Unplanned hospital readmission after cranial neurosurgery

Unplanned hospital readmission after cranial neurosurgery

Many readmissions may be preventable and occur at predictable time intervals. The causes and timing of readmission vary significantly across neurosurgical subgroups. Future studies should focus on detecting specific complications in select cohorts at predefined time points, which may allow for interventions to lower costs and reduce patient morbidity 1).


Hospital readmission to a hospital (non-index) other than the one from which patients received their original care (index) has been associated with increases in both morbidity and mortality for cancer patients.

Of patient readmissions following brain tumor resection, 15.6% occur at a non-index facility. Low procedure volume is a confounder for non-index analysis and is associated with an increased likelihood of major complications and mortality, as compared to readmission to high-procedure-volume hospitals. Further studies should evaluate interventions targeting factors associated with unplanned readmission 2).


In a single-center Canadian experience. Almost one-fifth of neurosurgical patients were readmitted within 30 days of discharge. However, only about half of these patients were admitted for an unplanned reason, and only 10% of all readmissions were potentially avoidable. This study demonstrates unique challenges encountered in a publicly funded healthcare setting and supports the growing literature suggesting 30-day readmission rates may serve as an inappropriate quality of care metric in neurosurgical patients. Potentially avoidable readmissions can be predicted, and further research assessing predictors of avoidable readmissions is warranted 3).

A study of Elsamadicy et al. suggested that infection, altered mental status, and new sensory/motor deficits were the primary complications leading to unplanned 30-day readmission after cranial neurosurgery 4).


The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management 5).


Obstructive sleep apnea (OSA) is known to be associated with negative outcomes and is underdiagnosed. The STOP-Bang questionnaire is a screening tool for OSA that has been validated in both medical and surgical populations. Given that readmission, after surgical intervention is an undesirable event, Caplan et al. sought to investigate, among patients not previously diagnosed with OSA, the capacity of the STOP-Bang questionnaire to predict 30-day readmissions following craniotomy for a supratentorial tumor.

For patients undergoing craniotomy for treatment of a supratentorial neoplasm within a multiple-hospital academic medical center, data were captured in a prospective manner via the Neurosurgery Quality Improvement Initiative (NQII) EpiLog tool. Data were collected over a 1-year period for all supratentorial craniotomy cases. An additional criterion for study inclusion was that the patient was alive at 30 postoperative days. Statistical analysis consisted of simple logistic regression, which assessed the ability of the STOP-Bang questionnaire and additional variables to effectively predict outcomes such as 30-day readmission, 30-day emergency department (ED) visit, and 30-day reoperation. The C-statistic was used to represent the receiver operating characteristic (ROC) curve, which analyzes the discrimination of a variable or model.

Included in the sample were all admissions for supratentorial neoplasms treated with craniotomy (352 patients), 49.72% (n = 175) of which were female. The average STOP-Bang score was 1.91 ± 1.22 (range 0-7). A 1-unit higher STOP-Bang score accurately predicted 30-day readmissions (OR 1.31, p = 0.017) and 30-day ED visits (OR 1.36, p = 0.016) with fair accuracy as confirmed by the ROC curve (C-statistic 0.60-0.61). The STOP-Bang questionnaire did not correlate with 30-day reoperation (p = 0.805) or home discharge (p = 0.315).

The results of this study suggest that undiagnosed OSA, as assessed via the STOP-Bang questionnaire, is a significant predictor of patient health status and readmission risk in the brain tumor craniotomy population. Further investigations should be undertaken to apply this prediction tool in order to enhance postoperative patient care to reduce the need for unplanned readmissions 6).


Lopez Ramos et al., from the Department of Neurological Surgery, University of California San Diego, La Jolla, CA, USA, examined clinical risk factors and postoperative complications associated with 30-day unplanned hospital readmissions after cranial neurosurgery.

They queried the American College of Surgeons National Surgical Quality Improvement Program database from 2011-2016 for adult patients that underwent a cranial neurosurgical procedure. Multivariable logistic regression with backwards model selection was used to determine predictors associated with 30-day unplanned hospital readmission.

Of 40,802 cranial neurosurgical cases, 4,147 (10.2%) had an unplanned readmission. Postoperative complications were higher in the readmission cohort (18.5% vs 9.9%, p <0.001). On adjusted analysis, clinical factors predictive of unplanned readmission included hypertension, COPD, diabetes, coagulopathy, chronic steroid use, and preoperative anemia, hyponatremia, and hypoalbuminemia (all p ≤ 0.01). Higher ASA class (III-V), operative time >216 minutes, and unplanned reoperation were also associated with an increased likelihood of readmission (all p ≤0.001). Postoperative complications predictive of unplanned readmissions were wound infection (OR 4.90, p <0.001), pulmonary embolus (OR 3.94, p <0.001), myocardial infarction/cardiac arrest (OR 2.37, p <0.001), sepsis (OR 1.73, p <0.001), deep venous thrombosis (1.50, p=0.002), and urinary tract infection (OR 1.45, p=0.002). Female sex, transfer status, and postoperative pulmonary complications were protective of readmission (all p <0.05)

Unplanned hospital readmission after cranial neurosurgery is a common event. Identification of high-risk patients who undergo cranial procedures may allow hospitals to reduce unplanned readmissions and associated healthcare costs 7).


Cusimano et al., conducted a systematic review of several databases; a manual search of the Journal of NeurosurgeryNeurosurgeryActa NeurochirurgicaCanadian Journal of Neurological Sciences; and the cited references of the selected articles. Quality review was performed using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

A total of 1344 articles published between 1947 and 2015 were identified; 25 were considered potentially eligible, of which 12 met inclusion criteria. The 30-day readmission rates varied from 6.9% to 23.89%. Complications arising during or after neurosurgical procedures were a prime reason for readmission. Race, comorbidities, and longer hospital stay put patients at risk for readmission.

Although readmission may be an important indicator for good care for the subset of acutely declining patients, neurosurgery should aim to reduce 30-day readmission rates with improved quality of care through systemic changes in the care of neurosurgical patients that promote preventive measures 8).

References

1)

Taylor BE, Youngerman BE, Goldstein H, Kabat DH, Appelboom G, Gold WE, Connolly ES Jr. Causes and Timing of Unplanned Early Readmission After Neurosurgery. Neurosurgery. 2016 Sep;79(3):356-69. doi: 10.1227/NEU.0000000000001110. PubMed PMID: 26562821.
2)

Jarvis CA, Bakhsheshian J, Ding L, Wen T, Tang AM, Yuan E, Giannotta SL, Mack WJ, Attenello FJ. Increased complication and mortality among non-index hospital readmissions after brain tumor resection is associated with low-volume readmitting hospitals. J Neurosurg. 2019 Oct 4:1-13. doi: 10.3171/2019.6.JNS183469. [Epub ahead of print] PubMed PMID: 31585421.
3)

Wilson MP, Jack AS, Nataraj A, Chow M. Thirty-day readmission rate as a surrogate marker for quality of care in neurosurgical patients: a single-center Canadian experience. J Neurosurg. 2018 Jul 1:1-7. doi: 10.3171/2018.2.JNS172962. [Epub ahead of print] PubMed PMID: 29979117.
4)

Elsamadicy AA, Sergesketter A, Adogwa O, Ongele M, Gottfried ON. Complications and 30-Day readmission rates after craniotomy/craniectomy: A single Institutional study of 243 consecutive patients. J Clin Neurosci. 2018 Jan;47:178-182. doi: 10.1016/j.jocn.2017.09.021. Epub 2017 Oct 12. PubMed PMID: 29031542.
5)

Dasenbrock HH, Yan SC, Smith TR, Valdes PA, Gormley WB, Claus EB, Dunn IF. Readmission After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis. Neurosurgery. 2017 Apr 1;80(4):551-562. doi: 10.1093/neuros/nyw062. PubMed PMID: 28362921.
6)

Caplan IF, Glauser G, Goodrich S, Chen HI, Lucas TH, Lee JYK, McClintock SD, Malhotra NR. Undiagnosed obstructive sleep apnea as a predictor of 30-day readmission for brain tumor patients. J Neurosurg. 2019 Jul 19:1-6. doi: 10.3171/2019.4.JNS1968. [Epub ahead of print] PubMed PMID: 31323636.
7)

Lopez Ramos C, Brandel MG, Rennert RC, Wali AR, Steinberg JA, Santiago-Dieppa DR, Burton BN, Pannell JS, Olson SE, Khalessi AA. Clinical Risk Factors and Postoperative Complications Associated with Unplanned Hospital Readmissions After Cranial Neurosurgery. World Neurosurg. 2018 Jul 24. pii: S1878-8750(18)31614-0. doi: 10.1016/j.wneu.2018.07.136. [Epub ahead of print] PubMed PMID: 30053566.
8)

Cusimano MD, Pshonyak I, Lee MY, Ilie G. A systematic review of 30-day readmission after cranial neurosurgery. J Neurosurg. 2017 Aug;127(2):342-352. doi: 10.3171/2016.7.JNS152226. Epub 2016 Oct 21. PubMed PMID: 27767396.

Safety net hospital

Safety net hospital

A safety net hospital (SNH) is one of the medical centers in the United States that has a legal obligation to provide healthcare for individuals regardless of their insurance status (the United States does not have a policy of universal health care) and regardless of their ability to pay.

Because of this legal mandate to serve all populations, safety net hospitals typically serve a proportionately higher number of uninsured, MedicaidMedicare, Children’s Health Insurance Program (CHiP), low-income, and other vulnerable individuals than their non-safety net hospital counterpart.

Safety-net hospitals are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood.

Lopez Ramos et al., examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms.

They conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals.

A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.

Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions 1).


SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with private hospital (PH) patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases 2).


Prior studies have identified poor outcomes, increased costs, and reduced access to certain complex, elective surgeries at Safety net hospitals (SNHs). However, it is unknown whether similar patterns exist for the Glioblastoma multiforme treatment (GBM). Brandel et al., sought to determine if patients treated at HBHs receive equitable care for GBM, and if safety-net burden status impacts post-treatment survival.

The National Cancer Database was queried for GBM patients diagnosed between 2010 and 2015. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital, and stratified as low (LBH), medium (MBH), and high-burden (HBH) hospitals. The impact of safety-net burden on the receipt of any treatment, trimodality therapy, gross total resection (GTR), radiation, or chemotherapy was investigated. Secondary outcomes included post-treatment 30-day mortality, 90-day mortality, and overall survival. Univariate and multivariate analyses were utilized.

Overall, 40,082 GBM patients at 1202 hospitals (352 LBHs, 553 MBHs, and 297 HBHs) were identified. Patients treated at HBHs were significantly less likely to receive trimodality therapy (OR = 0.75, p < 0.001), GTR (OR = 0.84, p < 0.001), radiation (OR = 0.73, p < 0.001), and chemotherapy (OR = 0.78, p < 0.001) than those treated at LBHs. Patients treated at HBHs had significantly increased 30-day (OR = 1.25, p = 0.031) and 90-day mortality (OR = 1.24, p = 0.001), and reduced overall survival (HR = 1.05, p = 0.039).

GBM patients treated at SNHs are less likely to receive standard-of-care therapies and have increased short- and long-term mortality. Additional research is needed to evaluate barriers to providing equitable care for GBM patients at SNHs 3).

References

1)

Lopez Ramos C, Rennert RC, Brandel MG, Abraham P, Hirshman BR, Steinberg JA, Santiago-Dieppa DR, Wali AR, Porras K, Almosa Y, Pannell JS, Khalessi AA. The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms. J Neurosurg. 2019 Feb 22:1-9. doi: 10.3171/2018.10.JNS18103. [Epub ahead of print] PubMed PMID: 30797220.
2)

Diao K, Sun Y, Yoo SK, Yu C, Ye JC, Trakul N, Jennelle RL, Kim PE, Zada G, Gruen JP, Chang EL. Safety-net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow-up care and outcomes. Cancer. 2018 Jan 1;124(1):167-175. doi: 10.1002/cncr.30984. Epub 2017 Sep 13. PubMed PMID: 28902402.
3)

Brandel MG, Rennert RC, Lopez Ramos C, Santiago-Dieppa DR, Steinberg JA, Sarkar RR, Wali AR, Pannell JS, Murphy JD, Khalessi AA. Management of glioblastoma at safety-net hospitals. J Neurooncol. 2018 Apr 24. doi: 10.1007/s11060-018-2875-8. [Epub ahead of print] PubMed PMID: 29691776.

Safety net hospital

Safety net hospital

A safety net hospital (SNH) is one of the medical centers in the United States that has a legal obligation to provide healthcare for individuals regardless of their insurance status (the United States does not have a policy of universal health care) and regardless of their ability to pay.
Because of this legal mandate to serve all populations, safety net hospitals typically serve a proportionately higher number of uninsured, MedicaidMedicare, Children’s Health Insurance Program (CHiP), low-income, and other vulnerable individuals than their non-safety net hospital counterpart.


SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with private hospital (PH) patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases 1).


Prior studies have identified poor outcomes, increased costs, and reduced access to certain complex, elective surgeries at Safety net hospitals (SNHs). However, it is unknown whether similar patterns exist for the Glioblastoma multiforme treatment (GBM). Brandel et al., sought to determine if patients treated at HBHs receive equitable care for GBM, and if safety-net burden status impacts post-treatment survival.
The National Cancer Database was queried for GBM patients diagnosed between 2010 and 2015. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital, and stratified as low (LBH), medium (MBH), and high-burden (HBH) hospitals. The impact of safety-net burden on the receipt of any treatment, trimodality therapy, gross total resection (GTR), radiation, or chemotherapy was investigated. Secondary outcomes included post-treatment 30-day mortality, 90-day mortality, and overall survival. Univariate and multivariate analyses were utilized.
Overall, 40,082 GBM patients at 1202 hospitals (352 LBHs, 553 MBHs, and 297 HBHs) were identified. Patients treated at HBHs were significantly less likely to receive trimodality therapy (OR = 0.75, p < 0.001), GTR (OR = 0.84, p < 0.001), radiation (OR = 0.73, p < 0.001), and chemotherapy (OR = 0.78, p < 0.001) than those treated at LBHs. Patients treated at HBHs had significantly increased 30-day (OR = 1.25, p = 0.031) and 90-day mortality (OR = 1.24, p = 0.001), and reduced overall survival (HR = 1.05, p = 0.039).
GBM patients treated at SNHs are less likely to receive standard-of-care therapies and have increased short- and long-term mortality. Additional research is needed to evaluate barriers to providing equitable care for GBM patients at SNHs 2).
1)

Diao K, Sun Y, Yoo SK, Yu C, Ye JC, Trakul N, Jennelle RL, Kim PE, Zada G, Gruen JP, Chang EL. Safety-net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow-up care and outcomes. Cancer. 2018 Jan 1;124(1):167-175. doi: 10.1002/cncr.30984. Epub 2017 Sep 13. PubMed PMID: 28902402.
2)

Brandel MG, Rennert RC, Lopez Ramos C, Santiago-Dieppa DR, Steinberg JA, Sarkar RR, Wali AR, Pannell JS, Murphy JD, Khalessi AA. Management of glioblastoma at safety-net hospitals. J Neurooncol. 2018 Apr 24. doi: 10.1007/s11060-018-2875-8. [Epub ahead of print] PubMed PMID: 29691776.
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