine, University of New Mexico, NM, 87131, Albuquerque, USA. .,Division of Pediatric Neuroscience, Joe DiMaggio Children's Hospital, 1150 N 35th Ave, Hollywood, FL, 33021, USA.
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Buttle SG, Muir K, Dehnoei S, Webster R, Tu A. Referral practices for epilepsy surgery in pediatric patients: A North American Study. Epilepsia 2021; 63:86-95. [PMID: 34747508 DOI: 10.1111/epi.17122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients with epilepsy who do not respond to two trials of appropriate antiepileptic drugs are considered to have drug-resistant epilepsy (DRE). The International League Against Epilepsy recommends patients with DRE be referred for surgical evaluation; however, prior literature suggests this is an underutilized intervention, especially in the pediatric setting. This study captures practices of North American pediatric neurologists regarding the management of DRE and factors that may promote or limit referrals for epilepsy surgical evaluation. METHODS A REDCap survey was distributed via the Child Neurology Society mailing list to pediatric neurologists practicing in North America. Ethics approval from the Children's Hospital of Eastern Ontario Research Ethics Board was granted prior to the start of data collection. RESULTS Ninety-eight responses were included in the analysis; 77% of participants currently practice in the United States; 73.5% of respondents reported they would refer a patient for surgical consultation after two failed medications. Of all potential predictors tested in a binary logistic regression model, only annual referral volume predicted whether participants refer patients after three or more failed medications. Centers with high referral volume were 37% more likely to adhere to the guideline of referral after two failed medications. SIGNIFICANCE Pediatric neurologists demonstrate fair knowledge of formal recommendations to refer patients for surgical evaluation after two failed medication trials, although referral rates remain unacceptably low. Participants continue to report that they would not refer patients with generalized electroencephalographic findings for surgical evaluation; this should continue to be addressed. Other modifiable factors reported, especially family perceptions of epilepsy surgery, should be prioritized when developing tools to enhance effective referrals and increase utilization of epilepsy surgery in the management of pediatric DRE.
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Affiliation(s)
- Sarah Grace Buttle
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Katherine Muir
- Division of Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sajjad Dehnoei
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Richard Webster
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Albert Tu
- Division of Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Lechtholz-Zey E, Bonney PA, Cardinal T, Mendoza J, Strickland BA, Pangal DJ, Giannotta S, Durham S, Zada G. Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in the Treatment of Pediatric Neurosurgical Diseases in the United States. World Neurosurg 2021; 158:65-83. [PMID: 34718199 DOI: 10.1016/j.wneu.2021.10.150] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Increasing light is being shed on how race, insurance, and socioeconomic status (SES) may be related to outcomes from disease in the United States. To better understand the impact of these health care disparities in pediatric neurosurgery, we performed a systematic review of the literature. METHODS We conducted a systematic review using PRISMA guidelines and MeSH terms involving neurosurgical conditions and racial, ethnic, and SES disparities. Three independent reviewers screened articles and analyzed texts selected for full analysis. RESULTS Thirty-eight studies were included in the final analysis, of which all but 2 were retrospective database reviews. Thirty-four studies analyzed race, 22 analyzed insurance status, and 13 analyzed SES/income. Overall, nonwhite patients, patients with public insurance, and patients from lower SES were shown to have reduced access to treatment and greater rates of adverse outcomes. Nonwhite patients were more likely to present at an older age with more severe disease, less likely to undergo surgery at a high-volume surgical center, and more likely to experience postoperative morbidity and mortality. Underinsured and publicly insured patients were more likely to experience delay in surgical referral, less likely to undergo surgical treatment, and more likely to experience inpatient mortality. CONCLUSIONS Health care disparities are present within multiple populations of patients receiving pediatric neurosurgical care. This review highlights the need for continued investigation into identifying and addressing health care disparities in pediatric neurosurgery patients.
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Affiliation(s)
- Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Susan Durham
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; Division of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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9
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Underrepresented Populations in Pediatric Epilepsy Surgery. Semin Pediatr Neurol 2021; 39:100916. [PMID: 34620462 DOI: 10.1016/j.spen.2021.100916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
As awareness of pediatric epilepsy increases, accompanied by advancements in technology and research, it is important to identify certain types of patients that are overlooked for surgical management of epilepsy. Identifying these populations will allow us to study and elucidate the factors contributing to the underutilization and/or delayed application of surgical interventions. Demographically, African-American and Hispanic patients, as well as patients of certain Asian ethnicities, have relatively lower rates of undergoing epilepsy surgery than non-Hispanic and white patients. Among patients with epilepsy, those with higher odds of seizure-freedom following surgery are more likely to be referred for surgical evaluation by their neurologists, with the most common diagnosis being lesional focal epilepsy. However, patients with multifocal or generalized epilepsy, genetic etiologies, or normal (non-lesional) brain magnetic resonance imaging (MRI) are less likely be to referred for evaluation for resective surgery. With an increasing number of high-quality imaging modalities to help localize the epileptogenic zone as well as new techniques for both curative and palliative epilepsy surgery, there are very few populations of patients and/or types of epilepsy that should be precluded from evaluation to determine the suitability of epilepsy surgery. Ultimately, a clearer understanding of the populations who are underrepresented among those considered for epilepsy surgery, coupled with further study of the underlying reasons for this trend, will lead to less disparity in access to this critical treatment among patients with epilepsy.
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Hagerty V, Hospedales E, Alayon A, Samuels S, Levene T, Spader H. Association of hospital characteristics and insurance type with quality outcomes for pediatric craniosynostosis patients. Clin Neurol Neurosurg 2021; 207:106742. [PMID: 34126452 DOI: 10.1016/j.clineuro.2021.106742] [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: 02/12/2021] [Revised: 04/29/2021] [Accepted: 05/22/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Our study aimed to assess the association of insurance status and hospital ownership type with inpatient hospital outcomes among a nationally representative population of pediatric craniosynostosis neurosurgery patients. METHODS This retrospective cohort study utilized data from the Healthcare Cost and Utilization Project 2006-2012 Kids Inpatient Database. Primary outcomes including length of stay, and favorable discharge disposition were assessed for all pediatric neurosurgery patients who underwent a neurosurgical procedure for craniosynostosis. RESULTS Pediatric neurosurgery patients with private insurance had a reduced length of stay of 0.75 days compared to patients insured by Medicaid. Compared to private, investor-owned hospitals, Government, non-federal, and private, not for profit hospital ownership types were associated with an increased length of stay greater than 1 day. CONCLUSIONS Our finding of increased LOS for craniosynostosis patients seen in other hospital ownership types compared to those seen in private, investor-owned hospitals is indicative of the possible role that financial incentives may play in influencing quality metrics. Although we observed a shortened LOS for privately-insured patients compared to patients insured by Medicaid, we found no difference in favorable discharge disposition based on insurance status. This suggests that patients with shorter LOS have similar outcomes and are likely not being prematurely discharged.
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Affiliation(s)
- Vivian Hagerty
- Florida Atlantic University, College of Medicine, 777 Glades Road, Boca Raton, FL 33431, USA
| | - Emilio Hospedales
- Florida Atlantic University, College of Medicine, 777 Glades Road, Boca Raton, FL 33431, USA
| | - Amaris Alayon
- Florida Atlantic University, College of Medicine, 777 Glades Road, Boca Raton, FL 33431, USA
| | - Shenae Samuels
- Office of Human Research, Memorial Healthcare System, 4411 Sheridan Street, Hollywood, FL 33021, USA
| | - Tamar Levene
- Division of Pediatric Surgery, Joe DiMaggio Children's Hospital, 1150 N 35th Ave., Hollywood, FL 33021, USA
| | - Heather Spader
- Department of Neurosurgery, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87106, USA.
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Peterson K, LaRoche S, Cummings T, Woodard V, Moise AM, Munger Clary H. Addressing the epilepsy surgery gap: Impact of community/tertiary epilepsy center collaboration. Epilepsy Behav Rep 2020; 14:100398. [PMID: 33313499 PMCID: PMC7720013 DOI: 10.1016/j.ebr.2020.100398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Collaboration agreements can improve epilepsy surgery referral volumes. Standardized referral pathways may help address epilepsy surgery gap. Internal and external process changes can improve referral process. Sociodemographic variables continue to influence referral completion.
To assess whether a formal collaboration between a non-surgical, community epilepsy center and a surgical, tertiary-care epilepsy center can improve patient progress throughout the pre-surgical referral process, and to elucidate predictors of referral completion among inter-center referrals. The inter-center referral process was tracked, and the number of patients completing surgical conference (primary outcome) and epilepsy surgery at the tertiary center were collected and compared in the 45-month immediate pre/post-collaboration periods. Demographic and clinical variables were collected on post-collaboration inter-center patient referrals to explore factors associated with completion of the referral process. Compared to the pre-collaboration period, the proportion of tertiary center epilepsy surgery conference patients referred from the community epilepsy center increased from 3/88 to 14/113 (263% increase, p = .01) during the post-collaboration period. The proportion of patients completing surgery via the community to tertiary referral process increased from 2/63 pre-collaboration to 8/71 post-collaboration (254% increase, p = .04). Referral completion was associated with higher seizure frequency, shorter travel distance, private insurance status and positive employment status (p < 0.05). Collaboration agreements between community and tertiary-care epilepsy centers may improve patient completion of the epilepsy surgery referral process. Implementation of similar programs at other centers may be beneficial in reducing the epilepsy surgery gap.
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Affiliation(s)
- Keyan Peterson
- Wake Forest University School of Medicine, Department of Neurology, Winston-Salem, NC, USA
| | | | - Tiffany Cummings
- Wake Forest University School of Medicine, Department of Neurology, Winston-Salem, NC, USA
| | - Valerie Woodard
- Wake Forest University School of Medicine, Department of Neurology, Winston-Salem, NC, USA
| | | | - Heidi Munger Clary
- Wake Forest University School of Medicine, Department of Neurology, Winston-Salem, NC, USA
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12
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Hagerty V, Samuels S, Levene T, Patel D, Levene H, Spader H. Inpatient Hospital Outcomes and its Association with Insurance Type Among Pediatric Neurosurgery Trauma Patients. World Neurosurg 2020; 141:e484-e489. [DOI: 10.1016/j.wneu.2020.05.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
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Pan I, LoPresti MA, Clarke DF, Lam S. The Effectiveness of Medical and Surgical Treatment for Children With Refractory Epilepsy. Neurosurgery 2020; 88:E73-E82. [DOI: 10.1093/neuros/nyaa307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 05/02/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Pediatric refractory epilepsy affects quality of life, clinical disability, and healthcare costs for patients and families.
OBJECTIVE
To show the impact of surgical treatment for pediatric epilepsy on healthcare utilization compared to medically treated pediatric epilepsy over 5 yr.
METHODS
The Pediatric Health Information System database was used to conduct a cohort study using 5 published algorithms. Refractory epilepsy patients treated with antiepileptic medications (AEDs) only or AEDs plus epilepsy surgery between 1/1/2008 and 12/31/2014 were included. Healthcare utilization following the index date at 2 and 5 yr including inpatient, emergency department (ED), and all epilepsy-related visits were evaluated. The propensity scores (PS) method was used to match surgically and medically treated patients. PS. SAS® 9.4 and Stata 14.0 were used for data management and statistical analysis.
RESULTS
A total of 2106 (17.1%) and 10186 (82.9%) were surgically and medically treated. A total of 4050 matched cases, 2025 per each treated group, were included. Compared to medically treated patients, utilization was reduced in the surgical group: at 2 and 5 yr postindex date, there was a reduction of 36% to 37% of inpatient visits and 47% to 50% of ED visits. The total number (inpatient, ED, ambulatory visits) of epilepsy-associated visits were reduced by 39% to 43% in the surgical group compared to the medically treated group. In those who had surgery, the average reduction in AEDs was 16% at 2 and 5 yr after treatment.
CONCLUSION
Patients with refractory epilepsy treated with surgery had significant reductions in healthcare utilization compared with patients treated only with medications.
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Affiliation(s)
- Iwen Pan
- Department of Health Services Research, Division of Cancer Prevention and Population Sciences, Houston, Texas
| | | | - Dave F Clarke
- Division of Pediatric Neurology, Department of Neurology, University of Texas at Austin Medical School, Austin, Texas
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Pan IW, Lam S, Clarke DF, Shih YCT. Insurance transitions and healthcare utilization for children with refractory epilepsy. Epilepsy Behav 2018; 89:48-54. [PMID: 30384099 DOI: 10.1016/j.yebeh.2018.09.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of the study is to investigate the association between insurance transitions and healthcare utilization among children with refractory epilepsy. METHODS We applied published algorithms to identify the study cohort of children with a diagnosis of refractory epilepsy who were treated between 10/1/2013 and 9/30/2014 at 36 children's hospitals in the United States. Insurance transition was defined as having any change in the type of primary payer from the first date of diagnosis to the date of the last visit at the same hospital. Univariate and multilevel multivariable analytical methods were used in the study. RESULTS Among 3488 children hospitalized with refractory epilepsy, rates of insurance transitions at 1, 2, and 5 years of refractory epilepsy diagnosis were 8.1%, 14%, and 29.9%, respectively. Patients whose primary payer at diagnosis was Private or Others were more likely to experience insurance transitions than patients whose primary payer was Medicaid. Younger children were associated with a higher risk of insurance transitions than older children. The high intensity of insurance transitions was associated with a higher number of emergency department and inpatient visits. CONCLUSIONS Insurance transitions interrupted the continuity of medical care for children with refractory epilepsy and were associated with more frequent hospitalizations and emergency department visits, which then translated to higher healthcare costs. Medicaid provided stable insurance coverage and is critically important for these patients and should be the main focus for policies aiming to minimize insurance transitions and optimize healthcare delivery.
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Affiliation(s)
- I-Wen Pan
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Sandi Lam
- Baylor College of Medicine, Department of Neurosurgery, 7200 Cambridge St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurosurgery, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Dave Fitzgerald Clarke
- Baylor College of Medicine, Department of Pediatrics, Neurology and Developmental Neuroscience Section, 6701 Fannin St, Houston, TX 77030, United States of America; Texas Children's Hospital, Department of Neurology, Epilepsy Center, 6701 Fannin St, Houston, TX 77030, United States of America.
| | - Ya-Chen Tina Shih
- University of Texas MD Anderson Cancer Center, Department of Health Services Research, 1155 Pressler St., Houston, TX 77030, United States of America.
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15
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Harris VC, Links AR, Kim JM, Walsh J, Tunkel DE, Boss EF. Follow-up and Time to Treatment in an Urban Cohort of Children with Sleep-Disordered Breathing. Otolaryngol Head Neck Surg 2018; 159:371-378. [PMID: 29685083 PMCID: PMC6551520 DOI: 10.1177/0194599818772035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/30/2018] [Indexed: 12/22/2022]
Abstract
Objective To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care. Study Design Retrospective longitudinal cohort analysis. Setting Tertiary health system. Subjects and Methods Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity. Results Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410). Conclusion In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.
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Affiliation(s)
- Vandra C. Harris
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Anne R. Links
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Julia M. Kim
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Jonathan Walsh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - David E. Tunkel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Emily F. Boss
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Medical Institutions, Baltimore, Maryland
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16
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Prideaux L, Barton S, Maixner W, Harvey AS. Potential delays in referral and assessment for epilepsy surgery in children with drug-resistant, early-onset epilepsy. Epilepsy Res 2018; 143:20-26. [PMID: 29631130 DOI: 10.1016/j.eplepsyres.2018.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 03/17/2018] [Accepted: 04/02/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To study potential delays in epilepsy surgery in children with drug-resistant epilepsy (DRE) of early-onset. METHODS Medical records were reviewed from 87 children with DRE and seizure onset before age 3 years who underwent epilepsy surgery between 2006 and 2015. Information was obtained about each child's epilepsy, treatment and specific time points in management. Time intervals along diagnostic, investigative, treatment and referral pathways were calculated. RESULTS Median ages at seizure onset, when seen in the epilepsy surgery program and surgery were 5.9 (IQR 10), 19 (IQR 29) and 36 (IQR 67) months; the median delay from seizure onset to surgery was 30 (IQR 67) months. Most children were promptly diagnosed, treated, investigated and seen by a pediatric neurologist. Focal abnormalities were reported on initial EEGs and MRIs in most children, and DRE developed within a median of 6.3 months from commencement of medication. There were median durations of 6.2 months between seeing a neurologist and being seen in the epilepsy surgery program, and then 6.1 months in determining surgical candidacy. Median durations from potential indications for a surgical evaluation to agreed surgical candidacy were 10 (DRE), 12 (focal MRI) and 17 (focal EEG) months. Children received a median of six antiepileptic drugs prior to surgery. Median interval from agreed surgical candidacy to surgery was only 3 months. There were longer durations from seizure onset to surgery in children needing PET (p = 0.001) and in children with seizure-free periods (p < 0.001), and shorter durations in children with a history of infantile spasms (p = 0.01). SIGNIFICANCE Delays in referral of children for epilepsy surgery are reported. Delays in assessment may be specific to centralized children's hospitals in public health systems.
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Affiliation(s)
- Laura Prideaux
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Sarah Barton
- Neurosciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia; Department of Neurology, The Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - Wirginia Maixner
- Neurosciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia; Department of Neurosurgery, The Royal Children's Hospital, Parkville, VIC 3052, Australia
| | - A Simon Harvey
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia; Neurosciences, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia; Department of Neurology, The Royal Children's Hospital, Parkville, VIC 3052, Australia.
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17
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Shen A, Quaid KT, Porter BE. Delay in pediatric epilepsy surgery: A caregiver's perspective. Epilepsy Behav 2018; 78:175-178. [PMID: 29126702 DOI: 10.1016/j.yebeh.2017.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
The timing of epilepsy surgery is complex, and there is not a structured pathway to help families decide whether to continue medical management or pursue surgical treatment. We surveyed caregivers of pediatric epilepsy surgery patients. Fifty-eight respondents answered the majority of questions. Thirty caregivers wished their child had undergone epilepsy surgery earlier compared with twenty who felt surgery was done at the appropriate time, and eight were unsure. In retrospect, caregivers who wished their child's surgery had been performed sooner had a significantly longer duration of epilepsy prior to the surgery [44.1±71.7 (months±standard deviation (SD), N=27)], compared with those who felt content with the timing of the surgery [12.8±14.1 (months±SD, N=20), p=0.0034]. Caregivers were willing to accept a lower likelihood of seizure freedom than their physician reported was likely. Most caregivers were willing to accept deficits in all domains surveyed; caregivers had high acceptance of motor deficits, cognitive deficits, behavioral change, and language loss. Future studies are needed to focus on how to improve the education of caregivers and neurologists about the benefits and risks of epilepsy surgery and accelerate the pipeline to epilepsy surgery to improve caregiver satisfaction.
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Affiliation(s)
- Alice Shen
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Kara T Quaid
- Case Western Reserve University, Department of Population and Quantitative Health Sciences, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Brenda E Porter
- Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
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18
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Abstract
First-line treatment for epilepsy is antiepileptic drug and requires an interdisciplinary approach and enduring commitment and adherence from the patient and family for successful outcome. Despite adherence to antiepileptic drugs, refractory epilepsy occurs in approximately 30% of children with epilepsy, and surgical treatment is an important intervention to consider. Surgical management of pediatric epilepsy is highly effective in selected patients with refractory epilepsy; however, an evidence-based protocol, including best methods of presurgical imaging assessments, and neurodevelopmental and/or behavioral health assessments, is not currently available for clinicians. Surgical treatment of epilepsy can be critical to avoid negative outcomes in functional, cognitive, and behavioral health status. Furthermore, it is often the only method to achieve seizure freedom in refractory epilepsy. Although a large literature base can be found for adults with refractory epilepsy undergoing surgical treatment, less is known about how surgical management affects outcomes in children with epilepsy. The purpose of the review was fourfold: (1) to evaluate the available literature regarding presurgical assessment and postsurgical outcomes in children with medically refractory epilepsy, (2) to identify gaps in our knowledge of surgical treatment and its outcomes in children with epilepsy, (3) to pose questions for further research, and (4) to advocate for a more unified presurgical evaluation protocol including earlier referral for surgical candidacy of pediatric patients with refractory epilepsy. Despite its effectiveness, epilepsy surgery remains an underutilized but evidence-based approach that could lead to positive short- and long-term outcomes for children with refractory epilepsy.
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19
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Wilson DA, Malek AM, Wagner JL, Wannamaker BB, Selassie AW. Mortality in people with epilepsy: A statewide retrospective cohort study. Epilepsy Res 2016; 122:7-14. [DOI: 10.1016/j.eplepsyres.2016.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 01/18/2016] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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20
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Lin Y, Pan IW, Harris DA, Luerssen TG, Lam S. The Impact of Insurance, Race, and Ethnicity on Age at Surgical Intervention among Children with Nonsyndromic Craniosynostosis. J Pediatr 2015; 166:1289-96. [PMID: 25919736 DOI: 10.1016/j.jpeds.2015.02.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 01/12/2015] [Accepted: 02/04/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the impact of demographic factors, including insurance type, family income, and race/ethnicity, on patient age at the time of surgical intervention for craniosynostosis surgery in the US. STUDY DESIGN The Kids' Inpatient Database was queried for admissions of children younger than 3 years of age undergoing craniosynostosis surgery in 2009. Descriptive data regarding age at surgery for various substrata are reported. Multivariate regression was used to evaluate the effect of patient and hospital characteristics on the age at surgery. RESULTS Children with private insurance were, on average, 6.8 months of age (95% CI 6.2-7.5) at the time of surgery; children with Medicaid were 9.1 months old (95% CI 8.4-9.8). White children received surgery at mean age of 7.2 months (95% CI 6.5-8.0) and black and Hispanic children at a mean age of 9.1 months (95% CI 8.2-10.1). Multivariate regression analysis found Medicaid insurance (beta coefficient [B]=1.93, P<.001), black or Hispanic race/ethnicity (B=1.34, P=.022), and having 2 or more chronic conditions (B=2.86, P<.001) to be significant independent predictors of older age at surgery. CONCLUSION Public insurance and nonwhite race/Hispanic ethnicity were statistically significant predictors for older age at surgery, adjusted for sex, zip code median family income, year, and hospital factors such as size, type, region, and teaching status. Further research into these disparities is warranted.
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Affiliation(s)
- Yimo Lin
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX; Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - I-Wen Pan
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX; Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Dominic A Harris
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX; Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX; Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX; Department of Neurosurgery, Baylor College of Medicine, Houston, TX.
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21
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Meekes J, van Schooneveld MMJ, Braams OB, Jennekens-Schinkel A, van Rijen PC, Hendriks MPH, Braun KPJ, van Nieuwenhuizen O. Parental education predicts change in intelligence quotient after childhood epilepsy surgery. Epilepsia 2015; 56:599-607. [DOI: 10.1111/epi.12938] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Joost Meekes
- Sector of Neuropsychology for Children and Adolescents; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
- Bio Research Center for Children; Arnhem The Netherlands
| | - Monique M. J. van Schooneveld
- Sector of Neuropsychology for Children and Adolescents; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | - Olga B. Braams
- Sector of Neuropsychology for Children and Adolescents; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
- Bio Research Center for Children; Arnhem The Netherlands
| | - Aag Jennekens-Schinkel
- Sector of Neuropsychology for Children and Adolescents; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
- Bio Research Center for Children; Arnhem The Netherlands
| | - Peter C. van Rijen
- Department of Neurosurgery; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | - Marc P. H. Hendriks
- Department of Behavioural Sciences; Kempenhaeghe Expertise Centre for Epileptology, Sleep Medicine and Neurocognition; Heeze The Netherlands
- Donders Institute for Brain; Cognition and Behavior; Radboud University Nijmegen; Nijmegen The Netherlands
| | - Kees P. J. Braun
- Department of Child Neurology; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
| | - Onno van Nieuwenhuizen
- Bio Research Center for Children; Arnhem The Netherlands
- Department of Child Neurology; Brain Center Rudolf Magnus; University Medical Center Utrecht; Utrecht The Netherlands
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22
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Lin Y, Harris DA, Curry DJ, Lam S. Trends in outcomes, complications, and hospitalization costs for hemispherectomy in the United States for the years 2000-2009. Epilepsia 2014; 56:139-46. [PMID: 25530220 DOI: 10.1111/epi.12869] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hemispherectomy is an established surgical treatment for carefully selected pediatric patients with intractable epilepsy. Published perioperative data report low mortality rates and seizure reduction rates of 50-89%. This study investigates trends in the demographics, hospital utilization, and in-hospital complication rates of patients undergoing hemispherectomy over the past decade in the United States, using the nationally representative Kids' Inpatient Database (KID). METHODS The KID was queried for all discharges with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code for hemispherectomy in the years 2000, 2003, 2006, and 2009. The patient cohorts from these four time points were compared, analyzing differences in demographic data, insurance and payer status, total cost, length of stay, in-hospital mortality, and complications. National estimates and 95% confidence intervals are reported given the weighted sample design of KID. RESULTS This study identified an estimated total of 552 hospital admissions for hemispherectomy surgery during the years studied in this cohort. The incidence of this procedure increased from 1.2/100,000 admissions in 2000 to 2.2/100,000 in 2009 (p=0.05). Mean age was 6.7 years (range 0-20). There were no significant changes in demographics (age, gender, or race), hospital descriptors (size or type), insurance type, or zip code income quartile. There was a significant increase in total cost, from $42,807 in 2003 to $57,443 in 2009 (p=0.015) (adjusted to 2009 dollars). There were no trends in postoperative complications. In-hospital mortality occurred in five subjects (0.9%). Ventricular shunt placement during hemispherectomy hospitalizations increased over time from 6.7% to 16.5% (p=0.056). Hospitals that performed two or more hemispherectomies yearly had a significantly decreased incidence of in-hospital mortality (odds ratio [OR] 0.08, p=0.04) and an increased incidence of blood transfusion (OR 3.7, p=0.01) compared to hospitals that performed 0-1 procedures a year. SIGNIFICANCE Hemispherectomy procedures increased slightly in frequency over the past decade, with no change in demographic characteristics of the patients over time. Rates of mortality and perioperative complications remained low. Total costs have increased significantly over time. In-hospital mortality was lower in higher volume hospitals.
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Affiliation(s)
- Yimo Lin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, U.S.A
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23
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Szaflarski M. Social determinants of health in epilepsy. Epilepsy Behav 2014; 41:283-9. [PMID: 24998313 DOI: 10.1016/j.yebeh.2014.06.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/05/2014] [Accepted: 06/07/2014] [Indexed: 10/25/2022]
Abstract
Social factors have been identified as key drivers of epilepsy care, outcomes, and disparities, but there is a limited understanding of what these factors are and how they translate into disparities. This targeted review provides an overview of the social determinants of health framework and applies this perspective to the literature about social and psychosocial factors in epilepsy; a social determinants of health--epilepsy model is proposed. The key social determinants of health in epilepsy include socioeconomic status, race/ethnicity, age, and gender. For example, low socioeconomic status and minority status have been associated with a higher risk of epilepsy, more hospitalizations and emergency room visits (versus neurology services), antiepileptic drug nonadherence, and a lower rate of epilepsy surgery. Such differences in care/treatment and outcomes translate into health disparities, many of which are considered unjust (inequitable) and modifiable through social action. Other social determinants of health include structural and sociocultural contextual conditions (e.g., health economy, policy, and social stigma/discrimination) and mediating mechanisms including material (e.g., housing), behavioral/biological (e.g., adherence), psychosocial (e.g., perceived stigma), and health system (e.g., access) factors. There are complex relationships among social determinants of health in epilepsy, which remain poorly understood and hamper efforts to address and eliminate disparities in epilepsy care and outcomes. Further empirical work grounded in sound theory and robust methodologies is needed to identify points of intervention and design effective and socially acceptable solutions to any pervasive disparities in epilepsy.
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Affiliation(s)
- Magdalena Szaflarski
- Department of Sociology, University of Alabama at Birmingham, HHB 460H, 1720 2nd Ave South, Birmingham, AL 35294-1152, USA.
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