Predictive validity of the All Patients Refined Diagnosis Related Group modifiers for costs and outcomes from intracranial hemorrhage.

OBJECTIVE: The All Patients Refined Diagnosis Related Group (APR-DRG) modifiers-severity of illness (SOI) and risk of mortality (ROM)-inform hospital reimbursement nationally. The ubiquitous APR-DRG data bear the potential to inform public health research; however, the algorithms that generate these modifiers are proprietary and therefore should be independently verified. This study evaluated the predictive value of APR-DRG modifiers for the outcomes and costs of intracranial hemorrhage. METHODS: The New York Statewide Planning and Research Cooperative System databases were accessed and searched for the intracranial hemorrhage Diagnosis Related Group in records from 2012 to 2020. Receiver operating characteristic and multiple logistic regressions characterized the predictive validity of the APR-DRG modifiers for patient outcomes. One-way ANOVA compared costs and charges between SOI and ROM designations. RESULTS: Among 46,019 patients, 12,627 (27.4%) died. The mean ± SEM costs per patient were $21,342 ± $145 and the mean ± SEM charges per patient were $68,117 ± $408. For prediction of mortality, the area under the curve (AUC) was 0.74 for SOI and 0.83 for ROM. For prediction of discharge to a facility, AUC was 0.62 for SOI and 0.64 for ROM. Regression analysis showed that ROM was a strong predictor of mortality, while SOI was a weak predictor; both were modest predictors of discharge to a facility. SOI and ROM were significant predictors of costs and charges. CONCLUSIONS: Compared with the prior studies, the authors identified several limitations of APR-DRG modifiers, including low specificity, modest AUC, and limited outcomes prediction. This report supports the limited use of APR-DRG modifiers in independent research on intracranial hemorrhage epidemiology and reimbursement and advocates for general caution in their use for evaluation of neurosurgical disease.

Deep brain stimulation for movement disorders after stroke: a systematic review of the literature.

OBJECTIVE: Stroke remains the leading cause of disability in the United States. Even as acute care for strokes advances, there are limited options for improving function once the patient reaches the subacute and chronic stages. Identification of new therapeutic approaches is critical. Deep brain stimulation (DBS) holds promise for these patients. A number of case reports and small case series have reported improvement in movement disorders after strokes in patients treated with DBS. In this systematic review, the authors have summarized the patient characteristics, anatomical targets, stimulation parameters, and outcomes of patients who have undergone DBS treatment for poststroke movement disorders. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The PubMed, Scopus, and SpringerLink databases were searched for the keywords "DBS," "stroke," "movement," and "recovery" to identify patients treated with DBS for movement disorders after a stroke. The Joanna Briggs Institute Critical Appraisal checklists for case reports and case series were used to systematically analyze the quality of the included studies. Data collected from each study included patient demographic characteristics, stroke diagnosis, movement disorder, DBS target, stimulation parameters, complications, and outcomes. RESULTS: The authors included 29 studies that described 53 patients who underwent placement of 82 total electrodes. Movement disorders included tremor (n = 18), dystonia (n = 18), hemiballism (n = 6), spastic hemiparesis (n = 1), chorea (n = 1), and mixed disorders (n = 9). The most common DBS targets were the globus pallidus internus (n = 32), ventral intermediate nucleus of thalamus (n = 25), and subthalamic area/subthalamic nucleus (n = 7). Monopolar stimulation was reported in 43 leads and bipolar stimulation in 13. High-frequency stimulation was used in 57 leads and low-frequency stimulation in 6. All patients but 1 had improvement in their movement disorders. Two complications were reported: speech impairment in 1 patient and hardware infection in another. The median (interquartile range) duration between stroke and DBS treatment was 6.5 (2.1-15.8) years. CONCLUSIONS: This is the first systematic review of DBS for poststroke movement disorders. Overall, most studies to date have been case reports and small series reporting heterogeneous patients and surgical strategies. This review suggests that DBS for movement disorders after a stroke has the potential to be effective and safe for diverse patients, and DBS may be a feasible option to improve function even years after a stroke.

Statin Use and Risk of Cognitive Decline in the ADNI Cohort.

OBJECTIVE: To investigate associations between statin use and cognitive change, as well as diagnostic conversion, in individuals with cognitively normal (CN) status, mild cognitive impairment (MCI), and dementia due to Alzheimer disease (AD-dementia). METHODS: A multicenter cohort study with 1629 adults 48 to 91 years old with CN status, early MCI (EMCI), late MCI (LMCI), or AD-dementia at baseline followed prospectively for 24 months. Statin use was assessed at baseline, and cognition was measured over time with a composite memory score, a composite executive function score, and a global cognition score (Alzheimer's Disease Assessment Scale). Conversion to a more impaired diagnostic category was determined by clinician assessment. Repeated measures linear mixed-effects models were used to evaluate associations between statin use and change in cognition over time. Cox proportional hazards models were used to evaluate associations between statin use and time to diagnostic conversion. All models were stratified by baseline diagnostic group. RESULTS: Statin use was not associated with change in cognitive measures for CN, LMCI, or AD-dementia participants. Among EMCI participants, statin use was associated with a significantly slower rate of decline on the memory composite, but no other cognitive measure. Statin use was not associated with time to conversion for any diagnostic group. CONCLUSIONS: This study did not support an association between statin use and diagnostic conversion but suggested a possible association between statin use and cognitive change in EMCI. Additional randomized clinical trials of statins may be warranted in the prodromal EMCI stage of AD.