Volume-outcome relationship in pediatric neurotrauma care: analysis of two national databases

The Relationship Between Procedural Volume, Hospital Quality, and Postoperative Mortality in Pediatric Neurosurgery: Review of the Literature

BACKGROUND

Studies of neurosurgical pediatric patients associate treatment at low-volume hospitals and by low-volume surgeons with increased odds of adverse outcomes. Although these associations suggest that increased centralization of care could be considered, we evaluate whether confounding endogenous factors mitigate against the proposed outcome benefits.

METHODS

Literature review of English language articles from 1999 to 2021. We included articles that assessed volume-outcome effects in pediatric neurosurgical patients.

RESULTS

Twelve papers were included from 1999 to 2021. Primary outcomes included mortality (9), length of stay (LOS) (6), complications (4), and shunt revision/failure rates (3). Volume was measured at the hospital level (8) and at the surgeon level (6). Four papers found that higher volume hospitals had lower odds of mortality. Two papers found that hospitals with higher volume had fewer complications. Two papers found that higher volume surgeons had decreased mortality (odds ratio [OR] 0.09-0.3). One paper found that high-volume surgeons had fewer complications (-2.4%; P = 0.006). After controlling for hospital factors (HF), two out of 7 analyses remained significant. Five analyses did not control for HF.

CONCLUSIONS

The literature consistently demonstrates a relationship between higher hospital and surgeon volume and better outcomes for pediatric neurosurgical patients. Of the 7 articles that assessed HF, only 2 analyses found that surgical volume remained associated with better outcomes. No reports assessed the degree of centralization already present. The call for centralization of pediatric care should be tempered until variables such as hospital factors, distribution of cases, and clinical thresholds can be defined and studied.

Assessing the volume-outcome relationship of carotid artery stenting in nationwide administrative data: a challenge of patient population bias

BACKGROUND

Studies have shown an association between surgical treatment volume and improved quality metrics. This study evaluated nationwide results in carotid artery stenting (CAS) procedural readmission rates, costs, and length of stay based on hospital treatment volume.

METHODS

We used the Nationwide Readmissions Database for carotid stenosis from 2010 to 2015. Patients receiving CAS were matched based on demographics, illness severity, and relevant comorbidities. Patients were matched 1:1 between low- and high-volume centers using a non-parametric preprocessing matching program to adjust for parametric causal inferences. Nearest-neighbor propensity score matching was performed using logit distance.

RESULTS

Low- and high-volume centers admitted a mean (SD) of 4.68 (3.79) and 25.10 (16.86) patients undergoing CAS per hospital, respectively. Comorbidities were significantly different and initially could not be adequately matched. Because of significant differences in baseline patient population characteristics after attempted matching between low- and high-volume centers, we used propensity adjustment with multivariate analysis. Using this alternative approach, no significant differences were observed between low- and high-volume centers for the presence of any complication, postoperative stroke, postoperative myocardial infarction, and readmission at 30 days.

CONCLUSION

In 1:1 nearest-neighbor matching with a high number of patients, our analysis did not result in well-matched cohorts for the effect of case volume on outcomes. Comparing analytical techniques for various outcomes highlights that outcome disparities may not be related to quality differences based on hospital size, but rather variability in patient populations between low- and high-volume institutions.

Single-surgeon approach in microvascular decompression for trigeminal neuralgia: Lessons from an Indonesian Tertiary-Level Neurological Center

BACKGROUND

Microvascular decompression (MVD) is effective for refractory trigeminal neuralgia (TN), but its accessibility is often limited in lower-to-middle-income countries (LMICs). This study aims to assess the impact of implementing a single-surgeon policy on MVD for TN in LMICs.

METHODS

A prospective cohort study was conducted from 2014 to 2020, comparing outcomes between multi-surgeon and single-surgeon policies. Residents were included in MVD procedures starting in 2019. The Barrow Neurological Institute (BNI) pain scale (P), numbness scale (N), and result conclusion scale (P + N) were used to evaluate outcomes (1 week, 1 month, 1 year, and yearly thereafter). Propensity score matching was performed before comparing the groups. Pain-free survival was assessed using Kaplan-Meier and Cox-regression analysis.

RESULTS

We comprehensively analyzed data from 72 patients with a minimum one-year follow-up. The implementation of the single-surgeon policy had several notable impacts. Firstly, it led to an increased referral rate (p < 0.05) and a reduced duration to surgery (p < 0.05). During MVD, there was a significant increase in the identification of complex compression (p < 0.05) and a reduced frequency of internal neurolysis (p < 0.05). After surgery, the single-surgeon group exhibited a superior pain-control profile (RR 1.9, p < 0.001; ARR 26-36%), higher pain-free survival rate (p < 0.001), lower likelihood of pain recurrence (HR 0.2, p < 0.0001), and fewer additional surgical interventions compared to the multi-surgeon group. Moreover, the involvement of residents did not significantly impact surgical outcomes.

CONCLUSIONS

Implementing a single-surgeon policy for MVD in LMICs has the potential to improve surgical outcomes, provide social benefits, and offer educational opportunities.

Case volume and rate are associated with outcomes in geriatric trauma: A case for geriatric trauma centers?

BACKGROUND

Increased morbidity and mortality in geriatric trauma patients are usually due to decreased physiologic reserve and increased comorbidities. It is unclear whether geriatric trauma case volume and rates correlate with survival. We hypothesized that geriatric patients would have increased survival when treated in high-case volume and rate trauma centers.

METHODS

A retrospective cohort study was conducted using the Trauma Quality Improvement Program database between 2015 and 2019. Geriatric trauma patients (≥65 years) with severe injury (Injury Severity Score ≥16) were included. Geriatric case volume (GCV) was defined as the mean annual number of treated geriatric trauma patients, while geriatric case rate (GCR) was the mean annual number of elderly trauma patients divided by all trauma patients in each center. Trauma centers were classified into low-, medium-, and high-volume and rate facilities based on GCV and GCR. The association of GCV and GCR with in-hospital mortality and complication rates was assessed using the generalized additive model (GAM) and multivariate generalized linear mixed model adjusted for patient characteristics (age, sex, Injury Severity Score, Revised Trauma Score, and Modified Frailty Index) as fixed-effect variables and hospital characteristics as random effect variables.

RESULTS

A total of 164,818 geriatric trauma patients from 812 hospitals were included in the analysis. The GAM plots showed that the adjusted odds of in-hospital mortality decreased as GCV and the GCR increased. The generalized linear mixed model revealed that both high GCV and high GCR hospitals had lower mortality rates than low GCV and GCR hospitals (adjusted odds ratio [95% confidence interval], high GCV and high GCR centers; 0.82 [0.72-0.92] and 0.81 [0.73-0.90], respectively).

CONCLUSION

Both high geriatric trauma volume and rates were associated with decreased mortality of geriatric trauma patients. Consolidation of care for elderly patients with severe injury in specialized high-volume centers may be considered.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

BACKGROUND

Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized.

OBJECTIVE

To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.

METHODS

We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention.

RESULTS

A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention.

CONCLUSION

For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.

Patient frailty association with cerebral arteriovenous malformation microsurgical outcomes and development of custom risk stratification score: an analysis of 16,721 nationwide admissions

OBJECTIVE

Patient frailty is associated with poorer perioperative outcomes for several neurosurgical procedures. However, comparative accuracy between different frailty metrics for cerebral arteriovenous malformation (AVM) outcomes is poorly understood and existing frailty metrics studied in the literature are constrained by poor specificity to neurosurgery. This aim of this paper was to compare the predictive ability of 3 frailty scores for AVM microsurgical admissions and generate a custom risk stratification score.

METHODS

All adult AVM microsurgical admissions in the National (Nationwide) Inpatient Sample (2002–2017) were identified. Three frailty measures were analyzed: 5-factor modified frailty index (mFI-5; range 0–5), 11-factor modified frailty index (mFI-11; range 0–11), and Charlson Comorbidity Index (CCI) (range 0–29). Receiver operating characteristic curves were used to compare accuracy between metrics. The analyzed endpoints included in-hospital mortality, routine discharge, complications, length of stay (LOS), and hospitalization costs. Survey-weighted multivariate regression assessed frailty-outcome associations, adjusting for 13 confounders, including patient demographics, hospital characteristics, rupture status, hydrocephalus, epilepsy, and treatment modality. Subsequently, k-fold cross-validation and Akaike information criterion–based model selection were used to generate a custom 5-variable risk stratification score called the AVM-5. This score was validated in the main study population and a pseudoprospective cohort (2018–2019).

RESULTS

The authors analyzed 16,271 total AVM microsurgical admissions nationwide, with 21.0% being ruptured. The mFI-5, mFI-11, and CCI were all predictive of lower rates of routine discharge disposition, increased perioperative complications, and longer LOS (all p < 0.001). Their AVM-5 risk stratification score was calculated from 5 variables: age, hydrocephalus, paralysis, diabetes, and hypertension. The AVM-5 was predictive of decreased rates of routine hospital discharge (OR 0.26, p < 0.001) and increased perioperative complications (OR 2.42, p < 0.001), postoperative LOS (+49%, p < 0.001), total LOS (+47%, p < 0.001), and hospitalization costs (+22%, p < 0.001). This score outperformed age, mFI-5, mFI-11, and CCI for both ruptured and unruptured AVMs (area under the curve [AUC] 0.78, all p < 0.001). In a pseudoprospective cohort of 2005 admissions from 2018 to 2019, the AVM-5 remained significantly associated with all outcomes except for mortality and exhibited higher accuracy than all 3 earlier scores (AUC 0.79, all p < 0.001).

CONCLUSIONS

Patient frailty is predictive of poorer disposition and elevated complications, LOS, and costs for AVM microsurgical admissions. The authors’ custom AVM-5 risk score outperformed age, mFI-5, mFI-11, and CCI while using threefold less variables than the CCI. This score may complement existing AVM grading scales for optimization of surgical candidates and identification of patients at risk of postoperative medical and surgical morbidity.

Association of Patient Frailty With Vestibular Schwannoma Resection Outcomes and Machine Learning Development of a Vestibular Schwannoma Risk Stratification Score

BACKGROUND

Patient frailty is predictive of higher neurosurgical morbidity and mortality. However, existing frailty measures are hindered by lack of specificity to neurosurgery.

OBJECTIVE

To analyze the association between 3 risk stratification scores and outcomes for nationwide vestibular schwannoma (VS) resection admissions and develop a custom VS risk stratification score.

METHODS

We identified all VS resection admissions in the National Inpatient Sample (2002-2017). Three risk stratification scores were analyzed: modified Frailty Index-5, modified Frailty Index-11(mFI-11), and Charlson Comorbidity Index (CCI). Survey-weighted multivariate regression evaluated associations between frailty and inpatient outcomes, adjusting for patient demographics, hospital characteristics, and disease severity. Subsequently, we used k-fold cross validation and Akaike Information Criterion-based model selection to create a custom risk stratification score.

RESULTS

We analyzed 32 465 VS resection admissions. High frailty, as identified by the mFI-11 (odds ratio [OR] = 1.27, P = .021) and CCI (OR = 1.72, P < .001), predicted higher odds of perioperative complications. All 3 scores were also associated with lower routine discharge rates and elevated length of stay (LOS) and costs (all P < .05). Our custom VS-5 score (https://skullbaseresearch.shinyapps.io/vs-5_calculator/) featured 5 variables (age ≥60 years, hydrocephalus, preoperative cranial nerve palsies, diabetes mellitus, and hypertension) and was predictive of higher mortality (OR = 6.40, P = .001), decreased routine hospital discharge (OR = 0.28, P < .001), and elevated complications (OR = 1.59, P < .001), LOS (+48%, P < .001), and costs (+23%, P = .001). The VS-5 outperformed the modified Frailty Index-5, mFI-11, and CCI in predicting routine discharge (all P < .001), including in a pseudoprospective cohort (2018-2019) of 3885 admissions.

CONCLUSION

Patient frailty predicted poorer inpatient outcomes after VS surgery. Our custom VS-5 score outperformed earlier risk stratification scores.

The National Inpatient Sample: A Primer for Neurosurgical Big Data Research and Systematic Review

OBJECTIVE

The National Inpatient Sample - the largest all-payer inpatient database in the United States - is an important instrument for big data analysis of neurosurgical inquiries. However, earlier research has determined that many NIS studies are limited by common methodological pitfalls. In this study, we provide the first primer of NIS methodological procedures in the setting of neurosurgical research and review all published neurosurgical studies utilizing the NIS.

METHODS

We designed a protocol for neurosurgical big data research using the NIS, based on the authors' subject matter expertise, NIS documentation, and input and verification from the Healthcare Cost and Utilization Project. We subsequently used a comprehensive search strategy to identify all neurosurgical studies utilizing the NIS in the PubMed and MEDLINE, Embase, and Web of Science databases from inception to August 2021. Studies underwent qualitative categorization (years of the NIS studied, neurosurgical subspecialty, age group, and thematic focus of study objective) and analysis of longitudinal trends.

RESULTS

We identified a canonical, four-step protocol for NIS analysis: study population selection, defining additional clinical variables, identification and coding of outcomes, and statistical analysis. Methodological nuances discussed include identifying neurosurgery-specific admissions, addressing missing data, calculating additional severity and hospital-specific metrics, coding perioperative complications, and applying survey weights to make nationwide estimates. Inherent database limitations and common pitfalls of NIS studies discussed include lack of disease process-specific variables and data following the index admission, inability to calculate certain hospital-specific variables after 2011, performing state-level analyses, conflating hospitalization charges and costs, and not following proper statistical methodology for performing survey-weighted regression. In a systematic review, we identified 647 neurosurgical studies utilizing the NIS. While almost 60% of studies were published after 2015, <10% of studies analyzed NIS data after 2015. The average sample size of studies was 507,352 patients (standard deviation=2,739,900). Most studies analyzed cranial procedures (58.1%) and adults (68.1%). The most prevalent topic areas analyzed were surgical outcome trends (35.7%) and health policy and economics (17.8%), while patient disparities (9.4%) and surgeon or hospital volume (6.6%) were the least studied.

CONCLUSIONS

We present a standardized methodology to analyze the NIS, systematically review the state of the NIS neurosurgical literature, suggest potential future directions for neurosurgical big data inquiries, and outline recommendations to improve the design of future neurosurgical data instruments.

Brain tumor craniotomy outcomes for dual-eligible medicare and medicaid patients: a 10-year nationwide analysis

INTRODUCTION

Dual-eligible (DE) patients, simultaneous Medicare and Medicaid beneficiaries, have been shown to have poorer clinical outcomes while incurring higher resource utilization. However, neurosurgical oncology outcomes for DE patients are poorly characterized. Accordingly, we examined the impact of DE status on perioperative outcomes following glioma, meningioma, or metastasis resection.

METHODS

We identified all admissions undergoing a craniotomy for glioma, meningioma, or metastasis resection in the National Inpatient Sample from 2002 to 2011. Assessed outcomes included inpatient mortality, complications, discharge disposition, length of stay (LOS), and hospital costs. Multivariable regression adjusting for 13 patient, severity, and hospital characteristics assessed the association between DE status and outcomes, relative to four reference insurance groups (Medicare-only, Medicaid-only, private insurance, self-pay).

RESULTS

Of 195,725 total admissions analyzed, 3.0% were dual-eligible beneficiaries (n = 5933). DEs were younger than Medicare admissions (P < 0.001) but older than Medicaid, private, and self-pay admissions (P < 0.001). Relative to other insurance groups, DEs also exhibited higher severity of illness, risk of mortality, and Charlson Comorbidity Index scores as well as treatment at low-volume hospitals (all P < 0.001). DEs had lower mortality than self-pay admissions (odds ratio [OR] 0.47, P = 0.017). Compared to Medicare, Medicaid, private, and self-pay admissions, DEs had lower rates of discharge disposition (OR 0.53, 0.50, 0.34, and 0.27, respectively, all P < 0.001). DEs also had higher complications (OR 1.23 and 1.20, respectively, both P < 0.05) and LOS (β = 1.06 and 1.13, respectively, both P < 0.01) than Medicare and private insurance beneficiaries. Differences in discharge disposition remained significant for all three tumor subtypes, but only glioma DE admissions continued to exhibit higher complications and LOS.

CONCLUSIONS

DEs undergoing definitive craniotomy for brain tumor had higher rates of unfavorable discharge disposition compared to all other insurance groups and, especially for glioma surgery, had higher inpatient complication rates and LOS. Practice and policy reforms to improve outcomes for this vulnerable clinical population are warranted.

Quality Indicators for Children With Traumatic Brain Injury After Transition to an American College of Surgeons Level I Pediatric Trauma Center

OBJECTIVE

The aim of the study was to compare quality indicators, including frequency of acute surgical and emergent interventions, and resource utilization before and after American College of Surgeons (ACS) level I trauma verification among children with moderate or severe traumatic brain injury (TBI).

METHODS

This is a retrospective review of patients younger than 18 years treated for moderate or severe TBI, as determined by International Classification of Disease codes. Our institution obtained ACS level I trauma verification in 2013. Outcomes during the pre-ACS (June 2003-May 2008), interim (June 2008-May 2013), and post-ACS (June 2013-May 2018) periods were compared via nonparametric tests. Tests for linear trend were conducted using Cochran-Armitage tests for categorical data and by linear regression for continuous variables.

RESULTS

There were 677 children with moderate or severe TBIs (pre-ACS, 125; interim, 198; post-ACS, 354). Frequency of any surgical intervention increased significantly in the post-ACS period (12.2%) compared with interim (5.1%) and pre-ACS periods (5.6%, P = 0.007). More children in the post-ACS period required intracranial pressure monitoring (P = 0.017), external ventricular drain placement (P = 0.003), or endotracheal intubation (P = 0.001) compared with interim and pre-ACS periods. There was no significant change in time to operating room (P = 0.514), frequency of decompression (P = 0.096), or time to decompression (P = 0.788) between study periods. The median time to head CT decreased significantly in the post-ACS period (26 minutes; interquartile range [IQR], 9-60) compared with interim (36 minutes; IQR, 21-69) and pre-ACS periods (53 minutes; IQR, 36-89; P < 0.001). Frequency of repeat head computed tomography decreased significantly in the post-ACS period (30.2%) compared with interim (56.1%) and pre-ACS periods (64.0%, Ptrend = 0.044).

CONCLUSIONS

Transition to an ACS level I trauma verification was associated with improvements in quality indicators for children with moderate or severe TBI.

Impact of insurance status, hospital ownership type, and children's hospital designation on outcomes for pediatric neurosurgery patients following spasticity procedures in the USA

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.

Measuring the effects of institutional pediatric traumatic brain injury volume on outcomes for rural-dwelling children

OBJECTIVE

Rural-dwelling children may suffer worse pediatric traumatic brain injury (TBI) outcomes due to distance from and accessibility to high-volume trauma centers. This study aimed to compare the impacts of institutional TBI volume and sociodemographics on outcomes between rural- and urban-dwelling children.

METHODS

This retrospective study identified patients 0-19 years of age with ICD-9 codes for TBI in the 2012-2015 National Inpatient Sample database. Patients were characterized as rural- or urban-dwelling using United States Census classification. Logistic and linear (in log scale) regressions were performed to measure the effects of institutional characteristics, patient sociodemographics, and mechanism/severity of injury on occurrence of medical complications, mortality, length of stay (LOS), and costs. Separate models were built for rural- and urban-dwelling patients.

RESULTS

A total of 19,736 patients were identified (median age 11 years, interquartile range [IQR] 2-16 years, 66% male, 55% Caucasian). Overall, rural-dwelling patients had higher All Patient Refined Diagnosis Related Groups injury severity (median 2 [IQR 1-3] vs 1 [IQR 1-2], p < 0.001) and more intracranial monitoring (6% vs 4%, p < 0.001). Univariate analysis showed that overall, rural-dwelling patients suffered increased medical complications (6% vs 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1-4 days ] vs 2 days [IQR 1-3 days], p < 0.001), but multivariate analysis showed rural-dwelling status was not associated with these outcomes after adjusting for injury severity, mechanism, and hospital characteristics. Institutional TBI volume was not associated with medical complications, disposition, or mortality for either population but was associated with LOS for urban-dwelling patients (nonlinear beta, p = 0.008) and cost for both rural-dwelling (nonlinear beta, p < 0.001) and urban-dwelling (nonlinear beta, p < 0.001) patients.

CONCLUSIONS

Overall, rural-dwelling pediatric patients with TBI have worsened injury severity, mortality, and in-hospital complications, but these disparities disappear after adjusting for injury severity and mechanism. Institutional TBI volume does not impact clinical outcomes for rural- or urban-dwelling children after adjusting for these covariates. Addressing the root causes of the increased injury severity at hospital arrival may be a useful path to improve TBI outcomes for rural-dwelling children.

The Impact of Interhospital Competition on Treatment Strategy and Outcomes for Unruptured Intracranial Aneurysms

BACKGROUND

Interhospital competition has been shown to affect surgical outcomes and expenditures. However, interhospital competition's impact on neurosurgery is poorly characterized.

OBJECTIVE

To assess how interhospital competition is associated with treatment strategy and outcomes for unruptured intracranial aneurysms (UIAs).

METHODS

We identified all elective UIA admissions in the National Inpatient Sample from 2002 to 2011. Competitive intensity of each hospital market was quantified using the validated Herfindahl-Hirschman Index (HHI), with lower values denoting higher competition. We then obtained nationwide HHI values for 2012 to 2016 from the Health Care Cost Project. Outcomes included treatment modality (clipping, coiling, or nonoperative management), inpatient mortality, disposition, complications, length of stay (LOS), and costs. Multivariate regression assessed the association between HHI and outcomes, controlling for patient demographics, severity metrics, hospital characteristics, and treatment.

RESULTS

We studied 157 979 elective UIA admissions at 1435 hospitals from 2002 to 2011, with an increase in coiling admissions (13.4% to 33.7%) and decrease in clipping admissions (30.9% to 17.6%). Mean hospital HHI was 0.11 (range = 0.001-0.97). Competition decreased for 61.8% of hospitals from 2002 to 2011 and 68.1% of metropolitan localities from 2012 to 2016. Admissions in more competitive hospital markets exhibited increased odds of undergoing surgery (odds ratio [OR] = 1.37, P < .001), with preference toward coiling over clipping (OR = 1.27, P < .001). HHI was not associated with mortality, disposition, or LOS. However, increased interhospital competition was associated with more complications (OR = 1.09, P = .001) and greater hospital costs (β-coefficient = 1.06, P < .001).

CONCLUSION

For UIA patients, admission to hospitals in more competitive geographies was associated with increased rates of surgical intervention, coiling utilization, complications, and hospitalization costs.

Association of hospital characteristics and insurance type with quality outcomes for pediatric craniosynostosis patients

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.

Association of hospital characteristics with outcomes for pediatric neurosurgical accidental trauma patients

OBJECTIVE

In the pediatric population, few studies have examined outcomes for neurosurgical accidental trauma care based on hospital characteristics. The purpose of this study was to explore the relationship between hospital ownership type and children's hospital designation with primary outcomes.

METHODS

This retrospective cohort study utilized data from the Healthcare Cost and Utilization Project 2006, 2009, and 2012 Kids' Inpatient Database. Primary outcomes, including inpatient mortality, length of stay (LOS), and favorable discharge disposition, were assessed for all pediatric neurosurgery patients who underwent a neurosurgical procedure and were discharged with a primary diagnosis of accidental traumatic brain injury.

RESULTS

Private, not-for-profit hospitals (OR 2.08, p = 0.034) and freestanding children's hospitals (OR 2.88, p = 0.004) were predictors of favorable discharge disposition. Private, not-for-profit hospitals were also associated with reduced inpatient mortality (OR 0.34, p = 0.005). A children's unit in a general hospital was associated with a reduction in hospital LOS by almost 2 days (p = 0.004).

CONCLUSIONS

Management at freestanding children's hospitals correlated with more favorable discharge dispositions for pediatric patients with accidental trauma who underwent neurosurgical procedures. Management within a children's unit in a general hospital was also associated with reduced LOS. By hospital ownership type, private, not-for-profit hospitals were associated with decreased inpatient mortality and more favorable discharge dispositions.

Timing of Surgery for Thoracolumbar Spine Trauma: Patients With Neurological Injury

STUDY DESIGN

Large multicenter retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze the effect of fusion timing on inpatient outcomes in a nationally representative population with thoracolumbar fracture and concurrent neurological injury.

SUMMARY OF BACKGROUND DATA

Among thoracolumbar trauma admissions, concurrent neurological injury is associated with greater long-term morbidity. There is little consensus on optimal surgical timing for these patients; previous investigations fail to differentiate thoracolumbar fracture with and without neurological injury.

MATERIALS AND METHODS

We analyzed 19,136 nonelective National Inpatient Sample cases (2004-2014) containing International Classifications of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes for closed thoracic/lumbar fracture with neurological injury and procedure codes for primary thoracolumbar/lumbosacral fusion, excluding open/cervical fracture. Timing classification from admission to fusion was same-day, 1-2-, 3-6-, and ≥7-day delay. Primary outcomes included in-hospital mortality, complications, and infection; secondary outcomes included total and postoperative length of stay and charges. Logistic regressions and generalized linear models with gamma distribution and log-link evaluated the effect of surgical timing on primary and secondary outcomes, respectively, controlling for age, sex, fracture location, fusion approach, multiorgan system injury severity score, and medical comorbidities.

RESULTS

Patients undergoing surgery ≤72 hours (n=12,845) had the lowest odds of in-hospital cardiac [odds ratio (OR)=0.595; 95% confidence interval (CI), 0.357-0.991] and respiratory complications (OR=0.495; 95% CI, 0.313-0.784) and infection (OR=0.615; 95% CI, 0.390-0.969). No differences were observed between same-day (n=4724) and 1-2-day delay (n=8121) (P>0.05). Lowest odds of hemorrhage or hematoma was observed following 3-6-day delay (OR=0.467; 95% CI, 0.236-0.922). A ≥7-day delay to fusion (n=2,002) was associated with greatest odds of hemorrhage/hematoma (OR=2.019; 1.107-3.683), respiratory complications (OR=1.850; 95% CI, 1.076-3.180), and infection (OR=3.155; 95% CI, 1.891-5.263) and greatest increases in mean postoperative length of stay (4.26% or 35.3% additional days) and charges (163,562 or 71.7% additional US dollars) (P<0.001).

CONCLUSIONS

Patients with thoracolumbar fracture and associated neurological injury who underwent surgery within 3 days of admission experienced fewer in-hospital complications. These benefits may be due to secondary injury mechanism avoidance and earlier mobilization.

LEVEL OF EVIDENCE

Level III.

The impact of hospital safety-net status on inpatient outcomes for brain tumor craniotomy: a 10-year nationwide analysis

Background

Outcome disparities have been documented at safety-net hospitals (SNHs), which disproportionately serve vulnerable patient populations. Using a nationwide retrospective cohort, we assessed inpatient outcomes following brain tumor craniotomy at SNHs in the United States.

Methods

We identified all craniotomy procedures in the National Inpatient Sample from 2002–2011 for brain tumors: glioma, metastasis, meningioma, and vestibular schwannoma. Safety-net burden was calculated as the number of Medicaid plus uninsured admissions divided by total admissions. Hospitals in the top quartile of burden were defined as SNHs. The association between SNH status and in-hospital mortality, discharge disposition, complications, hospital-acquired conditions (HACs), length of stay (LOS), and costs were assessed. Multivariate regression adjusted for patient, hospital, and severity characteristics.

Results

304,719 admissions were analyzed. The most common subtype was glioma (43.8%). Of 1,206 unique hospitals, 242 were SNHs. SNH admissions were more likely to be non-white (P < .001), low income (P < .001), and have higher severity scores (P = .034). Mortality rates were higher at SNHs for metastasis admissions (odds ratio [OR] = 1.48, P = .025), and SNHs had higher complication rates for meningioma (OR = 1.34, P = .003) and all tumor types combined (OR = 1.17, P = .034). However, there were no differences at SNHs for discharge disposition or HACs. LOS and hospital costs were elevated at SNHs for all subtypes, culminating in a 10% and 9% increase in LOS and costs for the overall population, respectively (all P < .001).

Conclusions

SNHs demonstrated poorer inpatient outcomes for brain tumor craniotomy. Further analyses of the differences observed and potential interventions to ameliorate interhospital disparities are warranted.