Regional and Institutional Practice Variations in Decompressive Spine Surgery for Patients with Penetrating Spinal Injury in the United States.

BACKGROUND: The surgical management of penetrating spinal injury (PSI) has been widely debated in the literature, and the benefit of decompressive surgery for neurological function remains controversial. No national guidelines exist for the PSI population, and surgical practice patterns are unknown. We studied regional and institutional trends in the surgical management of PSI in the United States from 1988 to 2011. METHODS: The National Inpatient Sample database was accessed to identify a 20% stratified sample of PSI admissions to US hospitals from 1988 to 2011. PSI patients were divided into surgical (SXPSI) and nonsurgical (NSXPSI) groups, and these groups were analyzed across several regional, institutional, and patient-related variables. RESULTS: A total of 6632 PSI admissions were identified between 1988 and 2011. Decreased age (P = 0.002) and male gender (P = 0.015) were significantly more common in SXPSI than NSXPSI. Surgical rates were higher in teaching hospitals (P < 0.001), large hospitals (P = 0.012), and non-Northeast region hospitals (P < 0.020). Surgical management was associated with decreased mortality, increased length of stay, and increased total hospital charges (P < 0.001). CONCLUSIONS: Decompressive surgery rates for PSI differ significantly across regions and institutions in the United States. Institutional bias, patient preferences, and regional practice patterns all influence decision-making in PSI. A lack of large outcome studies in PSI and the absence of national guidelines contribute to variation in practice patterns. Our study indicates the need for future studies to better describe outcomes in patients with PSI.

Dysphagia Rates after Anterior Cervical Diskectomy and Fusion: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Anterior cervical diskectomy and fusion (ACDF) is an effective surgical option for patients with cervical radiculopathy, myelopathy, or deformity. Although ACDF is generally safe, dysphagia is a common complication. Despite its high incidence, prolonged postoperative dysphagia is poorly understood; its etiology remains relatively unknown, and its risk factors are widely debated. METHODS: We searched MEDLINE, Scopus, Web of Science, and Embase for studies reporting complications for cervical diskectomy with plating. We recorded dysphagia events from all included studies and calculated effect summary values, 95% confidence intervals (CIs), Q values, and I2 values. RESULTS: Of the 7,780 retrieved articles, 14 met inclusion criteria. The overall dysphagia rate was 8.5% (95% CI 5.7 to 11.3%). The rate of moderate or severe dysphagia was 4.4% (0.4 to 8.4%). Follow-up times of <12, 12 to 24, and >24 months reported rates of 19.9% (6.0 to 33.7%), 7.0% (5.2 to 8.7%), and 7.6% (1.4 to 13.8%), respectively. Studies utilizing the Bazaz Dysphagia Score resulted in an increase in dysphagia diagnosis relative to studies with no outlined criteria (19.8%, 5.9 to 33.7% and 6.9%, 3.7 to 10.0%, respectively), indicating that the criteria used for dysphagia identification are critical. There was no difference in dysphagia rate with the use of autograft versus allograft. CONCLUSIONS: This review represents a comprehensive estimation of the actual incidence of dysphagia across a heterogeneous group of surgeons, patients, and criteria. The classification scheme for dysphagia varied significantly within the literature. To ensure its diagnosis and identification, we recommend the use of a standardized, well-outlined method for dysphagia diagnosis.

Trends in Inpatient Vertebroplasty and Kyphoplasty Volume in the United States, 2005-2011: Assessing the Impact of Randomized Controlled Trials.

STUDY DESIGN: Retrospective analysis of the Nationwide Inpatient Sample, 2005-2011. OBJECTIVE: To identify trends in procedural volume and rates in the time period surrounding publication of randomized controlled trials (RCTs) that examined the utility of vertebroplasty and kyphoplasty. SUMMARY OF BACKGROUND DATA: Vertebroplasty and kyphoplasty are frequently performed for vertebral compression fractures. Several RCTs have been published with conflicting outcomes regarding pain and quality of life compared with nonsurgical management and sham procedures. Four RCTs with discordant results were published in 2009. MATERIALS AND METHODS: The Nationwide Inpatient Sample provided longitudinal, retrospective data on United States' inpatients between 2005 and 2011. Inclusion was determined by a principal or secondary International Classification of Diseases, Ninth Revision, Clinical Modification code of 81.65 (percutaneous vertebroplasty) or 81.66 (percutaneous vertebral augmentation; "kyphoplasty"). No diagnoses were excluded. Years were stratified as "pre" (2005-2008) and "post" (2010-2011) in relation to the 4 RCTs published in 2009. Patient, hospital, and admission characteristics were compared using Pearson χ test. RESULTS: The estimated annual inpatient procedures performed decreased from 54,833 to 39,832 in the pre and post periods, respectively. The procedural rate for fractures decreased from 20.1% to 14.7% (P<0.0001). Patient and hospital demographics did not change considerably between the time periods. In the post period, weekend admissions increased (34.2% vs. 12.4%, P<0.0001), elective admissions decreased (21.4% vs. 40.0%, P<0.0001), routine discharge decreased (33.0% vs. 52.1%, P<0.0001), and encounters with ≥3 Elixhauser comorbidities increased (54.5% vs. 39.1%, P<0.0001). CONCLUSIONS: The absolute rate of inpatient vertebroplasty and kyphoplasty procedures for fractures decreased 5% in the period (2010-2011) following the publication of 4 RCTs in 2009. The proportion of elective admissions and routine discharges decreased, possibly indicating a population with greater disease severity. Although our analysis cannot demonstrate a cause-and-effect relationship, the decreased inpatient volume and procedural rates surrounding the publication of sentinel negative RCTs is clearly observed.

Value in Single-level Lumbar Discectomy: Surgical Disposable Item Cost and Relationship to Patient-reported Outcomes.

STUDY DESIGN: This is a retrospective study. OBJECTIVE: Compare improvements in health status measures (HSMs) and surgical costs to determine whether use of more costly items has any relationship to clinical outcome and value in lumbar disc surgery. SUMMARY OF BACKGROUND DATA: Association between cost, outcomes, and value in spine surgery, including lumbar discectomy is poorly understood. Outcomes were calculated as difference in mean HSM scores between preoperative and postoperative timeframes. Prospective validated patient-reported HSMs studied were EuroQol quality of life index score (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire (PHQ-9). Surgical costs consisted of disposable items and implants used in operating room. METHODS: We retrospectively identified all adult patients at Cleveland Clinic main campus between October 2009 and August 2013 who underwent lumbar discectomy (652) using administrative billing data, Current Procedural Terminology (CPT) code 63030. HSMs were obtained from Cleveland Clinic Knowledge Program Data Registry. RESULTS: In total, 67% of operations performed in the outpatient or ambulatory setting, 33% in the inpatient setting. Among 9 surgeons who performed >10 lumbar discectomies, there were 72.4 operations per surgeon, on average. Mean surgical costs of each surgeon differed (P<0.0001). In a multivariable regression, only the surgeon and surgery type (outpatient or inpatient) were statistically correlated with surgical costs (P<0.0001 and 0.046, respectively). Changes in EQ-5D, PDQ, and PHQ-9 were not correlated with surgical costs (P=0.76, 0.07, 0.76, respectively). In multivariable regression, only surgical cost was significantly correlated to mean difference in PDQ (P=0.030). More costly surgeries resulted in worse PDQ outcomes. CONCLUSIONS: Mean surgical costs varied statistically among 9 surgeons; costs were not shown to be positively correlated with patient outcomes. Performing an operation using more costly disposable supplies/implants does not seem to improve patient outcomes and should be considered when constructing preference cards and during an operation.

Propensity-matched Analysis of Outcomes and Hospital Charges for Anterior Versus Posterior Cervical Fusion for Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective analysis of data from the Nationwide Inpatient Sample, a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States. OBJECTIVE: The objective of this study is to compare anterior cervical fusion (ACF) to posterior cervical fusion (PCF) in the treatment of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Previous studies used retrospective single-institution level data to quantify outcomes for CSM patients fusion. It is unclear whether ACF or PCF is superior with regards to charges or outcomes for the treatment of CSM. MATERIALS AND METHODS: We used Nationwide Inpatient Sample data to compare ACF to PCF in the management of CSM. All patients 18 years or older with a diagnosis of CSM between 1998 and 2011 were included. ACF patients were matched to PCF patients using propensity scores based on patient characteristics (number of levels fused, spine alignment, comorbidities), hospital characteristics, and patient demographics. Multivariable regression was used to measure the effect of treatment assignment on in-hospital charges, length of hospital stay, in-hospital mortality, discharge disposition, and dysphagia diagnosis. RESULTS: From 1998 to 2011, we identified 109,728 hospitalizations with a CSM diagnosis. Of these patients, 45,629 (41.6%) underwent ACF and 14,439 (13.2%) underwent PCF. The PCF cohort incurred an average of $41,683 more in-hospital charges (P<0.001, inflation adjusted to 2011 dollars) and remained in hospital an average of 2.4 days longer (P<0.001) than the ACF cohort. The ACF cohort was just as likely to die in the hospital [odds ratio 0.91; 95% confidence interval (CI), 0.68-1.2], 3.0 times more likely to be discharged to home or self-care (95% CI, 2.9-3.2), and 2.5 times more likely to experience dysphagia (95% CI, 2.0-3.1) than the PCF cohort. CONCLUSIONS: In treating CSM, ACF led to lower hospital charges, shorter hospital stays, and an increased likelihood of being discharged to home relative to PCF.

Insurance status and reportable quality metrics in the cervical spine fusion population.

BACKGROUND CONTEXT: The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown. PURPOSE: This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events. STUDY DESIGN: This is a retrospective cohort design. PATIENT SAMPLE: All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included. OUTCOME MEASURES: Incidence of HAC and PSI from 1998 to 2011 served as outcome variables. METHODS: We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC. RESULTS: We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort. CONCLUSIONS: Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.

Predictors of outcomes and hospital charges following atlantoaxial fusion.

BACKGROUND CONTEXT: Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown. PURPOSE: This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies. STUDY DESIGN: A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States. PATIENT SAMPLE: We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission. OUTCOME MEASURES: Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition. METHODS: Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results. RESULTS: From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition. CONCLUSION: This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion.

Lumbar microdiscectomy complication rates: a systematic review and meta-analysis.

OBJECT Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy. METHODS The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques. RESULTS Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found. CONCLUSIONS This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

National Incidence of Medication Error in Surgical Patients Before and After Accreditation Council for Graduate Medical Education Duty-Hour Reform.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations. DESIGN: Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals. SETTING: We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions. PARTICIPANTS: A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates). RESULTS: The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted. CONCLUSIONS: After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform.

National Trends and In-hospital Complication Rates in More Than 1600 Hemispherectomies From 1988 to 2010: A Nationwide Inpatient Sample Study.

BACKGROUND: Anatomic and functional hemispherectomies are relatively infrequent and technically challenging. The literature is limited by small samples and single institution data. OBJECTIVE: We used the Nationwide Inpatient Sample (NIS) database to report on a large population of hemispherectomy patients and their in-hospital complication rates over a 23-year period. METHODS: Between 1988 and 2010, we identified 304 pediatric hospitalizations in the NIS database where hemispherectomy was performed. Using the NIS weighting scheme, this inferred an estimated 1611 hospitalizations nationwide during this time period. Descriptive statistics were calculated on this inferred sample for patient and hospital characteristics and stratified by the presence of in-hospital complications. The adjusted odds of in-hospital complications and nonroutine discharge were estimated using multivariable models. RESULTS: The mean age of the patients was 5.9 years; 46% were female, and 54% were white. In the inferred series, 909 hospitalizations (56%) encountered at least 1 in-hospital complication; 42% were surgery related, and 25% were related to the hospitalization itself. For every 1-year increase in age, there was a corresponding 8% increase in the odds of a nonroutine discharge, adjusting for other potential confounders (95% confidence interval: 1.01-1.16). The most common in-hospital complication was the need for a blood transfusion (30%), followed by meningitis (10%), hydrocephalus (8%), postoperative hematoma/stroke (8%), and adverse pulmonary event (8%). Thirty-three mortalities (2%) were inferred from this series. CONCLUSION: This is the largest study to date examining hemispherectomy and associated in-hospital complication rates. This study supports early surgery in patients with medically intractable epilepsy and severe hemispheric disease.

Thoracic range of motion, stability, and correlation to imaging-determined degeneration.

OBJECT The degenerative process of the spinal column results in instability followed by a progressive loss of segmental motion. Segmental degeneration is associated with intervertebral disc and facet changes, which can be quantified. Correlating this degeneration with clinical segmental motion has not been investigated in the thoracic spine. The authors sought to determine if imaging-determined degeneration would correlate with native range of motion (ROM) or the change in ROM after decompressive procedures, potentially guiding clinical decision making in the setting of spine trauma or following decompressive procedures in the thoracic spine. METHODS Multidirectional flexibility tests with image analysis were performed on thoracic cadaveric spines with intact ib cage. Specimens consisted of 19 fresh frozen human cadaveric spines, spanning C-7 to L-1. ROM was obtained for each specimen in axial rotation (AR), flexion-extension (FE), and lateral bending (LB) in the intact state and following laminectomy, unilateral facetectomy, and unilateral costotransversectomy performed at either T4-5 (in 9 specimens) or T8-9 (in 10 specimens). Image grading of segmental degeneration was performed utilizing 3D CT reconstructions. Imaging scores were obtained for disc space degeneration, which quantified osteophytes, narrowing, and endplate sclerosis, all contributing to the Lane disc summary score. Facet degeneration was quantified using the Weishaupt facet summary score, which included the scoring of facet osteophytes, narrowing, hypertrophy, subchondral erosions, and cysts. RESULTS The native ROM of specimens from T-1 to T-12 (n = 19) negatively correlated with age in AR (Pearson's r coefficient = -0.42, p = 0.070) and FE (r = -0.42, p = 0.076). When regional ROM (across 4 adjacent segments) was considered, the presence of disc osteophytes negatively correlated with FE (r = -0.69, p = 0.012), LB (r = -0.82, p = 0.001), and disc narrowing trended toward significance in AR (r = -0.49, p = 0.107). Facet characteristics, scored using multiple variables, showed minimal correlation to native ROM (r range from -0.45 to +0.19); however, facet degeneration scores at the surgical level revealed strong negative correlations with regional thoracic stability following decompressive procedures in AR and LB (Weishaupt facet summary score: r = -0.52 and r = -0.71; p = 0.084 and p = 0.010, respectively). Disc degeneration was not correlated (Lane disc summary score: r = -0.06, p = 0.861). CONCLUSIONS Advanced age was the most important determinant of decreasing native thoracic ROM, whereas imaging characteristics (T1-12) did not correlate with the native ROM of thoracic specimens with intact rib cages. Advanced facet degeneration at the surgical level did correlate to specimen stability following decompressive procedures, and is likely indicative of the terminal stages of segmental degeneration.

Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for patients presenting with cervical radiculopathy, myelopathy, or deformity. A systematic literature review and meta-analysis of pseudoarthrosis rates associated with ACDF with plate fixation have not been previously performed. PURPOSE: The purpose of this study was to identify all prospective studies reporting pseudoarthrosis rates for ACDF with plate fixation. STUDY DESIGN/SETTING: This study is based on a systematic review and meta-analysis. PATIENT SAMPLE: Studies reporting pseudoarthrosis rates in patients who received one-, two-, or three-level ACDF surgeries were included. OUTCOME MEASURES: Outcomes of interest included reported pseudoarthrosis events after ACDF with plate fixation. METHODS: We conducted a MEDLINE, SCOPUS, Web of Science, and EMBASE search for studies reporting complications for ACDF with plate fixation. We recorded pseudoarthrosis events from all included studies. A meta-analysis was performed to calculate effect summary mean values, 95% confidence intervals (CIs), Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS: Of the 7,130 retrieved articles, 17 met the inclusion criteria. The overall pseudoarthrosis rate was 2.6% (95% CI: 1.3-3.9). Use of autograft fusion (0.9%, 95% CI: -0.4 to 2.1) resulted in a reduced pseudoarthrosis rate compared with allograft fusion procedures (4.8%, 95% CI: 1.7-7.9). Studies were separated based on the length of follow-up: 12 to 24 and greater than 24 months. These groups reported rates of 3.1% (95% CI: 1.2-5.0) and 2.3% (95% CI: 0.1-4.4), respectively. Studies performing single-level ACDF yielded a rate of 3.7% (95% CI: 1.6-5.7). Additionally, there was a large difference in the rate of pseudoarthrosis in randomized controlled trials (4.8%, 95% CI: 2.6-7.0) versus prospective cohort studies (0.2%, 95% CI: -0.1 to 0.5), indicating that the extent of follow-up criteria affects the rate of pseudoarthrosis. CONCLUSIONS: This review represents a comprehensive estimation of the actual incidence of pseudoarthrosis across a heterogeneous group of surgeons, patients, and ACDF techniques. The definition of pseudoarthrosis varied significantly within the literature. To ensure its diagnosis and prevent sequelae, standardized criteria need to be established. This investigation sets the framework for surgeons to understand the impact of surgical techniques on the rate of pseudoarthrosis.

A new Elixhauser-based comorbidity summary measure to predict in-hospital mortality.

BACKGROUND: Recently, van Walraven developed a weighted summary score (VW) based on the 30 comorbidities from the Elixhauser comorbidity system. One of the 30 comorbidities, cardiac arrhythmia, is currently excluded as a comorbidity indicator in administrative datasets such as the Nationwide Inpatient Sample (NIS), prompting us to examine the validity of the VW score and its use in the NIS. METHODS: Using data from the 2009 Maryland State Inpatient Database, we derived weighted summary scores to predict in-hospital mortality based on the full (30) and reduced (29) set of comorbidities and compared model performance of these and other comorbidity summaries in 2009 NIS data. RESULTS: Weights of our derived scores were not sensitive to the exclusion of cardiac arrhythmia. When applied to NIS data, models containing derived summary scores performed nearly identically (c statistics for 30 and 29 variable-derived summary scores: 0.804 and 0.802, respectively) to the model using all 29 comorbidity indicators (c=0.809), and slightly better than the VW score (c=0.793). Each of these models performed substantially better than those based on a simple count of Elixhauser comorbidities (c=0.745) or a categorized count (0, 1, 2, or ≥ 3 comorbidities; c=0.737). CONCLUSIONS: The VW score and our derived scores are valid in the NIS and are statistically superior to summaries using simple comorbidity counts. Researchers wishing to summarize the Elixhauser comorbidities with a single value should use the VW score or those derived in this study.

Comparing clinician- and patient-reported outcome measures after hemicraniectomy for ischemic stroke.

BACKGROUND: The association between clinician- and patient-reported health status measures (HSM) after hemicraniectomy for ischemic stroke is understudied. We compared HSMs to determine how HSM type and follow-up affect the interpretation of outcomes. METHODS: We identified patients that underwent hemicraniectomy for ischemic stroke at the Cleveland Clinic (CC) from January 2009 through May 2013. HSMs were obtained from the CC Knowledge Program Data Registry. Outpatient follow-up was divided into "Early" (3±2 months (standard deviation)) and "Late" (9±3 months) time periods. Clinician-reported HSMs (National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS)) were compared to patient-reported HSMs (EuroQol quality of life index (EQ-5D), Patient Health Questionnaire-9 (PHQ-9), and the Stroke Impact Scale-16 (SIS-16)). RESULTS: 11 of 32 patients completed all HSMs during both follow-up periods. Clinician-reported median NIHSS scores improved from 12 to 7 (p=0.003). Median mRS scores demonstrated little improvement from 4 to 3 (p=0.2). Patient-reported median EQ-5D scores improved from 0.33 to 0.69 (p=0.03). Among EQ-5D sub-scores, "usual activity" improved from a median score of 3 (extreme problems) to 2 (some problems) (p=0.008). Median PHQ-9 scores improved from 9 to 1 (p=0.06) as did SIS-16 scores from 23 to 57 (p=0.01). EQ-5D and mRS score differences between periods were correlated (r=-0.65, p=0.03), but only the EQ-5D showed significant improvement over time. CONCLUSIONS: Both HSM types, clinician- and patient-reported outcome measures, improved over time. The structure of clinical trials, and, in particular, defining clinical endpoints and framing outcomes, has a profound impact on the interpretation of what a "favorable" outcome means.

Improving and measuring inpatient documentation of medical care within the MS-DRG system: education, monitoring, and normalized case mix index.

Documentation of the care delivered to hospitalized patients is a ubiquitous and important aspect of medical care. The majority of references to documentation and coding are based on the Centers for Medicare and Medicaid Services (CMS) Medicare Severity Diagnosis Related Group (MS-DRG) inpatient prospective payment system (IPPS). We educated the members of a clinical care team in a single department (neurosurgery) at our hospital. We measured subsequent documentation improvements in a simple, meaningful, and reproducible fashion. We created a new metric to measure documentation, termed the "normalized case mix index," that allows comparison of hospitalizations across multiple unrelated MS-DRG groups. Compared to one year earlier, the traditional case mix index, normalized case mix index, severity of illness, and risk of mortality increased one year after the educational intervention. We encourage other organizations to implement and systematically monitor documentation improvement efforts when attempting to determine the accuracy and quality of documentation achieved.

Neurologic disorders, in-hospital deaths, and years of potential life lost in the USA, 1988-2011.

Premature mortality is a public health concern that can be quantified as years of potential life lost (YPLL). Studying premature mortality can help guide hospital initiatives and resource allocation. We investigated the categories of neurologic and neurosurgical conditions associated with in-hospital deaths that account for the highest YPLL and their trends over time. Using the Nationwide Inpatient Sample (NIS), we calculated YPLL for patients hospitalized in the USA from 1988 to 2011. Hospitalizations were categorized by related neurologic principal diagnoses. An estimated 2,355,673 in-hospital deaths accounted for an estimated 25,598,566 YPLL. The traumatic brain injury (TBI) category accounted for the highest annual mean YPLL at 361,748 (33.9% of total neurologic YPLL). Intracerebral hemorrhage, cerebral ischemia, subarachnoid hemorrhage, and anoxic brain damage completed the group of five diagnoses with the highest YPLL. TBI accounted for 12.1% of all inflation adjusted neurologic hospital charges and 22.4% of inflation adjusted charges among neurologic deaths. The in-hospital mortality rate has been stable or decreasing for all of these diagnoses except TBI, which rose from 5.1% in 1988 to 7.8% in 2011. Using YPLL, we provide a framework to compare the burden of premature in-hospital mortality on patients with neurologic disorders, which may prove useful for informing decisions related to allocation of health resources or research funding. Considering premature mortality alone, increased efforts should be focused on TBI, particularly in and related to the hospital setting.

Aneurysmal subarachnoid hemorrhage: relationship to solar activity in the United States, 1988-2010.

Aneurysmal subarachnoid hemorrhage (SAH) is a common condition treated by neurosurgeons. The inherent variability in the incidence and presentation of ruptured cerebral aneurysms has been investigated in association with seasonality, circadian rhythm, lunar cycle, and climate factors. We aimed to identify an association between solar activity (solar flux and sunspots) and the incidence of aneurysmal SAH, all of which appear to behave in periodic fashions over long time periods. The Nationwide Inpatient Sample (NIS) provided longitudinal, retrospective data on patients hospitalized with SAH in the United States, from 1988 to 2010, who underwent aneurysmal clipping or coiling. Solar activity and SAH incidence data were modeled with the cosinor methodology and a 10-year periodic cycle length. The NIS database contained 32,281 matching hospitalizations from 1988 to 2010. The acrophase (time point in the cycle of highest amplitude) for solar flux and for sunspots were coincident. The acrophase for aneurysmal SAH incidence was out of phase with solar activity determined by non-overlapping 95% confidence intervals (CIs). Aneurysmal SAH incidence peaks appear to be delayed behind solar activity peaks by 64 months (95% CI; 56-73 months) when using a modeled 10-year periodic cycle. Solar activity (solar flux and sunspots) appears to be associated with the incidence of aneurysmal SAH. As solar activity reaches a relative maximum, the incidence of aneurysmal SAH reaches a relative minimum. These observations may help identify future trends in aneurysmal SAH on a population basis.

Variations in cost calculations in spine surgery cost-effectiveness research.

OBJECT: Cost-effectiveness research in spine surgery has been a prominent focus over the last decade. However, there has yet to be a standardized method developed for calculation of costs in such studies. This lack of a standardized costing methodology may lead to conflicting conclusions on the cost-effectiveness of an intervention for a specific diagnosis. The primary objective of this study was to systematically review all cost-effectiveness studies published on spine surgery and compare and contrast various costing methodologies used. METHODS: The authors performed a systematic review of the cost-effectiveness literature related to spine surgery. All cost-effectiveness analyses pertaining to spine surgery were identified using the cost-effectiveness analysis registry database of the Tufts Medical Center Institute for Clinical Research and Health Policy, and the MEDLINE database. Each article was reviewed to determine the study subject, methodology, and results. Data were collected from each study, including costs, interventions, cost calculation method, perspective of cost calculation, and definitions of direct and indirect costs if available. RESULTS: Thirty-seven cost-effectiveness studies on spine surgery were included in the present study. Twenty-seven (73%) of the studies involved the lumbar spine and the remaining 10 (27%) involved the cervical spine. Of the 37 studies, 13 (35%) used Medicare reimbursements, 12 (32%) used a case-costing database, 3 (8%) used cost-to-charge ratios (CCRs), 2 (5%) used a combination of Medicare reimbursements and CCRs, 3 (8%) used the United Kingdom National Health Service reimbursement system, 2 (5%) used a Dutch reimbursement system, 1 (3%) used the United Kingdom Department of Health data, and 1 (3%) used the Tricare Military Reimbursement system. Nineteen (51%) studies completed their cost analysis from the societal perspective, 11 (30%) from the hospital perspective, and 7 (19%) from the payer perspective. Of those studies with a societal perspective, 14 (38%) reported actual indirect costs. CONCLUSIONS: Changes in cost have a direct impact on the value equation for concluding whether an intervention is cost-effective. It is essential to develop a standardized, accurate means of calculating costs. Comparability and transparency are essential, such that studies can be compared properly and policy makers can be appropriately informed when making decisions for our health care system based on the results of these studies.

Practice patterns of in-hospital surgical treatment of trigeminal neuralgia from 1988 to 2010.

OBJECTIVE: Neurosurgeons have a variety of procedures to offer when treating medically intractable trigeminal neuralgia (TN). We reviewed the national trends in procedural volume for in-hospital treatment of TN. METHODS: The Nationwide Inpatient Sample (1988-2010) provided data on patients hospitalized with a principal diagnosis of TN and a related principal procedure. We categorized principal procedures as open, other, percutaneous, or radiosurgery. RESULTS: We identified 13,466 relevant hospital admissions. The volume for open procedures and radiosurgery remained relatively constant, whereas percutaneous procedures decreased. Mean age of patients undergoing percutaneous and radiosurgery procedures (67.9 and 69.5 years) was higher than open and other procedures (60.4 and 63.4 years) (p-value <0.001). The mean total in-hospital inflation-adjusted charges for all four categories increased over time (p-values <0.001). The mean total in-hospital inflation-adjusted charge for radiosurgery ($37,666) was higher than open ($28,046) procedures (p-value <0.001). CONCLUSIONS: Patients who undergo an open procedure to treat TN are younger than those who undergo a percutaneous or a radiosurgery procedure. The perceived risk of open surgery in older patients may drive offering percutaneous or radiosurgical procedures. In addition, the in-hospital inflation-adjusted charges for all procedures increased over time, with radiosurgery being higher than those of open procedures.

Myelomeningocele: surgical trends and predictors of outcome in the United States, 1988-2010.

OBJECT: Myelomeningocele repair is an uncommonly performed surgical procedure. The volume of operations has been decreasing in the past 2 decades, probably as the result of public health initiatives for folate supplementation. Because of the rarity of myelomeningocele, data on patient or hospital factors that may be associated with outcome are scarce. To determine these factors, the authors investigated the trends in myelomeningocele surgical repair in the United States over a 23-year period and examined patient and hospital characteristics that were associated with outcome. METHODS: The Nationwide Inpatient Sample database for 1988-2010 was queried for hospital admissions for myelomeningocele repair. This database reports patient, hospital, and admission characteristics and surgical trends. The authors used univariate and multivariate logistic regression to assess associations between patient and hospital characteristics and in-hospital deaths, nonroutine discharge, long hospital stay, and shunt placement. RESULTS: There were 4034 hospitalizations for surgical repair of myelomeningocele. The annual volume decreased since 1988 but plateaued in the last 4 years of the study. The percentages of myelomeningocele patients with low income (30.8%) and Medicaid insurance (48.2%) were disproportionately lower than those for the overall live-born population (p < 0.0001). More operations per 10,000 live births were performed for Hispanic patients (3.2) than for white (2.0) or black (1.5) patients (p < 0.0001). Overall, 56.6% of patients required shunt placement during the same hospital stay as for surgical repair; 95.0% of patients were routinely discharged; and the in-hospital mortality rate was 1.4%. Nonwhite race was associated with increased in-hospital risk for death (OR 2.8, 95% CI 1.2-6.3) independent of socioeconomic or insurance status. CONCLUSIONS: Overall, the annual surgical volume of myelomeningocele repairs decreased after public health initiatives were introduced but has more recently plateaued. The most disproportionately represented populations are Hispanic, low-income, and Medicaid patients. Among nonwhite patients, increased risk for in-hospital death may represent a disparity in care or a difference in disease severity.