Costs and Complications Associated With Resection of Supratentorial Tumors With and Without the Operative Microscope in the United States.

BACKGROUND: The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon. OBJECTIVES: To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections. METHODS: A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions, and costs between patients who underwent resection with and without use of microscope. RESULTS: The cohort included 12,058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.90 in additional costs of index hospitalization among glioma patients (P <0.001), and $2824.00 among metastasis patients (P <0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the nonmicroscope cohort (P <0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, P = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs. CONCLUSIONS: Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs.

Incidence and predictors of 30-day readmission for patients discharged home after craniotomy for malignant supratentorial tumors in California (1995-2010).

OBJECT: Hospital readmission within 30 days of discharge is a major contributor to the high cost of health care in the US and is also a major indicator of patient care quality. The purpose of this study was to investigate the incidence, causes, and predictors of 30-day readmission following craniotomy for malignant supratentorial tumor resection. METHODS: The longitudinal California Office of Statewide Health Planning & Development inpatient-discharge administrative database is a data set that consists of 100% of all inpatient hospitalizations within the state of California and allows each patient to be followed throughout multiple inpatient hospital stays, across multiple institutions, and over multiple years (from 1995 to 2010). This database was used to identify patients who underwent a craniotomy for resection of primary malignant brain tumors. Causes for unplanned 30-day readmission were identified by principle ICD-9 diagnosis code and multivariate analysis was used to determine the independent effect of various patient factors on 30-day readmissions. RESULTS: A total of 18,506 patients received a craniotomy for the treatment of primary malignant brain tumors within the state of California between 1995 and 2010. Four hundred ten patients (2.2%) died during the index surgical admission, 13,586 patients (73.4%) were discharged home, and 4510 patients (24.4%) were transferred to another facility. Among patients discharged home, 1790 patients (13.2%) were readmitted at least once within 30 days of discharge, with 27% of readmissions occurring at a different hospital than the initial surgical institution. The most common reasons for readmission were new onset seizure and convulsive disorder (20.9%), surgical infection of the CNS (14.5%), and new onset of a motor deficit (12.8%). Medi-Cal beneficiaries were at increased odds for readmission relative to privately insured patients (OR 1.52, 95% CI 1.20-1.93). Patients with a history of prior myocardial infarction were at an increased risk of readmission (OR 1.64, 95% CI 1.06-2.54) as were patients who developed hydrocephalus (OR 1.58, 95% CI 1.20-2.07) or venous complications during index surgical admission (OR 3.88, 95% CI 1.84-8.18). CONCLUSIONS: Using administrative data, this study demonstrates a baseline glioma surgery 30-day readmission rate of 13.2% in California for patients who are initially discharged home. This paper highlights the medical histories, perioperative complications, and patient demographic groups that are at an increased risk for readmission within 30 days of home discharge. An analysis of conditions present on readmission that were not present at the index surgical admission, such as infection and seizures, suggests that some readmissions may be preventable. Discharge planning strategies aimed at reducing readmission rates in neurosurgical practice should focus on patient groups at high risk for readmission and comprehensive discharge planning protocols should be implemented to specifically target the mitigation of potentially preventable conditions that are highly associated with readmission.

A retrospective cohort-matched comparison of conscious sedation versus general anesthesia for supratentorial glioma resection. Clinical article.

OBJECT: Glioma resection under conscious ("awake") sedation (CS) is used for eloquent areas of the brain to minimize postoperative neurological deficits. The objective of this study was to compare the duration of hospital stay, overall hospital cost, perioperative morbidity, and postoperative patient functional status in patients whose gliomas were resected using CS versus general endotracheal anesthesia (GEA). METHODS: Twenty-two cases in 20 patients who underwent surgery for cerebral gliomas under CS and a matched cohort of 22 cases in 19 patients who underwent surgery under GEA over a 3-year period were retrospectively evaluated. Criteria for inclusion in the study were as follows: 1) a single cerebral lesion; 2) gross-total resection as evidenced by postoperative Gd-enhanced MR imaging within 48 hours of surgery; 3) a WHO Grade II, III, or IV glioma; 4) a supratentorial lesion location; 5) a Karnofsky Performance Scale score ≥ 70; 6) an operation performed by the same neurosurgeon; and 7) an elective procedure. RESULTS: The average hospital stay was significantly different between the 2 groups: 3.5 days for patients who underwent CS and 4.6 days for those who underwent GEA. This result translated into a significant decrease in the average inpatient cost after intensive care unit (ICU) care for the CS group compared with the GEA group. Other variables were not significantly different. CONCLUSIONS: Patients undergoing glioma resection using CS techniques have a significantly shorter hospital stay with reduced inpatient hospital expenses after postoperative ICU care.

A comparison of three anesthetic techniques in patients undergoing craniotomy for supratentorial intracranial surgery.

UNLABELLED: Several anesthetic techniques have been used successfully to provide anesthesia for resection of intracranial supratentorial mass lesions. One technique used to enhance recovery involves changing anesthesia from vapor-based to propofol-based for cranial closure. However, there are no data to support a beneficial effect of this approach in the immediate postoperative period after craniotomy. We evaluated 3 anesthetic techniques in 60 patients undergoing elective surgery for supratentorial mass lesions. Patients were randomly assigned to three anesthesia study groups: propofol infusion, isoflurane inhalation, and these two techniques combined. In the combination group, once the dura was closed, isoflurane was discontinued and propofol infusion simultaneously started. We studied intra- and postoperative hemodynamics and several recovery variables for 2 h after the end of anesthesia. Baseline and average intraoperative blood pressure and heart rate values did not differ among the groups. Heart rate and blood pressure increased similarly in all groups in response to intubation and pin placement and postoperatively. None of the recovery event times (open eyes, extubation, follow commands, oriented, Aldrete score) or psychomotor test performance differed significantly. We conclude that the sequential administration of isoflurane and propofol did not provide earlier recovery and cognition than the intraoperative use of isoflurane alone. IMPLICATIONS: We evaluated three anesthetic techniques with and without propofol in patients undergoing elective surgery for supratentorial mass lesions by using a prospective, randomized clinical study design and found that the three anesthetics did not differ in intra- or postoperative hemodynamic stability or early postoperative recovery variables.