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Highlights • We didn't observe any statistical association between SBP variation and long term clinical outcome. • We didn't observe association between SBP during the acute phase and clinical outcome. • We advocate lowering SBP to <185 mmHg to increase IVrt-PA eligibility rates. • We recruited new stroke patients eligible for MT through the TS network. • 38% of MT patients had an mRS ≤ 2 on their last follow-up visit. • Fulfilling new strategies and approaches to stroke patients leads to better results. Abstract Background Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process. Methods Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome. Results Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity. Conclusions This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings. [ABSTRACT FROM AUTHOR]

Highlights • The emergent disposition of acute stroke patients remains an issue of debate. • Patients treated in hub-and-spoke models did not have inferior outcomes. • This needs to be taken into consideration when considering acute emergency services. Abstract Background The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers. Methods We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) 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 simulate a randomized trial. Results During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, −0.1% to 9.0%), rate discharge to a facility (Adjusted difference, −2.3%; 95% CI, −5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, −2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy. Conclusions Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting. [ABSTRACT FROM AUTHOR]

Background An increasing number of elderly patients with dementia are undergoing surgical operations. Little is known about the differential impact of dementia on surgical outcomes. We investigated whether demented patients undergoing surgical operations have worse outcomes than their non-demented counterparts. Methods We performed a cohort study of all patients undergoing a series of surgical operations who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of dementia with inpatient case-fatality, discharge to a facility, and length of stay (LOS). Coarsened exact matching was used to balance comorbidities among the comparison groups, and mixed effect methods were used to control for clustering at the hospital level. Results During the study period, 342,075 patients underwent surgical operations that met the inclusion criteria. Multivariable logistic regression models, after coarsened exact matching, demonstrated that demented patients were not associated with higher case-fatality (OR, 0.43; 95% CI, 0.13–1.36), but were associated with higher rates of discharge to a facility (OR, 1.71; 95% CI, 1.26–2.31) and longer LOS (Adjusted difference, 31%; 95% CI, 26%–36%). These persisted in pre-specified subgroups stratified on particular operations. Conclusions Using a comprehensive all-payer cohort of surgical patients in New York State we identified an association of dementia with increased rate of discharge to rehabilitation and longer LOS. No difference was identified in the case fatality of the two groups. Policy makers, payers, and physicians should take these findings into account when designing new policies, and when counseling patients. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulant (DOAC) use is growing as monotherapy and combined with platelet inhibitors. The safety of such combination therapy, especially in comparison to regimens including warfarin, in real world populations remains uncertain. We investigated hemorrhage associated with DOAC and antiplatelet combination therapy in a cohort of elderly coronary artery stent recipients. We employed Medicare data 2010–2013 for a 40% random sample of beneficiaries enrolled in inpatient, outpatient and prescription benefits. We used Cox proportional hazards models to examine the association of the combination anticoagulant (DOAC or warfarin) plus antiplatelets with major hemorrhage events (upper gastrointestinal or intracranial) in the 12 months following stent placement. We identified 70,900 stent recipients. 14.4% had atrial fibrillation (AF) diagnosis preoperatively. Among the 24.5 million observation days, exposure distribution was: 73.8% antiplatelets only, 4.7% antiplatelets plus warfarin, 0.6% antiplatelets plus DOAC, 2.2% warfarin only, 0.3% DOAC only and 18.4% no observed antiplatelets or anticoagulant. Overall, 8,029 patients (11.3%) experienced major hemorrhage. Among AF patients, compared to antiplatelets only, DOAC plus antiplatelets was associated with increased hemorrhage risk (HR, 1.94; 95%CI, 1.48–2.54); warfarin plus antiplatelets conferred comparable bleed risk (HR, 1.69; 95%CI, 1.47–1.94). In the non-AF group, compared to antiplatelets alone, combination DOAC plus antiplatelets (HR, 3.09; 95%CI, 2.15–4.46), and warfarin plus antiplatelets (HR, 2.21; 95%CI, 1.97–2.48) conferred greater bleed risk. Among elderly coronary artery stent recipients with AF, the two drug combinations, DOAC plus antiplatelets and warfarin plus antiplatelets, were associated with similarly increased risk of major hemorrhage compared to antiplatelets alone. [ABSTRACT FROM AUTHOR]

Background Centers of excellence focusing on quality improvement have demonstrated superior outcomes for a variety of surgical interventions. We investigated the presence of access disparities to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC) for patients undergoing neurosurgical operations. Methods We performed a cohort study of all neurosurgery patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race and lack of insurance with Magnet status hospitalization for neurosurgical procedures. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. Results During the study period, 190,535 neurosurgical patients met the inclusion criteria. Using a multivariable logistic regression, we demonstrate that African-Americans had lower admission rates to Magnet institutions (OR 0.62; 95% CI, 0.58–0.67). This persisted in a mixed effects logistic regression model (OR 0.77; 95% CI, 0.70–0.83) to adjust for clustering at the patient county level, and a propensity score adjusted logistic regression model (OR 0.75; 95% CI, 0.69–0.82). Additionally, lack of insurance was associated with lower admission rates to Magnet institutions (OR 0.71; 95% CI, 0.68–0.73), in a multivariable logistic regression model. This persisted in a mixed effects logistic regression model (OR 0.72; 95% CI, 0.69–0.74), and a propensity score adjusted logistic regression model (OR 0.72; 95% CI, 0.69–0.75). Conclusions Using a comprehensive all-payer cohort of neurosurgery patients in New York State we identified an association of African-American race and lack of insurance with lower rates of admission to Magnet hospitals. [ABSTRACT FROM AUTHOR]

Access disparities to centers of excellence can have detrimental consequences for population health. We investigated the presence of racial disparities in the access of stroke patients to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC). We performed a cohort study of all ischemic stroke patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African–American race with Magnet status hospitalization after ischemic stroke. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. During the study period, 176,557 patients presented with ischemic stroke, and met the inclusion criteria. Overall, 4,624 (13.7%) African-Americans, and 27,468 (19.2%) non African-Americans with ischemic stroke were admitted to Magnet hospitals. Using a multivariable logistic regression, we demonstrate that African-Americans were associated with lower admission rates to Magnet institutions (OR 0.70; 95% CI, 0.68–0.73) (Table 2). This persisted in a mixed effects logistic regression model (OR 0.75; 95% CI, 0.71–0.78) to adjust for clustering at the county level, and a propensity score adjusted logistic regression model (OR 0.87; 95% CI, 0.83–0.90). Using a comprehensive all-payer cohort of ischemic stroke patients in New York State we identified an association of African–American race with lower rates of admission to Magnet hospitals. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Context: The value of continuity of care in preventing 30-day readmissions after surgical procedures remains an issue of debate.Purpose: This study aimed to investigate the association of being evaluated in the emergency room (ER) of the hospital where the original procedure was performed with 30-day readmissions for spine surgery patients.Study Design/setting: This is a cohort study.Patient Sample: A total of 16,483 spine surgery patients were evaluated in the emergency department within 30-days postoperatively.Outcome Measures: A 30-day post-discharge readmission was the outcome measure.Methods: We performed a cohort study involving patients who were evaluated in the ER within 30-days after discharge following spine surgery from 2009 to 2013, and were registered in the Statewide Planning and Research Cooperative System database. A propensity score adjusted model was used to control for confounding.Results: From our patients, 11,638 (70.6%) were seen in a hospital different from the one where the original procedure was performed (12.0% readmitted), and 4,845 (29.4%) were evaluated at the original hospital (10.9% readmitted). In a multivariable analysis, we demonstrated that being evaluated in the original hospital was associated with decreased rate of 30-day readmission (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.77-0.97). We found similar associations in a propensity score adjusted model (OR, 0.87; 95% CI, 0.78-0.97). This corresponded to seven patients who needed to be evaluated in the hospital where the original procedure was performed to prevent one readmission.Conclusions: Using a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ER after spine surgery, we identified an association of assessment in the hospital where the original procedure was performed with lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients. [ABSTRACT FROM AUTHOR]

Introduction: The influence of non-medical factors on the volume of procedures undergone by TBI patients remains an issue of debate. We investigated the association of lack of insurance and African-American race with the procedural volume of TBI patients. Methods: We performed a retrospective cohort study involving TBI patients, who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011. Multivariable logistic regression with mixed effects to control for clustering at the hospital level was used to investigate the association of insurance status and race with high volume of procedures for TBI patients. Results: Of the 392,292 TBI patients, who were registered in NTDB and met the inclusion criteria, 9850 (3.8%) underwent high procedural volume, defined as 2 or more procedures during hospitalization (2 standard deviations over the mean). Multivariable logistic regression analysis demonstrated an association of uninsured patients with decreased possibility of high procedural volume (OR, 0.68; 95% CI, 0.63-0.73). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 0.66; 95% CI, 0.61-0.71). In stratified samples, uninsured patients demonstrated similar associations even for GCS below 8 (OR, 0.69; 95% CI, 0.64-0.75), or ISS above 15 (OR, 0.74; 95% CI, 0.69-0.79). Multivariable logistic regression analysis did not demonstrate an association of African Americans with procedural volume (OR, 0.93; 95% CI, 0.86-1.02). Conclusions: During the hospitalization of TBI patients, lack of insurance was associated with lower procedural volume. When controlling for insurance status, we did not observe any race associated disparities in procedural volume. [ABSTRACT FROM AUTHOR]

The objective of this study was to develop and validate a predictive model of hospitalization costs after spine surgery. Several initiatives have been put in place to minimize healthcare expenditures but there are limited data on the magnitude of the contribution of procedure-specific drivers of cost. We performed a retrospective cohort study involving 672,591 patients who underwent spine surgery and were registered in the National Inpatient Sample from 2005–2010. The cohort underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model of total hospitalization cost after spine surgery. Included were 356,783 patients (53.1%) who underwent fusions, and 315,808 (46.9%) non-fusion surgeries. The median hospitalization cost was $14,202 (interquartile range $4772–23,632). Common drivers of cost identified in the multivariate analysis included the length of stay, number of admission diagnoses and procedures, hospital size and region, patient income, fusion surgery, acute renal failure, sex, and coagulopathy. The model was validated in an independent cohort and demonstrated a final coefficient of determination that was very similar to the initial model. The predicted and observed values in the validation cohort demonstrated good correlations. This national study quantified the magnitude of significant drivers of hospitalization cost after spine surgery. We developed a predictive model that can be utilized as an adjunct in the cost containment debate and the creation of data driven policies. [ABSTRACT FROM AUTHOR]

Background context The influence of nonmedical factors on the disposition of spine trauma patients, initially seen in less specialized institutions, remains an issue of debate. Purpose To investigate the association of lack of insurance and African-American race with the probability of being transferred to a Level I or II trauma center, after being evaluated in the emergency department (ED) of Level III or IV trauma centers for spine trauma. Study design/setting This was a retrospective cohort study. Patient sample A total of 14,133 patients who were registered in National Trauma Data Bank (NTDB) from 2009 to 2011 and initially evaluated in the ED of Level III or IV trauma centers for spine trauma were included. Outcome measures The outcome measures were rates of transfer to a higher level of care trauma center. Methods We performed a retrospective cohort study involving spine trauma patients, who were registered in the NTDB between 2009 and 2011. Regression techniques, controlling for clustering at the hospital level, were used to investigate the association of insurance status and race with the possibility of transfer. Results Overall, 4,142 patients (29.31%) were transferred to a higher level of care institution, and 9,738 (70.69%) were admitted to a Level III or IV trauma center. Multivariable logistic regression analysis demonstrated an association of uninsured patients with increased possibility of transfer (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.22–1.61). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 1.65; 95% CI, 1.37–1.96). African-American race was not associated with the decision to transfer, when using a mixed effects model (OR, 1.15; 95% CI, 0.89–1.48). However, African-Americans with Glasgow Coma Scale greater than 8 (OR, 1.40; 95% CI, 1.13–1.74) or Injury Severity Score less than 15 (OR, 1.54; 95% CI, 1.21–1.96) were associated with a higher likelihood of transfer. Conclusions In summary, lack of insurance was associated with increased possibility of transfer to higher level of care institutions, after evaluation in a Level III or IV trauma center ED for spine trauma. The same was true for African-Americans with milder injuries. [ABSTRACT FROM AUTHOR]

Background Benchmarking of outcomes and individualized risk prediction are central in patient-oriented shared decision making. We attempted to create a predictive model of complications in patients undergoing benign intracranial tumor resection. Methods We performed a retrospective cohort study involving patients who underwent craniotomies for benign intracranial tumor resection during the period 2005–2011 and were registered in the National (Nationwide) Inpatient Sample database. A model for outcome prediction based on individual patient characteristics was developed. Results There were 19,894 patients who underwent benign tumor resection. The respective inpatient postoperative incidences were 1.3% for death, 22.7% for unfavorable discharge, 4.2% for treated hydrocephalus, 1.1% for cardiac complications, 0.9% for respiratory complications, 0.5% for wound infection, 0.5% for deep venous thrombosis, 2.3% for pulmonary embolus, and 1.5% for acute renal failure. Multivariable analysis identified risk factors independently associated with the above-mentioned outcomes. A model for outcome prediction based on patient and hospital characteristics was developed and subsequently validated in a bootstrap sample. The models demonstrated good discrimination with areas under the curve of 0.85, 0.76, 0.72, 0.74, 0.72, 0.74, 0.76, 0.68, and 0.86 for postoperative risk of death, unfavorable discharge, hydrocephalus, cardiac complications, respiratory complications, wound infection, deep venous thrombosis, pulmonary embolus, and acute renal failure. The models also had good calibration, as assessed by the Hosmer-Lemeshow test. Conclusions Our models can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and potentially can be used as an adjunct for decision making in benign intracranial tumor surgery. [ABSTRACT FROM AUTHOR]

Background context The correlation of negative outcomes with aggressiveness of malpractice liability has been questioned in the literature. Purpose The aim of this study was to investigate the association of malpractice liability with unfavorable outcomes and hospitalization charges in spine surgery. Study design/setting This was a retrospective cohort study. Patient sample The sample included a total of 709,951 patients undergoing spine surgery who were registered in the Nationwide Inpatient Sample (NIS) database from 2005 to 2010. Outcome measures The outcome measures were state-level mortality, length of stay (LOS), and hospitalization charges after spinal surgery. Methods We performed a retrospective cohort study involving patients who underwent spine surgery from 2005 to 2010 and were registered in NIS. We used data from the National Practitioner Data Bank from 2005 to 2010 to create measures of volume and size of malpractice claim payments. Their association of the latter with the outcome measures was investigated. Results During the study period, there were 707,951 patients (mean age, 54.4 years, with 49.7% females) who underwent spine surgery and were registered in NIS. In a multivariable regression model, higher number of claims per 100 physicians in a state was associated with increased hospitalization charges (β=0.14; 95% confidence interval [CI], 0.13–0.14) and LOS (β=0.041; 95% CI, 0.036–0.047). On the contrary, there was no association with mortality (odds ratio [OR], 0.99; 95% CI, 0.87–1.12). Larger magnitude of awarded claims was associated with increased hospitalization charges (β=0.08; 95% CI, 0.075–0.09) and LOS (β=0.02; 95% CI, 0.016–0.031). On the contrary, there was no association with mortality (OR, 0.95; 95% CI, 0.82–1.11). Conclusions In the present national study, aggressive malpractice environment was not correlated with mortality but was associated with higher hospitalization charges after spine surgery. Further research is needed to identify ways to regulate the malpractice system to address these disparities. [ABSTRACT FROM AUTHOR]

Background context There is a persistent trend for more outpatient lumbar discectomies in the United States. Purpose To investigate the characteristics of the patients selected for ambulatory procedures. Study design Retrospective cohort study. Patient sample Forty-seven thousand one hundred twenty-five patients who underwent outpatient and 102,592 patients undergoing inpatient lumbar discectomies and were were registered in the State Ambulatory Surgery Database (SASD) and State Inpatient Database (SID), respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Outcome measures Rate of outpatient procedures, 30-day readmissions, and hospital charges. Methods We performed a retrospective cohort study involving patients who underwent outpatient and inpatient lumbar discectomies and were registered in SASD and SID, respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Logistic regression models were used to demonstrate the association of socioeconomic factors with the odds of undergoing an outpatient procedure. Results Male gender (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.08), private insurance (OR, 1.93; 95% CI, 1.86-2.01), lower Charlson Comorbidity Index (OR, 4.04; 95% CI, 3.17-5.16), and higher volume hospitals (OR, 1.06; 95% CI, 1.04-1.08) were significantly associated with outpatient procedures. Higher income (OR, 0.83; 95% CI, 0.81-0.85), older age (OR, 0.996; 95% CI, 0.995-0.997), coverage by Medicaid (OR, 0.89; 95% CI, 0.83-0.96), African Americans (OR, 0.65; 95% CI, 0.60-0.70), and other minority races were associated with decreased odds of outpatient procedures. The rate of 30-day postoperative readmissions was higher among inpatients. Institutional charges were significantly lower for outpatient lumbar discectomies. The median charge for inpatient surgery was $24,273 as compared with $11,339 for the outpatient setting (p<.0001). Conclusions Access to ambulatory lumbar discectomies appears to be more common for younger, white, male patients, with private insurance and less comorbidities, in the setting of higher volume hospitals. Further investigation is needed in the direction of mapping these disparities for appropriate resource utilization. [ABSTRACT FROM AUTHOR]

Abstract: Background context: There is increasing scrutiny by several regulatory bodies regarding the complications of spine surgery. Precise delineation of the risks contributing to those complications remains a topic of debate. Purpose: We attempted to create a predictive model of complications in patients undergoing spine surgery. Study design/setting: Retrospective cohort study. Patient sample: A total of 13,660 patients registered in the American College of Surgeons National Quality Improvement Project (NSQIP) database. Outcome measures: Thirty-day postoperative risks of stroke, myocardial infarction, death, infection, urinary tract infection (UTI), deep vein thrombosis (DVT), pulmonary embolism (PE), and return to the operating room. Methods: We performed a retrospective cohort study involving patients who underwent spine surgery between 2005 and 2010 and were registered in NSQIP. A model for outcome prediction based on individual patient characteristics was developed. Results: Of the 13,660 patients, 2,719 underwent anterior approaches (19.9%), 565 corpectomies (4.1%), and 1,757 fusions (12.9%). The respective 30-day postoperative risks were 0.05% for stroke, 0.2% for MI, 0.25% for death, 0.3% for infection, 1.37% for UTI, 0.6% for DVT, 0.29% for PE, and 3.15% for return to the operating room. Multivariate analysis demonstrated that increasing age, more extensive operations (fusion, corpectomy), medical deconditioning (weight loss, dialysis, peripheral vascular disease, coronary artery disease, chronic obstructive pulmonary disease, diabetes), increasing body mass index, non-independent mobilization (preoperative neurologic deficit), and bleeding disorders were independently associated with a more than 3 days' length of stay. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated by the area under the receiver operating characteristic curve, which was 0.95, 0.82, 0.87, 0.75, 0.74, 0.78, 0.76, 0.74, and 0.65 for postoperative risk of stroke, myocardial infarction, death, infection, DVT, PE, UTI, length of stay of 3 days or longer, and return to the operating room, respectively. Conclusions: Our model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions, and can potentially be used as an adjunct in decision-making for spine surgery. [Copyright &y& Elsevier]

Background: Thrombosis in unusual locations in the lower extremity veins has not been assessed. These veins are not imaged routinely and therefore information about them is lacking. Methods: This study was designed to evaluate the natural history of deep vein thrombosis (DVT) in unusual sites. Patients with DVT in all thigh veins but the femoral vein were included. Patients with thrombi in any other vein in the first examination and those with history of DVT were excluded. Duplex ultrasound (DU) examination was performed to exclude thrombosis in the lower extremity in patients with signs and symptoms of venous thromboembolism and also in high-risk, asymptomatic patients. All veins from the distal external iliac vein to the lower calf were imaged. The deep femoral, femoropopliteal, lateral thigh, sciatic, and muscular thigh veins were examined. These patients were followed at 1 week, 1 month, 6 months, 1 year, and yearly thereafter, for thrombus propagation, resolution, and reflux. Results: Among the 15,850 DU performed in the vascular laboratory at Loyola University Medical Center, in a 10-year period to rule out DVT, 2568 (16.2%) were positive and 14 cases (7 males, 0.54% among the patients with DVT and 0.088% among the entire population) involved thromboses in unusual locations. Ten cases involved the left lower extremity and four the right. The unusual DVT cases were associated with medical and surgical conditions or were idiopathic in 11 patients, whereas three had Klippel-Trenaunay syndrome (KTS). The veins involved in the first group of patients were the deep femoral (8), the femoropopliteal (2), and the deep external pudendal (1). The patients with KTS had involvement of muscular thigh veins (1), and the lateral thigh vein and the sciatic vein (2). Thrombi propagation with extension to the common femoral vein was seen in four of the 14 patients: two from the deep femoral vein, one from the femoropopliteal vein, and one from the deep external pudendal vein. There were two incidences of pulmonary embolism (PE) one of which was fatal. At final follow-up, two patients developed recurrent DVT and nine had signs and symptoms of chronic venous disease. Conclusions: The involvement of the studied veins in DVT is extremely rare. Thrombosis in these veins can follow the natural course of thrombosis in the more usual locations and is associated with lethal incidences of PE. Therefore, the association of these veins with all the grave sequelae of thromboembolic disease suggests that inclusion of these veins in routine lower extremity duplex scans would be beneficial. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The association of surgical duration with the risk of surgical site infection (SSI) has not been quantified in neurosurgery. We investigated the association of operative duration in neurosurgical procedures with the incidence of SSI. Methods We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. To control for confounding, we used multivariable regression models and propensity score conditioning. Results During the study period there were 94,744 patients who underwent a neurosurgical procedure and met the inclusion criteria. Of these patients, 4.1% developed a postoperative SSI within 30 days. Multivariable logistic regression showed an association between longer operative duration with higher incidence of SSI (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16–1.20). Compared with procedures of moderate duration (third quintile, 40th–60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 2.07; 95% CI, 1.86–2.31) of developing SSI. The shortest procedures (<20th percentile) were associated with decreased incidence of SSI (OR, 0.72; 95% CI, 0.61–0.83) compared with those of moderate duration. The same associations were present in propensity score adjusted models and models stratified by subgroups of cranial, spinal, peripheral nerve, and carotid procedures. Conclusions In a cohort of patients from a national prospective surgical registry, longer operative duration was associated with increased incidence of SSI for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management and to stratify patients with regard to SSI risk. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two. We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers. We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%. Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage. [ABSTRACT FROM AUTHOR]

Background Regulatory agencies are standardizing quality metrics on the basis of which surgical procedures will be evaluated. We attempted to create a predictive model of perioperative complications in patients undergoing craniotomies for glioma resection. Methods We performed a retrospective cohort study involving patients who underwent craniotomies for glioma resection from 2005–2011 and were registered in the National Inpatient Sample (NIS) database. A predictive model for complications was developed and validated. Results Overall, 21,384 patients underwent glioma resection. The respective inpatient postoperative risks were 1.6% for death, 25.8% for discharge to rehabilitation, 4.0% for treated hydrocephalus, 0.7% for cardiac complications, 0.5% for respiratory complications, 0.8% for deep wound infection, 0.6% for deep venous thrombosis (DVT), 3.1% for pulmonary embolus (PE), and 1.3% for acute renal failure (ARF). Predictive models for individual complications were developed on the basis of a logistic regression analysis and subsequently validated in a bootstrapped sample. The models demonstrated good discrimination with areas under the curve (AUC) of 0.71, 0.71, 0.69, 0.71, 0.74, 0.70, 0.73, 0.64, and 0.81 for postoperative risk of death, discharge to rehabilitation, hydrocephalus, cardiac complications, respiratory complications, deep wound infection, DVT, PE, and ARF, respectively. Additionally, the Hosmer-Lemeshow test was used to assess the calibration of all models. Conclusions The presented models can assist in the preoperative estimation of the complication risk for glioma patients and be used as an adjunct for outcome benchmarking in this population. [ABSTRACT FROM AUTHOR]