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Background: The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes., Methods: We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial., Results: During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals., Conclusions: Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: It is unclear whether publicly reported benchmarks correlate with quality of physicians and institutions. We investigated the association of patient satisfaction measures from a public reporting platform with performance of neurosurgeons in New York State., Methods: This cohort study comprised patients undergoing neurosurgical operations from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. The cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services Hospital Compare website. Propensity-adjusted regression analysis was used to investigate the association of patient satisfaction metrics with neurosurgeon quality, as measured by the neurosurgeon's individual rate of mortality and average length of stay., Results: During the study period, 166,365 patients underwent neurosurgical procedures. Using propensity-adjusted multivariable regression analysis, we demonstrated that undergoing neurosurgical operations in hospitals with a greater percentage of patient-assigned "high" scores was associated with higher chance of being treated by a physician with superior performance in terms of mortality (odds ratio 1.90, 95% confidence interval 1.86-1.95), and a higher chance of being treated by a physician with superior performance in terms of length of stay (odds ratio 1.24, 95% confidence interval 1.21-1.27). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others., Conclusions: Merging a comprehensive all-payer cohort of neurosurgery patients in New York State with data from the Hospital Compare website, we observed an association of superior hospital-level patient satisfaction measures with objective performance of individual neurosurgeons in the corresponding hospitals., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Despite the increasing number of elderly patients undergoing neurosurgical interventions, there are limited resources for preoperative assessment of frailty in this population. We investigated the association between recent history of falls and surgical outcomes for these patients., Methods: We performed a prospective cohort study of all patients, 65 years and older, undergoing elective neurosurgical procedures from 2014-2015 in a tertiary referral medical center. We examined the association of sustaining a fall in the 6 months before the operation with discharge to a facility, readmissions, and complications in the first 30 days after discharge. In order to control for confounding, we used multivariable regression models and propensity score conditioning. Mixed-effects models were used to control for clustering at the surgeon level., Results: During the study period, 143 elderly patients underwent a neurosurgical procedure and met the inclusion criteria. Of these, 53.1% had a history of falls preoperatively. Mixed-effects multivariable logistic regression analysis demonstrated an association between preoperative falls and discharge to a facility (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.23-1.47), 30-day readmissions (OR, 1.57; 95% CI, 1.36-1.78), and 30-day complications (OR, 1.13; 95% CI, 1.03-1.23). Similar associations were present in propensity score-adjusted models and models stratified by cranial and spinal procedures., Conclusions: History of at least 1 fall in the 6 months before a neurosurgical operation was associated with increased risk of discharge to a facility, readmissions, and complications in the first 30 days after discharge. History of prior falls should be taken into account during the preoperative risk assessment of neurosurgical patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The impact of early physician follow-up on out-of-hospital outcomes after cerebral aneurysm treatment has not been studied previously. We investigated the association of early physician follow-up (within 30 days of discharge) with mortality and readmissions for elderly patients undergoing treatment for cerebral aneurysms., Methods: We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent treatment for cerebral aneurysms from 2007 to 2012. To control for confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the Hospital Referral Region level., Results: Of 8703 patients presenting with unruptured aneurysms, 5673 (65.2%) had early physician follow-up, and 3030 (34.8%) did not. Of 3211 patients with subarachnoid hemorrhage, 1504 (46.8%) had early physician follow-up, and 1707 (53.2%) did not. Propensity score-adjusted analysis demonstrated that patients with unruptured aneurysms who visited a physician within 30 days of discharge had lower 3-month mortality (odds ratio [OR] 0.52; 95% confidence interval [95% CI] 0.36-0.74) but a greater rate of 90-day readmissions (OR 1.14; 95% CI 1.03-1.28). Similarly, early follow-up was associated with lower 3-month mortality (OR, 0.33; 95% CI, 0.24-0.46), and a greater rate of 90-day readmissions (OR 1.79; 95% CI 1.02-3.14) for patients presenting with subarachnoid hemorrhage., Conclusions: In a cohort of Medicare patients undergoing treatment for cerebral aneurysms, we identified an association of early physician follow-up with decreased short-term post-discharge mortality, but increased 90-day readmissions. More studies on the impact of strengthening the post-discharge network on the outcomes of this population are warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine whether antibiotic impregnated external ventricular drains (AI-EVDs) are effective in preventing ventriculostomy associated infection (VAI), and to examine their cost effectiveness., Methods: A comprehensive literature search was performed for published data through May 2014, including randomized controlled trials and observational cohort studies comparing AI-EVDs with nonimpregnated controls. A meta-analysis of included studies was performed using a random effects model. Historical data at the authors' institution were used to estimate both the incremental price of AI-EVDs and the hospital expenses associated with VAI., Results: Three randomized controlled trials and 5 observational studies met inclusion criteria. The analysis demonstrated a statistically significant protective effect of AI-EVDs against VAI (risk ratio = 0.31 [0.15-0.64]; P = 0.002), although there was significant heterogeneity (χ(2) = 18.08; P = 0.01; I(2) = 61%). The number of AI-EVDs needed to prevent one infection (Number needed to treat [NNT]) was 19. Based on $100 as the incremental price, and $30,000 as the estimated expense of one episode of VAI, AI-EVDs would result in an overall savings estimate of $28,100 (range, $26,400-$28,500) per NNT. If a hospital places 150 AI-EVDs annually, savings could range from $109,292 to $278,577 per year., Conclusions: Meta-analysis demonstrated a significant protective benefit of AI-EVDs against VAI, and this benefit is likely associated with cost savings. However, current data on AI-EVDs are limited, and overall hospital costs will vary among institutions. Although both the efficacy and cost effectiveness of AI-EVDs are supported by this analysis, further study of AI-EVDs is clearly warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)