Impact of neurosurgeon specialization on patient outcomes for intracranial and spinal surgery: a retrospective analysis of the Nationwide Inpatient Sample 1998–2009

Distribution of case volumes in surgery: an analysis of the British Spine Registry

Objectives

To characterize the distribution of case volumes within a surgical field.

Design

An analysis of British Spine Registry.

Setting

295 centers in England that conducted at least one spinal operation either within the NHS or private settings between 1 May 2016 and 27 February 2021.

Participants

644 surgeons.

Main outcome measures

Mathematical descriptions of distributions of cases among surgeons and the extent of workforce-level case-volume concentration as a surrogate marker.

Results

There were wide variations in monthly caseloads between surgeons, ranging from 0 to average monthly high of 81.8 cases. The curves showed that 37.7% of surgeons were required to perform 80% of all spinal operations, which is substantially less than in fields outside of healthcare.With the COVID-19 pandemic, the case volumes of surgeons with the highest volumes dropped dramatically, whereas those with the lowest case numbers remained nearly unchanged. This, along with the relatively low level of case-volume concentration within spinal surgery, may indicate an inevitability of at least some level of surgical care being provided by the relatively lower volume surgeons.

Conclusions

While there is a reasonable degree of workforce-level case volume concentration within spinal surgery, with high volume spinal surgeons providing a large proportion of care, it is not clear whether a further concentration of case volumes into those few hands is possible or desirable.

Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK

PURPOSE

We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago.

METHODS

A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments.

RESULTS

We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12 h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12 h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80 mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists.

CONCLUSIONS

Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines.

Early Extubation After Elective Infratentorial Craniotomy: Results of the International PRICE Survey

BACKGROUND

Early extubation, defined as removal of the endotracheal tube at the end of surgery before transfer to a designated postoperative care area, is associated with better outcomes after elective infratentorial craniotomy. The Predicting Infratentorial Craniotomy Extubation (PRICE) project was an international survey designed to estimate the rate of early extubation after elective infratentorial craniotomy, as reported by neuroanesthesiologists, neurosurgeons, and neurocritical care specialists.

METHODS

Following research ethics board waiver, the 15-question online PRICE survey was circulated to the members of 5 international medical societies over a 15-week period.

RESULTS

One hundred and ninety of 5453 society members completed the survey (3.5% response rate). Respondents represented a total of 99 institutions from 92 cities, in 27 countries. While 84 of 188 (44.7%) respondents reported achieving early extubation in more than 95% of cases, 43 of 188 (22.9%) reported extubating fewer than 75% of cases early. The proportion of physicians who reported extubating at least 75% of cases early was greater in high-volume compared with low-volume institutions (73.5% vs. 50.9%, respectively; P =0.003) and among anesthesiologists compared with other specialties (75.6% vs. 45.6%, respectively; P <0.001). Preoperative bulbar dysfunction, preoperative altered consciousness and the course of surgery were the 3 factors with the biggest impact on the decision to extubate early versus late among respondents.

CONCLUSIONS

The reported rate of early extubation after elective infratentorial craniotomy varies widely between institutions, with respondents from high-volume institutions reporting greater rates of early extubation than those from lower-volume centers. The course of surgery, evidence of bulbar dysfunction, and altered consciousness, appear to affect the decision to extubate early more than other predictors.

Structure of Neurosurgical Care in Germany in Comparison to Countries Organized in the European Association of Neurosurgical Societies: A Need to Reorganize Neurosurgical Training and Care in Germany

BACKGROUND

 Although the world is experiencing a deficit in the neurosurgical workforce, the number of neurosurgeons in Germany has increased within the last two decades. The aim of the present study was to assess the neurosurgical workforce in Germany, compare it to European countries, and assess structures in neurosurgical departments in Germany.

METHODS

 Data regarding the number of neurosurgeons in Germany as well as the number of departments, beds, cases, and neurosurgical procedures were gathered. A survey among German neurosurgical departments was performed to assess the structure of neurosurgical care. Furthermore, another survey among European countries was performed to acquire information regarding the number of surgeons and the regulation of training.

RESULTS

 From 2000 to 2019, the number of board-certified neurosurgeons in Germany increased by 151% from 973 to 2,446. During the same period, the German population increased by only 1% from 82.26 million to 83.17 million. Thus, the number of neurosurgeons per 100,000 inhabitants increased from 1.18 to 2.94. The increase of neurosurgeons is not paralleled by an increase in departments or an increase in neurosurgical procedures within the active neurosurgical departments. In comparison to the participating European countries, where the number of neurosurgeons per 100,000 inhabitants ranged from 0.45 to 2.94, with Germany shows the highest number.

CONCLUSIONS

 German institutions of medical administration urgently need to consider regulation of neurosurgical specialist training to prevent a further uncontrolled increase in neurosurgeons in a manner that is not adapted to the needs of neurosurgical care for the German population. Actions might include a regulation of entry to the training and of the number of training sites. Furthermore, an integration of non-physician assistant health care professionals and delegation of non-surgical workload from neurosurgeons is necessary. A further increase in neurosurgeons would be associated with a decrease in the surgical caseload per surgeons during training and after board certification, which might compromise the quality of neurosurgical care.

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England

BACKGROUND

Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England.

METHODS

Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure.

RESULTS

Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied.

CONCLUSIONS

A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

The National Provider Identifier Taxonomy: Does it Align With a Surgeon's Actual Clinical Practice?

INTRODUCTION

The taxonomy code(s) associated with each National Provider Identifier (NPI) entry should characterize the provider's role (e.g., physician) and any specialization (e.g., orthopedic surgery). While the intent of the taxonomy system was to monitor medical appropriateness and the expertise of care provided, this system is now being used by researchers to identify providers and their practices. It is unknown how accurate the taxonomy codes are in describing a provider's true specialization.

METHODS

Department websites of orthopedic surgery and general surgery from three large academic institutions were queried for practicing surgeons. The surgeon's specialty and subspeciality information listed was compared to the provider's taxonomy code(s) listed on the National Plan and Provider Enumeration System (NPPES). The match rate between these data sources was evaluated based on the specialty, subspecialty, and institution.

RESULTS

There were 295 surgeons (205 general surgery and 90 orthopedic surgery) and 24 relevant taxonomies (8 orthopedic and 16 general or plastic) for analysis. Of these, 294 surgeons (99%) selected their general specialty taxonomy correctly, while only 189 (64%) correctly chose an appropriate subspecialty. General surgeons correctly chose a subspecialty more often than orthopedic surgeons (70 versus 51%, P = 0.002). The institution did not affect either match rate, however there were some differences noted in subspecialty match rates inside individual departments.

CONCLUSIONS

In these institutions, the NPI taxonomy is not accurate for describing a surgeon's subspecialty or actual practice. Caution should be taken when utilizing this variable to describe a surgeon's subspecialization as our findings might apply in other groups.

The impact of sub specialization within functional neurosurgery on patient outcomes in a comprehensive epilepsy center

BACKGROUND

One in three patients with epilepsy are medication-refractory and may benefit from investigations and operative treatment at a comprehensive epilepsy center. However, while these centers have capabilities for advanced seizure monitoring and surgical intervention, they are not required to have a functional neurosurgeon who is primarily focused in epilepsy surgery. Therefore, the objective of this study is to determine the impact of having a sub-specialized, epilepsy-focused functional neurosurgeon on patient outcomes.

METHODS

We conducted a retrospective chart review for all patients who underwent surgical intervention for medically refractory epilepsy at a Level 4 comprehensive Epilepsy Center from 2008 through 2019. Data was divided into two groups: group 1 comprised patients who had surgery before the hiring of a dedicated epilepsy-focused functional neurosurgeon in 2016, and group 2 was afterwards. We compared surgical procedures, significant complications, and seizure outcomes.

RESULTS

A total of 101 patients underwent 105 operations (52 in group 1 and 53 in group 2), not including intracranial EEG insertion. Compared to group 1, group 2 had more surgeries performed per year (15.1 vs. 6.5), and a significantly lower Engel score at last follow-up (1.78 vs. 2.57; p < 0.001). There was no difference in percentage of cases undergoing iEEG, and no difference in complication rates.

CONCLUSIONS

In this series, the hiring of a sub-specialized functional neurosurgeon dedicated to epilepsy surgery in a comprehensive epilepsy center was associated with an increase in surgical volume and improved seizure outcomes.

The Potential Impact of "Take the Volume Pledge" on Outcomes After Carotid Artery Stenting

BACKGROUND

The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively.

OBJECTIVE

To compare outcomes after CAS between hospitals and surgeons meeting or not meeting the Volume Pledge thresholds.

METHODS

We queried the Nationwide Inpatient Sample for CAS admissions. Hospitals and surgeons were categorized as low volume and high volume (HV) based on the Volume Pledge. Multivariable hierarchical regression models were used to examine the impact of hospital volume (2005-2011) and surgeon volume (2005-2009) on perioperative outcomes.

RESULTS

Between 2005 and 2011, 22 215 patients were identified. Most patients underwent CAS by HV hospitals (86.4%). No differences in poor outcome (composite endpoint of in-hospital mortality, postoperative neurological or cardiac complications) were observed by hospital volume but HV hospitals did decrease the likelihood of other complications, nonroutine discharge, and prolonged hospitalization. From 2005 to 2009, 9454 CAS admissions were associated with physician identifiers. Most patients received CAS by HV surgeons (79.2%). On multivariable analysis, hospital volume was not associated with improved outcomes but HV surgeons decreased odds of poor outcome (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.97; P = .028), complications (OR 0.56, 95% CI 0.46-0.71, P < .001), nonroutine discharge (OR 0.70, 95% CI 0.57-0.87; P = .001), and prolonged hospitalization (OR 0.52, 95% 0.44-0.61, P < .001).

CONCLUSION

Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.

Impact of facility type and volume in low-grade glioma outcomes

OBJECTIVE

The object of this study was to investigate the impact of facility type (academic center [AC] vs non-AC) and facility volume (high-volume facility [HVF] vs low-volume facility [LVF]) on low-grade glioma (LGG) outcomes.

METHODS

This retrospective cohort study included 5539 LGG patients (2004-2014) from the National Cancer Database. Patients were categorized by facility type and volume (non-AC vs AC, HVF vs LVF). An HVF was defined as the top 1% of facilities according to the number of annual cases. Outcomes included overall survival, treatment receipt, and postoperative outcomes. Kaplan-Meier and Cox proportional-hazards models were applied. The Heller explained relative risk was computed to assess the relative importance of each survival predictor.

RESULTS

Significant survival advantages were observed at HVFs (HR 0.67, 95% CI 0.55-0.82, p < 0.001) and ACs (HR 0.84, 95% CI 0.73-0.97, p = 0.015), both prior to and after adjusting for all covariates. Tumor resection was 41% and 26% more likely to be performed at HVFs vs LVFs and ACs vs non-ACs, respectively. Chemotherapy was 40% and 88% more frequently to be utilized at HVFs vs LVFs and ACs vs non-ACs, respectively. Prolonged length of stay (LOS) was decreased by 42% and 24% at HVFs and ACs, respectively. After tumor histology, tumor pattern, and codeletion of 1p19q, facility type and surgical procedure were the most important contributors to survival variance. The main findings remained consistent using propensity score matching and multiple imputation.

CONCLUSIONS

This study provides evidence of survival benefits among LGG patients treated at HVFs and ACs. An increased likelihood of undergoing resections, receiving adjuvant therapies, having shorter LOSs, and the multidisciplinary environment typically found at ACs and HVFs are important contributors to the authors' finding.

What Does it Mean for a Surgeon to “Run Two Rooms”? A Comprehensive Literature Review of Overlapping and Concurrent Surgery Policies

The aim of this study was to review and analyze all of the “concurrent surgery” (CS) and “overlapping surgery” (OS) literature with the goal of: standardizing terminology, defining discrepancies in the literature and proposing solutions for the current challenges of regulating surgery to achieve maximal safety and efficiency. The CS and OS literature has grown exponentially over the past two years. Before this, there were no significant publications addressing this topic. There is an extremely wide variance on how “running two rooms” is defined and whether it should be permitted. These differences affect our patients’ perception of this practice. The literature lacks any comprehensive review of the topic and terminology. We performed a PubMed search to identify studies that considered the issue of OS. The terms “overlapping surgery”, “concurrent surgery”, and “simultaneous surgery” (SS) were used in the query. We then analyzed the publications identified. The literature contained 18 published studies analyzing OS safety between November 2016 and June 2018. Eight were neurosurgical studies, three were orthopedic, and the remaining seven articles were in other surgical specialties. A total of 1,207,155 surgical cases (range 250–>500,000 patients) were analyzed among the 18 studies. There were 57,880 (5.04%) OS cases. The OS rates in the individual studies ranged from 1.2 to 68 per cent (Table 1). Neurosurgical studies had the highest average OS rate of 54 per cent (range 37–68%), whereas the average OS rate in orthopedic surgery was 43 per cent (range 2.7–68%). Approximately one-third of the studies were multicenter investigations (27.7%). The studies measured more than 20 distinct outcomes, but there were only five outcomes that were included in the majority of the studies: mortality rates, reoperation rates, procedure length of time, readmission rates, and hospital length of stay. The current body of literature repeatedly demonstrates that OS is a safe and effective option when undertaken by experienced surgeons who practice it frequently. For successful OS, the Mandatory Attending Portion for two surgeries must not overlap and Unnecessary Anesthesia Time must be prohibited. Hospitals and surgical specialty organizations must implement policies to assure the safe practice of OS.

Are we ready for urological subspecialty-based practice in India? The resident's perspective

Introduction:

In the current era, every broad specialty has diversified into many subspecialties including urology, which is one of the most dynamic fields. The concept of early sub-specialization relies on excelling in a niche area of interest. While this concept is appealing to the most, no formal evaluation of our residency programs has ever been conducted with regard to their adequacy in terms of equipping residents to make informed sub-specialization choices. We performed a survey amongst urological residents, in an attempt to gather information on some unanswered questions related to our residency training programs and the concept of sub-specialization.

Methods:

Using the Delphi principles, we conducted a survey consisting of 46 questions, amongst the Indian Urological residents (n = 85), to assess the overall exposure to various subspecialties during their residency program, and the inclination of residents towards them.

Results:

Residents get a fair exposure to endourology, uro-oncology, female urology and reconstructive urology during their residency. However, the same did not hold true for pediatric urology, andrology and laparoscopic/robotic surgery. 90% of the residents expressed an inclination towards academic practice, while 76.5% were interested in sub-specialization. 60% of the residents felt that they had obtained adequate exposure during residency to make a decision in this regard. Less than 20% were inclined towards female urology, andrology or pediatric urology as a career option.

Conclusion:

There is a growing interest and inclination amongst Indian Urological residents to attain expertise in sub-specialised fields. However, our current residency programs need consolidated efforts to ensure an adequate exposure to all the aspects of Urology, especially in the subspecialties of pediatric urology, andrology and minimally invasive urology. Training should be optimized to a level, which enables the residents to take a well informed decision regarding their choice of subspecialised career path.

Relationship between surgeon volume and outcomes in spine surgery: a dose-response meta-analysis

Background

The relationship between surgeon volume and outcomes in spine surgery is unclear and published studies report inconsistent results. Therefore, a dose-response meta-analysis was conducted to clarify the influence of surgeon volume on outcomes in spine surgery.

Methods

PubMed, Embase, and The Cochrane Library were systematically searched without language limitation for observational studies which investigated the relationship between surgeon volume and outcomes in spine surgery. The primary outcome was postoperative morbidity and the secondary outcomes consisted of mortality, length of hospital stay, readmission, and hospital costs. For binary variable and continuous variable, odds ratios (ORs) with 95% CIs and weighted mean differences (WMDs) with 95% CIs were pooled respectively. Additionally, a dose-response meta-analysis was performed for the primary outcome.

Results

Eleven studies with 1,986,545 patients were included in the current meta-analysis. Pooled estimate indicated that a higher surgeon volume was associated with lower postoperative morbidity (OR, 0.62; 95% CI: 0.52-0.75; I²=93.9%), lower mortality (OR, 0.76; 95% CI: 0.66-0.87; I²=0), shorter length of hospital stay (WMD, -7.07; 95% CI: -7.08 to -7.06; I²=100%), less readmission (OR, 0.78; 95% CI: 0.72-0.85; I²=93.1%), and lower hospital costs (WMD, -25,497.47; 95% CI: -25,528.43 to -25,466.51; I²=100%). Dose-response analysis suggested a nonlinear relationship between surgeon volume and postoperative morbidity (P for nonlinearity less than 0.00001).

Conclusions

The current evidence indicate that higher surgeon volume is associated with lower morbidity and mortality, shorter length of hospital stay, less readmission, and lower hospital costs in spine surgery.