Neurosurgical Patient Population Research Articles

Systematic reviews and meta-analyses in neurosurgery part I: interpreting and critically appraising as a guide for clinical practice.

Neurosurgeons are inundated with the Herculean task to keep abreast with the rapid pace at which clinical research is proliferating. Systematic reviews and meta-analyses (SRMAs) have consequently surged in popularity because when executed properly, they constitute the highest level of evidence, and may save busy neurosurgeons many hours of combing the literature. Well-executed SRMAs may prove instructive for clinical practice, but poorly conducted reviews sow confusion and may potentially cause harm. Unfortunately, many SRMAs within neurosurgery are relatively lackluster in methodological rigor. When neurosurgeons apply the results of an SRMA to patient care, they should start by evaluating the extent to which the employed methods have likely protected against misleading results. The present article aims to educate the reader about how to interpret an SRMA, to assess the potential relevance of its results in the special context of the neurosurgical patient population.

Risk Analysis Index Frailty Score as a Predictor of Otolaryngology Surgical Outcomes.

The Risk Analysis Index (RAI) score is a screening tool to assess patient frailty. It has been shown to be predictive of postoperative outcomes and mortality in orthopedic, urologic, and neurosurgical patient populations. We sought to evaluate the predictive ability of RAI score for surgical outcomes in an otolaryngology patient population. Retrospective study. Academic tertiary medical center. A retrospective study was conducted of adult patients undergoing otolaryngology surgery at a tertiary medical care center over 21 months. Patients were sent electronic RAI survey questionnaires via direct messaging, which was completed prior to surgery. Endpoint data were analyzed, including demographics, RAI score, and patient outcome data. Univariate analysis, ROC curves, and predictive modeling were utilized. A total of 517 patients responded to the RAI questionnaire, resulting in a 59.6% response rate. Mean RAI score was 21.38 ± 11.83. Higher RAI scores were associated with increased 30-day readmissions (P < .0015), postoperative complications (P < .001), hospital length of stay (P < .001), and discharge with home health (P < .001). Predictive models for RAI score and postoperative outcomes were created, and a cutoff score of RAI = 30 was established to identify frail patients. We evaluated if RAI scoring predicted postoperative complications in an otolaryngology patient population. Increased RAI score is significantly associated with poorer surgical outcomes, including increased hospital length of stay, 30-day readmissions, and postoperative complications. We propose a predictive model with suggested RAI cutoff scoring for use in the otolaryngology surgical population.

361 The Frailty-Driven Predictive Model for Failure to Rescue After Cervical Decompression and Fusion: An ACS-NSQIP Analysis of 3,632 Cases (2011-2020)

INTRODUCTION: Cervical decompression &amp; fusion (CDF) outcome prognostication relies on preoperative risk factors to predict complications and outcomes in order to help guide pre- and perioperative decision-making. METHODS: CDF cases were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database 2011-2020. Patients who underwent CDF and experienced a major complication were identified. Within this cohort, FTR was calculated as death or hospice within 30 days of a major complication. Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Demographics and baseline characteristics of patients were compared by FTR. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic curve analysis. RESULTS: There were 3,632 patients who suffered a major complication from CDF, and 7.6% (277 patients) experienced FTR. Independent predictors of FTR were non-elective surgery, frailty status, preoperative intubation, thrombosis or embolism complication, unplanned intubation, prolonged ventilator use (&gt;48 hours), cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSIONS: Preoperative and postoperative risk factors yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication following the development of a major complication. Future studies may determine the predictive ability of this model in other neurosurgical patient populations. Our predictive model may be deployed by-the-beside here: https://nsgyfrailtyoutcomeslab.shinyapps.io/FailureToRescueCervicalFusion/

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example.

The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population. Literature review and illustrative case example. A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema. DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011–2020)

BACKGROUND CONTEXTPreoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSEThis study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTINGCross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLEThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURESCDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODSFrailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTSThere were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883–0.919). CONCLUSIONPreoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Consultations During COVID: Effects of a Pandemic on Neurosurgical Care

COVID-19 has impacted Neurosurgical care around the world. But reports describing patient admission trends during the pandemic have provided limited time frames and diagnoses. The purpose of this paper was to analyze the impact of COVID-19 on Neurosurgical care provided to our Emergency Department during the outbreak. Patient admission data were collected based on a list of 35 ICD-10 codes, which were placed into one of four categories: head and spine trauma ("Trauma"), head and spine infection ("Infection"), degenerative spine ("Degenerative") and subarachnoid hemorrhage / brain tumor ("Control"). Emergency room consultations to the Neurosurgery Department were collected from March 2018 to March 2022, representing 2 years before COVID and 2 years of pandemic. We hypothesized that Control cases would remain stable throughout the two time periods while Trauma, and Infection would decrease. Because of widespread clinic restrictions we postulated Degenerative (spine) cases presenting to the ER would increase. During the first two years of the COVID pandemic, Neurosurgical Trauma and Degenerative ER patients decreased compared to pre-pandemic levels, while Cranial and Spinal infections increased, and continued to do so during the pandemic period studied. Brain tumors and sub-arachnoid hemorrhages ('control' cases) did not change in a significant way throughout the four-year analysis. The COVID pandemic significantly altered the demographics of our Neurosurgical Emergency Room patient population and continues to do so.

Factors Predicting Leaving Against Medical Advice in Neurosurgery: A Prospective Observational Study

Introduction: The decision of a patient for leaving the hospital against medical advice (AMA)affects the patient management adversely by increasing morbidity, mortality and escalates the cost of treatment. Objectives: The main objective of the study is to find the factors predicting leaving against medical advice in neurosurgery. Material and methods: This cross-sectional study was conducted in King Edward Medical University during February 2022 to July 2022. Data was collected with the permission of ethical committee of hospital. Data on gender, age, marital status, day and time of admission and discharge, duration of stay, primary specialty for care, reason for leaving against medical advice, prior history of hospitalizations, mode of payment, medication and follow-up advice at time of LAMA, revisit to the hospital and development of morbidity at follow-up was collected from patient charts and the LAMA form. Results: Data was collected from 300 patients of both genders. There were 142 male and 158 female patients from age range 0 to 75 years. During the same period, 263 patients were discharged from the neurosurgical service and the rate of LAMA in the neurosurgery department was calculated to be 16.73%. Practical implication: This study will be helpful in neurology department of the hospital and used for the betterment of results. Conclusion: It is concluded that leaving AMA rates are high in neurological in-patients. Low income and level of health literacy were the most common causes of LAMA in this neurosurgical patient population. Keywords: LAMA, Patients, Surgical. Population, AMA, Health

Resident assistant training level is not associated with patient spinal fusion outcomes

ObjectiveA hallmark of surgical training is resident involvement in operative procedures. While resident-assisted surgeries have been deemed generally safe, few studies have rigorously isolated the impact of resident post-graduate year (PGY) level on post-operative outcomes in a neurosurgical patient population. The objective of this study is to evaluate the relationship between resident training level and outcomes following single-level, posterior-only lumbar fusion, after matching on key patient demographic/clinical characteristics and attending surgeon. Patients and methodsThis coarsened-exact matching (CEM) study analyzed 2338 consecutive adult patients who underwent single-level lumbar fusion with a resident assistant surgeon at a multi-hospital university health system from 2013 to 2019. Primary outcomes were 30-day and 90-day readmissions, Emergency Department (ED) visits, reoperations, surgical complications, and mortality. First, univariate logistic regression examined the relationship between PGY level and outcomes. Then, CEM was used to control for key patient characteristics – such as race and comorbid status – and supervising attending surgeon, between the most junior (PGY-2)-assisted cases and the most senior (PGY-7)-assisted cases, thereby isolating the relationship between training level and outcomes. ResultsAmong all patients, resident training level was not associated with risk of adverse post-surgical outcomes. Similarly, between exact-matched cohorts of PGY-2- and PGY-7-assisted cases, no significant differences in adverse events or discharge disposition were observed. Patients with the most senior resident assistant surgeons demonstrated longer length of stay (mean 100.5 vs. 93.8 h, p = 0.022) and longer duration of surgery (mean 173.5 vs. 159.8 min, p = 0.036). ConclusionTraining level of the resident assistant surgeon did not impact adverse outcomes provided to patients in the setting of single-level, posterior-only lumbar fusion. These findings suggest that attending surgeons appropriately manage cases with resident surgeons at different levels of training.

353 Comprehensive Evaluation of Telehealth Service Effectiveness in the Neurosurgical Patient Population During the COVID-19 Pandemic

INTRODUCTION: In recent years, remote access for medical care is increasingly being utilized. However its efficacy for neurosurgical patients is not widely studied, especially in the setting of a global pandemic. METHODS: A HIPAA-compliant survey was created via RedCap addressing satisfaction and utility of telehealth (televideo or telephone) in patients from 03/2020 – Present. Out of 246 currently emailed patients, 22 responses were recorded (televideo, n=11; telephone, n=11). RESULTS: Telephone users found the phone call a suitable method, with no preference for video format. However, 3 of these phone respondents (27.3%) still required an in-person visit. For televideo service, no user reported finding difficulty in accessing their appointment. Interestingly, 45.5% of televideo users (n=5) reported that the attending physician displayed multimedia tools, such as radiographic imaging, during the visit. When examining both telephone and televideo cohorts, 95.5% of respondents (n=21) felt satisfied overall with telehealth’s ability to meet their needs. Despite this high satisfaction rate, 22.7% of all respondents were either ambivalent (n=4) or strongly disagreed (n=1) that telehealth improved access to healthcare services. CONCLUSION: Our study illustrates the importance of differentiating between satisfaction—which can expectedly be high in a “stay-at-home” service—and efficacy in providing neurosurgical care. We suggest that telehealth is a technologically robust tool given its reported ease of use. Yet, preliminary results show that telehealth’s comprehensiveness may hold up less for patients who still require in-person evaluation for certain diagnoses and examinations. Almost a quarter of respondents believed that telehealth did not improve access to healthcare services, arguing that telehealth visits may be less useful for some.

Neurosurgery outcomes and complications in a monocentric 7-year patient registry

IntroductionCapturing adverse events reliably is paramount for clinical practice and research alike. In the era of “big data”, prospective registries form the basis of clinical research and quality improvement. Research questionTo present results of long-term implementation of a prospective patient registry, and evaluate the validity of the Clavien-Dindo grade (CDG) to classify complications in neurosurgery. Materials and methodsA prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013. The CDG – a complication grading focused on need for unplanned therapeutic intervention – was used to grade complications. We assess construct validity of the CDG. ResultsData acquisition integrated into our hospital workflow permitted to include all eligible patients into the registry. We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020. Similarly, we have captured 1245 complications on 6308 patient discharge forms (20%) since full operational status of the registry. The majority of complications (819/6308 ​= ​13%) were treated without invasive treatment (CDG 1 or CDG 2). At discharge, there was a clear correlation of CDG and the Karnofsky Performance Status (KPS, rho ​= ​-0.29, slope -7 KPS percentage points per increment of CDG) and the length of stay (rho ​= ​0.43, slope 3.2 days per increment of CDG). Discussion and conclusionPatient registries with high completeness and objective capturing of complications are central to the process of quality improvement. The CDG demonstrates construct validity as a measure of complication classification in a neurosurgical patient population.

Commentary: Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs.

Correspondence: Aaron S. Dumont, MD, MBA, Department of Neurological Surgery, Tulane University School of Medicine, 1415 Tulane Ave, New Orleans, LA 70112, USA. Email: [email protected]

Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs.

Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions. To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs. We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2%vs 4.1%) or an acute/inpatient rehabilitation facility (22.7%vs 1.7%, P<.0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P=.048). The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.

Patient-Reported Outcomes: Quality of Care on a Neurosurgical Ward.

Patient experience has become a quality measure in hospitals across the United States. To improve our understanding of our neurosurgical patient population's satisfaction needs, we undertook a detailed survey to identify areas of needed improvement. Upon institutional review board approval, a detailed survey adopted from the Swedish quality-of-care patient questionnaire was distributed to all patients being discharged from the neurosurgical ward over a month period. From June 2014 to July 2014, all patients admitted to the neurosurgery service through the emergency department, clinic, or other facilities were enrolled. There were no specific inclusion criteria except for age older than 18 years, intact cognition to complete the survey, and return of a completed survey. Data were collected in 6 major categories, including information availability, patient accessibility, treatment received, caring perception, hospital environment, and overall satisfaction. Patients were evaluated by age, gender, surgery, and admission type. Our analysis demonstrated an improved overall satisfaction in those patients being admitted electively from the clinic as compared with emergency department admissions or hospital transfers. In addition, patients admitted on an emergent basis reported a lower satisfaction pertaining to receiving information, specifically test results. Emergent admissions represent a subpopulation that may require additional strategies to improve patient satisfaction survey scores.

Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure

ObjectivesSepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations.MethodsMulticenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012–2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS.ResultsThere were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location.ConclusionsThe data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.

Introducing a Supportive Care Team for Advance Directive Education in a Neurological and Neurosurgical Patient Population.

Background:Patient-centered care includes delineation of patient treatment values (ie, advance care planning [ACP]). Advance care planning often includes advance directive (AD) completion and is underutilized, particularly among neurology and neurosurgery patients. Implementation of a supportive care team (SCT) in outpatient clinic settings may offer opportunities for AD education and completion.Objective:This study assesses the effectiveness of an integrative SCT composed of hospice volunteers and undergraduate quality improvement interns in their efforts to provide ACP education in neurological and neurosurgical outpatient clinics. Assessment includes a description of different types of SCT-patient encounters, as well as patient interest in and completion of ADs after interacting with the SCT.Results:Across the data collection period, 2770 encounters were initiated. The majority of encounters resulted in patient ACP education. Some patients completed ADs during their SCT encounter (3.45%) or after their SCT encounter (10.18%).Conclusion:The SCT effectively enhances ACP education in this patient population. The utilization of trained interns to assist with ACP is beneficial and practical in clinic workflow.

Telemedicine in Neurosurgery: Lessons Learned and Transformation of Care During the COVID-19 Pandemic

BackgroundBefore the COVID-19 pandemic, telemedicine utilization was mostly used for postoperative visits only in neurosurgery. Shelter-in-place measures led the rapid expansion of telemedicine to address the needs of the neurosurgical patient population. Our goal is to determine the extent of adoption of telemedicine across tumor, vascular, spine, and function neurosurgery and utilization for new patient visits.MethodsA single-center retrospective cohort study of patients who received neurosurgical care at a tertiary academic center from February to April 2020 was conducted. Patients evaluated from March to April 2019 were included for comparison. A total of 10,746 patients were included: 1247 patients underwent surgery, 8742 were seen in clinic via an in-person outpatient visit, and 757 were assessed via telemedicine during the study period.ResultsA 40-fold increase in the use of telemedicine was noted after the shelter-in-place measures were initiated with a significant increase in the mean number of patients evaluated via telemedicine per week across all divisions of neurosurgery (4.5 ± 0.9 to 180.4 ± 13.9, P < 0.001). The majority of telemedicine appointments were established patient visits (61.2%), but the proportion of new patient visits also significantly increased to an average of 8.2 ± 5.3 per week across all divisions.ConclusionsUse of telemedicine drastically increased across all 4 divisions within neurosurgery with a significant increase in online-first encounters in order to meet the needs of our patients once the shelter-in-place measures were implemented. We provide a detailed account of the lessons learned and discuss the anticipated role of telemedicine in surgical practices once the shelter-in-place measures are lifted.

Face-to-Face Meetings with Neurosurgical Patients Before Hospital Discharge: Impact on Telephone Outreach, Emergency Department Visits, and Hospital Readmissions.

The Johns Hopkins Community Health Partnerships (JCHiP) was developed in 2010 within the Johns Hopkins Health Systems. As part of JCHiP, the Patient Access Line call center was created. The average telephone reach rate at The Johns Hopkins Hospital in 2014 was only 53%. In a population of adult neurosurgical patients, this study aimed to: determine the impact of face-to-face meetings with neurosurgical patients before hospital discharge on telephone follow-up (TFU) reach rates, and determine the association between TFU reach rates and subsequent emergency department (ED) visits and hospital readmission rates. This quasi-experimental study used a posttest-only research design with a comparison group. Two adult inpatient neurosurgical units at the Johns Hopkins Hospital were selected as the intervention and comparison groups. A convenience sampling technique was used. Face-to-face meetings pre hospital discharge resulted in a TFU reach rate of 97.7% on the intervention unit while the comparison unit had only a 76.1% TFU reach rate (P < .001). Reached patients had fewer ED visits (7.8%) than not reached patients (17.4%); however, the difference was not statistically significant (P = .138). Reached patients also had fewer hospital readmissions (3.3%) than not reached patients (8.7%); this also was not statistically significant (P = .214). This study demonstrated that face-to-face meetings with neurosurgical patients prior to discharge increased TFU rates. Results were statistically significant. ED visits and hospital readmissions were also reduced in reached patients and the findings were clinically significant.

Validation of the LACE Index (Length of Stay, Acuity of Admission, Comorbidities, Emergency Department Use) in the Adult Neurosurgical Patient Population.

The LACE index (Length of stay, Acuity of admission, Comorbidities, Emergency department use) quantifies the risk of mortality or unplanned readmission within 30 d after hospital discharge. The index was validated originally in a large, general population and, subsequently, in several specialties, not including neurosurgery. To determine if the LACE index accurately predicts mortality and unplanned readmission of neurosurgery patients within 30 d of discharge. We performed a retrospective, cohort study of consecutive neurosurgical procedures between January 1 and September 29, 2017 at our institution. The LACE index and other clinical data were abstracted. Data analysis included univariate and multivariate logistic regressions. Of the 1,054 procedures on 974 patients, 52.7% were performed on females. Mean age was 54.2±15.4 yr. At time of discharge, the LACE index was low (1-4) in 58.3% of patients, moderate (5-9) in 32.4%, and high (10-19) in 9.3%. Rates of readmission and mortality within 30 d were 7.0, 11.4, and 14.3% in the low-, moderate-, and high-risk groups, respectively. Moderate-risk (odds ratio [OR] 1.62, 95% CI 1.02-2.56, P=.04) and high-risk LACE indexes (OR 2.20, 95% CI 1.15-4.19, P=.02) were associated with greater odds of readmission or mortality, adjusting for all variables. Additionally, longer operations (OR 1.11, 95% CI 1.02-1.21, P=.02) had greater odds of readmission. Specificity of the high-risk score to predict 30-d readmission or mortality was 91.2%. A moderate- or high-risk LACE index can be applied to neurosurgical populations to predict 30-d readmission and mortality. Longer operations are potential predictors of readmission or mortality.

Reducing Preventable Readmissions in a Neurosurgical Patient Population at an Academic Medical Center

Abstract INTRODUCTION Hospital readmissions are extremely costly in terms of time and resources and negatively impact patient safety and satisfaction. In this study, we performed a Pareto analysis of 30-day readmissions in a neurosurgical patient population in order to identify patients at high-risk for readmission. Using this information, we implemented a new practice parameter with the goal of reducing preventable readmissions. METHODS Patient characteristics and causes for readmission were prospectively collected for all neurosurgical patients readmitted to an academic medical center within 30 d of discharge between July and October 2018. A program was then initiated where postoperative neurosurgical spine patients were contacted by phone at standardized intervals before their 2-wk follow-up appointment, with the purpose of more quickly addressing surgical concerns and/or coordinating care for general medical issues. Finally, 30-d readmission rates were compared between the initial 4-mo period and January 2019 through April 2019. RESULTS Prior to intervention, the largest group of readmitted patients included those who had undergone recent spinal surgery (16/47, 34%). Among spine readmissions during this time, 47% were readmitted before their two-week follow-up appointment, 67% lived over 50 miles from the medical center, and 40% were Medicare-insured. There was a statistically significant difference in the mean rate of spine readmissions per month in the periods before (7.0%) and after (3.0%) the program onset (P = .029, 57% decline). The total number of surgically and medically related spine readmissions decreased between the pre- and postintervention periods from 10 to 3 (70%) and 3 to 1 (67%), respectively. CONCLUSION Our data suggests that a large number of neurosurgical readmissions may be prevented by the simple process of early follow-up and consistent communication via telephone. Readmission rates may be further reduced by standardizing the coordination of postoperative general medical follow-up and providing thorough wound care teaching for high-risk patients.

Preoperative risk stratification of patient mortality following elective craniotomy; a comparative analysis of prediction algorithms

Factors associated with mortality following craniotomy for non-traumatic etiologies are not well studied. We performed a retrospective case-control study to investigate the utility of the Gupta, RCRI, KPS, ASA, and NSQIP risk calculators in predicting complication and mortality rates among a neurosurgical patient population undergoing elective craniotomy and used ROC curves to determine their relative predictive accuracy. We identified 17 patients who died following elective craniotomy and 17 control patients who survived, matched for sex, age, comorbid conditions, and intervention. The deceased cohort experienced a greater degree of surgical complications, with concordantly higher preoperative risk scores as assessed by Gupta, KPS, ASA, and NSQIP scales. Cause of death was secondary to a surgical complication in 11 (65%) cases and nonsurgical in 6 (35%) cases. When comparing our deceased and survival cohorts for specific complication profiles, higher RCRI score was significantly associated with postoperative cardiac death. Poor preoperative ASA and KPS score were both associated with mortality. NSQIP risk was significantly associated with mortality and nonsurgical and cardiopulmonary complications. ROC analyses comparing predictive scales found no clearly superior prediction algorithm for postoperative complications or mortality; NSQIP and RCRI were highly predictive of cardiac death, KPS and NSQIP with nonsurgical complications, and Gupta, ASA, KPS, and NSQIP with postoperative mortality. NSQIP scores correlated most broadly with nonsurgical complications and mortality. Future efforts at quality improvement in healthcare value will be rooted in the development of more accurate and specific risk assessment strategies specific to neurosurgery.