1
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Yu C, Liu Y, Tang Z, Zhang H. Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis. Brain Res 2023; 1816:148467. [PMID: 37348748 DOI: 10.1016/j.brainres.2023.148467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy. METHODS Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care. RESULT Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group. CONCLUSION ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.
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Affiliation(s)
- Chunyang Yu
- Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuqing Liu
- Department of Rehabilitation Medicine, Peking University Third Hospital, China
| | - Zhiqing Tang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China
| | - Hao Zhang
- School of Rehabilitation, Capital Medical University, China; Beijing Bo'ai Hospital, China Rehabilitation Research Center, China; University of Health and Rehabilitation Sciences, China; Cheeloo College of Medicine, Shandong University, China.
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2
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Long term evaluation of a multidisciplinary trigeminal neuralgia service. J Headache Pain 2022; 23:114. [PMID: 36057552 PMCID: PMC9441024 DOI: 10.1186/s10194-022-01489-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background Trigeminal neuralgia is an episodic severe neuralgic pain and can be managed both medically and surgically. If possible, this should be directed by a Multidisciplinary Team (MDT) of specialised surgeons, physicians, dentists, psychologists and specialist nurses with access to all treatment modalities, which enables patients to make an informed decision about their future management. Objective The aim of this study was to review the outcomes of patients managed by an MDT clinic, in a single institute over an eleven-year period. Methods A prospective database was used to identify patients with trigeminal neuralgia or its variants who had attended a joint MDT clinic. The electronic notes were examined for demographics, onset and duration of trigeminal neuralgia, medications history, pain scores and details of surgical procedures if any by two independent assessors. Results Three hundred thirty-four patients attended the MDT between 2008–2019. Forty-nine of them had surgery before being referred to the service and were included but analysed as a subgroup. Of the remaining patients, 54% opted to have surgery following the MDT either immediately or at a later date. At the last reported visit 55% of patients who opted to have surgery were pain free and off medications, compared to 15.5% of medically managed patients. Surgical complications were mostly attributable to numbness and in the majority of cases this was temporary. All patients who were not pain free, had complications after surgery or opted to remain on medical therapy were followed up in a facial pain clinic which has access to pain physicians, clinical nurse specialists and a tailored pain management program. Regular patient related outcome measures are collected to evaluate outcomes. Conclusion An MDT clinic offers an opportunity for shared decision making with patients deciding on their personal care pathway which is valued by patients. Not all patients opt for surgery, and some continue to attend a multidisciplinary follow up program. Providing a full range of services including psychological support, improves outcomes.
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3
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Lu X, Fang X, Huang Y, Zhou P, Wang Z, Brinjikji W, Chen G. Cerebral Revascularization for the Management of Symptomatic Pure Arterial Malformations. Front Neurol 2021; 12:755312. [PMID: 34975720 PMCID: PMC8716448 DOI: 10.3389/fneur.2021.755312] [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] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Pure arterial malformations (PAMs) are extremely rare abnormalities defined as dilated, overlapping, and tortuous arteries with a coil-like appearance in the absence of venous components. Over the last half century, only seven published reports have described cases of patients with PAMs who received treatment. Methods: Here, we report two cases of women with PAMs who received surgical treatment, and we present a systematic review of the literature. We searched the PubMed, Embase, Web of Science, and Medline databases (up until October 1, 2021) for relevant publications. We performed independent-sample t-tests and Fisher's exact tests to compare continuous and categorical characteristics among the available cases. Results: Our first patient was a 43-year-old woman with PAM of the left internal carotid artery (ICA), who received an ICA-radial artery (RA)-M2 bypass. Post-operative digital subtraction angiography (DSA) revealed the disappearance of the left ICA PAM without ischemic events during follow-up. The second patient was a 53-year-old woman with PAMs of the right ICA and posterior cerebral artery. The P1 lesion was treated by proximal occlusion combined with a superficial temporal artery-P2 bypass. During the 12-month follow-up period, the size of the PAMs decreased significantly as indicated by the post-operative DSA showing the absence of hemorrhages. Our systematic review, which includes 56 PAMs, shows that the reported PAMs were more common in the anterior circulation (33/56, 58.9%) than in the posterior circulation (11/56, 19.7%). Bilateral PAMs were more likely to affect bilateral anterior cerebral arteries (ACA) (ACAbilateral vs. ACAunilateral: 63.6 vs. 26.2%, p = 0.02). In addition, PAMs involving the anterior circulation were likely to affect multiple arteries (anteriormulti vs. posteriormulti: 30.3 vs. 0%, p = 0.038). Conclusion: We found very few reports on treated PAMs; further studies with large sample sizes and long follow-up periods are required to explore the appropriate treatment strategy for PAMs.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xinggen Fang
- Department of Neurosurgery, Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Yabo Huang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Waleed Brinjikji
- Departments of Radiology, Mayo Clinic, Rochester, MN, United States
- Departments of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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4
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Stumpo V, Staartjes VE, Quddusi A, Corniola MV, Tessitore E, Schröder ML, Anderer EG, Stienen MN, Serra C, Regli L. Enhanced Recovery After Surgery strategies for elective craniotomy: a systematic review. J Neurosurg 2021; 135:1857-1881. [PMID: 33962374 DOI: 10.3171/2020.10.jns203160] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/26/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery. METHODS The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction. RESULTS A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse. CONCLUSIONS A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.
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Affiliation(s)
- Vittorio Stumpo
- 2Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Victor E Staartjes
- 1Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
- 2Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Ayesha Quddusi
- 3Center for Neuroscience, Queens University, Kingston, Ontario, Canada
| | - Marco V Corniola
- 4Department of Neurosurgery, Geneva University Hospital (HUG), Geneva, Switzerland
| | - Enrico Tessitore
- 4Department of Neurosurgery, Geneva University Hospital (HUG), Geneva, Switzerland
| | - Marc L Schröder
- 5Department of Neurosurgery, Bergman Clinics Amsterdam, The Netherlands
| | - Erich G Anderer
- 6Department of Neurosurgery, NYU Langone Hospital Brooklyn, New York; and
| | - Martin N Stienen
- 1Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
- 7Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland
| | - Carlo Serra
- 1Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- 1Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Switzerland
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5
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Lim MJR. Letter: Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery. Neurosurgery 2021; 89:E187-E188. [PMID: 34131740 DOI: 10.1093/neuros/nyab214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Mervyn Jun Rui Lim
- Division of Neurosurgery University Surgical Centre National University Hospital Singapore
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6
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Bakr SM, Patel A, Zaazoue MA, Wagner K, Lam SK, Curry DJ, Raskin JS. Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning. J Neurosurg Pediatr 2021; 27:411-419. [PMID: 33482632 DOI: 10.3171/2020.8.peds20420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term "dynamic sEEG" and define standard work tools and related common data elements to promote uniformity in the field. METHODS A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded. RESULTS The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes. CONCLUSIONS The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.
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Affiliation(s)
- Salma M Bakr
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
- 2Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ajay Patel
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mohamed A Zaazoue
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kathryn Wagner
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi K Lam
- 4Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital, Chicago; and
- 5Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel J Curry
- 3Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Raskin
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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7
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Thatikunta M, Raman NV, Zieles KN, Ducis K, Jea A. An incidental pure arterial malformation in a child: case report and review of the literature. Childs Nerv Syst 2020; 36:2877-2881. [PMID: 32052157 DOI: 10.1007/s00381-020-04539-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Pure arterial malformations of the brain are rare vascular lesions. METHODS We present a 10-year-old healthy boy who presented with an incidental finding of pure arterial malformation. RESULTS Our case seems to represent the second description of pure arterial malformation discovered incidentally in a child. CONCLUSION We review the clinical presentation, angiographic findings, and management of our case in the context of other reported pediatric cases.
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Affiliation(s)
- Meena Thatikunta
- Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA
| | - Natasha V Raman
- Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA
| | - Kristin N Zieles
- Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA
| | - Katrina Ducis
- Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA
| | - Andrew Jea
- Section of Pediatric Neurosurgery, Department of Neurological Surgery, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Suite 1601, Indianapolis, IN, 46202, USA.
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8
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Goretti G, Marinari GM, Vanni E, Ferrari C. Value-Based Healthcare and Enhanced Recovery After Surgery Implementation in a High-Volume Bariatric Center in Italy. Obes Surg 2020; 30:2519-2527. [PMID: 32096016 PMCID: PMC7260281 DOI: 10.1007/s11695-020-04464-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients' adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients' engagement and outcomes. METHOD A multiprofessional team redesigned the process considering ERAS recommendations and patients' feedbacks. Outcomes that matter to patients were defined with structured patients' interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. RESULTS A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. CONCLUSION Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients' engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.
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Affiliation(s)
- Giulia Goretti
- Quality Department, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy.
| | - Giuseppe M Marinari
- Bariatric Surgery, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
| | - Elena Vanni
- Performance audit, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
| | - Chiara Ferrari
- Anesthesia, Humanitas Clinical and Research Center -IRCCS, via Manzoni, 56 20089, Rozzano, MI, Italy
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9
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Rao AJ, Bullis C, Holste KG, Teton Z, Burchiel KJ, Raslan AM. Balancing Operative Efficiency and Surgical Education: A Functional Neurosurgery Model. Oper Neurosurg (Hagerstown) 2019; 17:622-631. [PMID: 30997509 DOI: 10.1093/ons/opz048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/19/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Attending surgeons have dual obligations to deliver high-quality health care and train residents. In modern healthcare, lean principles are increasingly applied to processes preceding and following surgery. However, surgeons have limited data regarding variability and waste during any given operation. OBJECTIVE To measure variability and waste during the following key functional neurosurgery procedures: retrosigmoid craniectomy (microvascular decompression [MVD] and internal neurolysis) and deep brain stimulation (DBS). Additionally, we correlate variability with residents' self-reported readiness for the surgical steps. The aim is to guide surgeons as they balance operative safety and efficiency with training obligations. METHODS For each operation (retrosigmoid craniectomy and DBS), a standard workflow, segmenting the operation into components, was defined. We observed a representative sample of operations, timing the components, with a focus on variability. To assess perceptions of safety and risk among surgeons of various training levels, a survey was administered. Survey results were correlated with operative variability, attempting to identify areas for increasing value without compromising trainee experience. RESULTS A sampling of each operation (n = 36) was observed during the study period. For MVD, craniectomy had the highest mean duration and standard deviation, whereas the MVD itself had the lowest mean duration and standard deviation. For DBS, the segments with largest standard deviation in duration were registration and electrode placement. For many steps of both procedures, there was a statistically significant relationship between increasing level of training and increasing perception of safety. CONCLUSION This proof-of-concept study introduces an educational and process-improvement tool that can be used to aid surgeons in increasing the efficiency of patient care.
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Affiliation(s)
- Abigail J Rao
- Department of Neurosurgery, University of California-Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon.,Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
| | - Carli Bullis
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Katherine G Holste
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Zoe Teton
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kim J Burchiel
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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10
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de Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review. Neurocrit Care 2019; 28:35-42. [PMID: 28808901 DOI: 10.1007/s12028-017-0433-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. METHODS We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." RESULTS The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. CONCLUSION Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.
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Affiliation(s)
- Cesar Cimonari de Almeida
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | - M Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Yosef Laviv
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
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11
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Ajmera S, Motiwala M, Khan NR, Smith LJ, Giles K, Vaughn B, Klimo P. Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges. Neurosurgery 2019; 85:E765-E770. [DOI: 10.1093/neuros/nyz090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery.
OBJECTIVE
To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN).
METHODS
Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department.
RESULTS
Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively.
CONCLUSION
From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.
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Affiliation(s)
- Sonia Ajmera
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey, Memphis, Tennessee
- Le Bonheur Children's Hospital, Memphis, Tennessee
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12
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Elsamadicy AA, Sergesketter A, Sampson JH, Gottfried ON. Institutional Review of Mortality in 5434 Consecutive Neurosurgery Patients: Are We Improving? Neurosurgery 2017; 83:1269-1276. [DOI: 10.1093/neuros/nyx603] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 11/22/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Duke Uni– versity Medical Center, Durham, North Carolina
| | - Amanda Sergesketter
- Department of Neurosurgery, Duke Uni– versity Medical Center, Durham, North Carolina
| | - John H Sampson
- Department of Neurosurgery, Duke Uni– versity Medical Center, Durham, North Carolina
| | - Oren N Gottfried
- Department of Neurosurgery, Duke Uni– versity Medical Center, Durham, North Carolina
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Zusman EE, Benzil DL. The Continuum of Neurosurgical Care: Increasing the Neurosurgeon's Role and Responsibility. Neurosurgery 2017; 80:S34-S41. [DOI: 10.1093/neuros/nyw151] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/28/2017] [Indexed: 11/12/2022] Open
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Nilsson K, Bååthe F, Andersson AE, Wikström E, Sandoff M. Experiences from implementing value-based healthcare at a Swedish University Hospital - an longitudinal interview study. BMC Health Serv Res 2017; 17:169. [PMID: 28241823 PMCID: PMC5330026 DOI: 10.1186/s12913-017-2104-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/18/2017] [Indexed: 11/18/2022] Open
Abstract
Background Implementing the value-based healthcare concept (VBHC) is a growing management trend in Swedish healthcare organizations. The aim of this study is to explore how representatives of four pilot project teams experienced implementing VBHC in a large Swedish University Hospital over a period of 2 years. The project teams started their work in October 2013. Methods An explorative and qualitative design was used, with interviews as the data collection method. All the participants in the four pilot project teams were individually interviewed three times, with interviews starting in March 2014 and ending in November 2015. All the interviews were transcribed and analyzed using qualitative analysis. Results Value for the patients was experienced as the fundamental drive for implementing VBHC. However, multiple understandings of what value for patients’ means existed in parallel. The teams received guidance from consultants during the first 3 months. There were pros and cons to the consultant’s guidance. This period included intensive work identifying outcome measurements based on patients’ and professionals’ perspectives, with less interest devoted to measuring costs. The implementation process, which both gave and took energy, developed over time and included interventions. In due course it provided insights to the teams about the complexity of healthcare. The necessity of coordination, cooperation and working together inter-departmentally was critical. Conclusions Healthcare organizations implementing VBHC will benefit from emphasizing value for patients, in line with the intrinsic drive in healthcare, as well as managing the process of implementation on the basis of understanding the complexities of healthcare. Paying attention to the patients’ voice is a most important concern and is also a key towards increased engagement from physicians and care providers for improvement work.
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Affiliation(s)
- Kerstin Nilsson
- Institute of Health and Caring Sciences, Sahlgrenska Academy, University of Gothenburg, Box 457, 405 30, Göteborg, Sweden.
| | - Fredrik Bååthe
- Sahlgrenska University Hospital, Göteborg, Sweden/Institute of Health and Caring Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Annette Erichsen Andersson
- Sahlgrenska University Hospital, Göteborg, Sweden/Institute of Health and Caring Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Ewa Wikström
- Department of Business Administration, School of Business, Economics and Law, University of Gothenburg, Göteborg, Sweden
| | - Mette Sandoff
- Department of Business Administration, School of Business, Economics and Law, University of Gothenburg, Göteborg, Sweden
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Lawrence JD, Tuchek C, Cohen-Gadol AA, Sekula RF. Utility of the intensive care unit in patients undergoing microvascular decompression: a multiinstitution comparative analysis. J Neurosurg 2016; 126:1967-1973. [PMID: 27518528 DOI: 10.3171/2016.5.jns152118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Use of the ICU during admission to a hospital is associated with a significant portion of the total health care costs for that stay. Patients undergoing microvascular decompression (MVD) for cranial neuralgias are routinely admitted postoperatively to the ICU for monitoring. The primary purpose of this study was to compare complication rates of patients with and without a postoperative ICU stay following MVD. The secondary intents were to identify predictors of complications, to analyze variables of health care resource utilization, and to estimate the cost of postoperative management. METHODS The authors performed a retrospective comparative analysis of consecutive patients undergoing MVD at 2 institutions. A total of 199 patients without a postoperative ICU stay from Institution A and 119 patients with an ICU stay from Institution B were reviewed. Inclusion criteria included any adult (i.e., 18 years of age or older) undergoing MVD for trigeminal neuralgia, hemifacial spasm, glossopharyngeal neuralgia, or geniculate neuralgia. Patients with incomplete medical records were excluded. Medical comorbidities, intraoperative variables, complications, postoperative interventions, and variables indicating health care resource utilization were reviewed. RESULTS The study compared 190 patients without a postoperative ICU stay from Institution A with 90 patients with an ICU stay from Institution B. Seven patients without an ICU stay and 5 patients with an ICU stay experienced complications after surgery (p = 0.53). Multivariate analysis identified coronary artery disease to be a predictor of complications (p = 0.037, OR 6.23, 95% CI 1.12-34.63). Patients from Institution A without a postoperative ICU stay had a significantly shorter length of stay, by approximately 16 hours (p < 0.001), and received less postoperative imaging (p < 0.001, OR 14.39, 95% CI 7.75-26.74) and postoperative diagnostic testing (p < 0.001) than patients from Institution B with an ICU stay. Estimated cost savings in patients without an ICU stay and 1 less day of inpatient recovery was calculated as $1400 per patient. CONCLUSIONS Selective versus routine use of ICU care as well as postoperative imaging and diagnostic testing may be safe after MVD and can lead to a reduction in overall health care costs.
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Affiliation(s)
| | | | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Indiana University.,Goodman Campbell Brain and Spine; and.,Simon Cancer Center, Indiana University, Indianapolis, Indiana
| | - Raymond F Sekula
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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McLaughlin N, Burke MA, Setlur NP, Niedzwiecki DR, Kaplan AL, Saigal C, Mahajan A, Martin NA, Kaplan RS. Time-driven activity-based costing: a driver for provider engagement in costing activities and redesign initiatives. Neurosurg Focus 2015; 37:E3. [PMID: 25363431 DOI: 10.3171/2014.8.focus14381] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT To date, health care providers have devoted significant efforts to improve performance regarding patient safety and quality of care. To address the lagging involvement of health care providers in the cost component of the value equation, UCLA Health piloted the implementation of time-driven activity-based costing (TDABC). Here, the authors describe the implementation experiment, share lessons learned across the care continuum, and report how TDABC has actively engaged health care providers in costing activities and care redesign. METHODS After the selection of pilots in neurosurgery and urology and the creation of the TDABC team, multidisciplinary process mapping sessions, capacity-cost calculations, and model integration were coordinated and offered to engage care providers at each phase. RESULTS Reviewing the maps for the entire episode of care, varying types of personnel involved in the delivery of care were noted: 63 for the neurosurgery pilot and 61 for the urology pilot. The average cost capacities for care coordinators, nurses, residents, and faculty were $0.70 (range $0.63-$0.75), $1.55 (range $1.28-$2.04), $0.58 (range $0.56-$0.62), and $3.54 (range $2.29-$4.52), across both pilots. After calculating the costs for material, equipment, and space, the TDABC model enabled the linking of a specific step of the care cycle (who performed the step and its duration) and its associated costs. Both pilots identified important opportunities to redesign care delivery in a costconscious fashion. CONCLUSIONS The experimentation and implementation phases of the TDABC model have succeeded in engaging health care providers in process assessment and costing activities. The TDABC model proved to be a catalyzing agent for cost-conscious care redesign.
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Fredriksson JJ, Ebbevi D, Savage C. Pseudo-understanding: an analysis of the dilution of value in healthcare. BMJ Qual Saf 2015; 24:451-7. [DOI: 10.1136/bmjqs-2014-003803] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 04/25/2015] [Indexed: 11/04/2022]
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18
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Zaidi HA, Awad AW, Chowdhry SA, Fusco D, Nakaji P, Spetzler RF. Microvascular decompression for hemifacial spasm secondary to vertebrobasilar dolichoectasia: Surgical strategies, technical nuances and clinical outcomes. J Clin Neurosci 2015; 22:62-8. [DOI: 10.1016/j.jocn.2014.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/21/2014] [Indexed: 10/24/2022]
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Hemifacial spasm and neurovascular compression. ScientificWorldJournal 2014; 2014:349319. [PMID: 25405219 PMCID: PMC4227371 DOI: 10.1155/2014/349319] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/19/2014] [Accepted: 09/24/2014] [Indexed: 12/15/2022] Open
Abstract
Hemifacial spasm (HFS) is characterized by involuntary unilateral contractions of the muscles innervated by the ipsilateral facial nerve, usually starting around the eyes before progressing inferiorly to the cheek, mouth, and neck. Its prevalence is 9.8 per 100,000 persons with an average age of onset of 44 years. The accepted pathophysiology of HFS suggests that it is a disease process of the nerve root entry zone of the facial nerve. HFS can be divided into two types: primary and secondary. Primary HFS is triggered by vascular compression whereas secondary HFS comprises all other causes of facial nerve damage. Clinical examination and imaging modalities such as electromyography (EMG) and magnetic resonance imaging (MRI) are useful to differentiate HFS from other facial movement disorders and for intraoperative planning. The standard medical management for HFS is botulinum neurotoxin (BoNT) injections, which provides low-risk but limited symptomatic relief. The only curative treatment for HFS is microvascular decompression (MVD), a surgical intervention that provides lasting symptomatic relief by reducing compression of the facial nerve root. With a low rate of complications such as hearing loss, MVD remains the treatment of choice for HFS patients as intraoperative technique and monitoring continue to improve.
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Microvascular decompression surgery is effective for the laterocollis subtype of spasmodic torticollis: a long-term follow-up result. Acta Neurochir (Wien) 2014; 156:1551-6. [PMID: 24838841 DOI: 10.1007/s00701-014-2120-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Spasmodic torticollis (ST) is characterized by sustained, involuntary, and painful spasms of specific muscle (s), which results into abnormal posture of the neck and head. Although various treatments for ST have been introduced, none of them shows absolute effectiveness. Earlier research from our department showed that microvascular decompression (MVD) surgery is effective in the short-term for ST patients with confirmed accessory nerve compression. However, the long-term outcome of MVD remains unknown. METHOD Twelve ST patients with confirmed accessory nerve compression received MVD surgery of their accessory nerves. We utilized the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the long-term outcome (5.4 ± 0.87 years). RESULTS The MVD lowered total TWSTRS scores by 42.8 % in all ST patients. This result, however, only counted for moderate relief. Interestingly, we observed that the laterocollis (LC) subtypes of ST (n = 3) obtained a higher TWSTRS score improvement (86.9 ± 6.2 %), compared to that of the non-LC (28.1 ± 12 %) (P =0.0001). Additionally, the disability (92.7 ± 2 %) subscale score in the LC subtypes had the most prominent improvement compared to the pain (88.1 ± 5.1 %) and severity (81.3 ± 10.5 %). CONCLUSIONS In the cases of confirmed accessory nerve compression, the MVD could be considered as a treatment alternative for ST, especially for the LC subtypes.
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Raslan AM, Burchiel KJ. Letters to the editor: value-based neurosurgery and microvascular decompression. J Neurosurg 2014; 121:495-7. [PMID: 24972131 DOI: 10.3171/2014.4.jns14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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