Mechanical Thrombectomy in Acute Stroke: Utilization Variances and Impact of Procedural Volume on Inpatient Mortality
An increasing number of endovascular mechanical thrombectomy procedures are being performed for the treatment of acute ischemic stroke. This study examines variances in the allocation of these procedures in the United States at the hospital level. We investigate operative volume across centers performing mechanical revascularization and establish that procedural volume is independently associated with inpatient mortality.
Data was collected using the Nationwide Inpatient Sample database in the United States for 2008. Medical centers performing mechanical thrombectomy were identified using International Classification of Diseases, 9th revision codes, and procedural volumes were evaluated according to hospital size, location, control/ownership, geographic characteristics, and teaching status. Inpatient mortality was compared for hospitals performing ≥10 mechanical thrombectomy procedures versus those performing<10 procedures annually. After univariate analysis identified the factors that were significantly related to mortality, multivariable logistic regression was performed to compare mortality outcome by hospital procedure volume independent of covariates.
Significant allocation differences existed for mechanical thrombectomy procedures according to hospital size (P<.001), location (P<.0001), control/ownership (P<.0001), geography (P<.05), and teaching status (P<.0001). Substantial procedural volume was independently associated with decreased mortality (P=.0002; odds ratio 0.49) when adjusting for demographic covariates.
The number of mechanical thrombectomy procedures performed nationally remains relatively low, with a disproportionate distribution of neurointerventional centers in high-volume, urban teaching hospitals. Procedural volume is associated with mortality in facilities performing mechanical thrombectomy for acute ischemic stroke patients. These results suggest a potential benefit for treatment centralization to facilities with substantial operative volume.
Available from: Shuhan He
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Mechanical revascularization procedures performed for treatment of acute ischemic stroke have increased in recent years. Data suggest association between operative volume and mortality rates. Understanding procedural allocation and patient access patterns is critical. Few studies have examined these demographics.
Data were collected from the 2008 Nationwide Inpatient Sample database. Patients hospitalized with ischemic stroke and the subset of individuals who underwent mechanical thrombectomy were characterized by race, payer source, population density, and median wealth of the patient's zip code. Demographic data among patients undergoing mechanical thrombectomy procedures were examined. Stroke admission demographics were analyzed according to thrombectomy volume at admitting centers and patient demographics assessed according to the thrombectomy volume at treating centers.
Significant allocation differences with respect to frequency of mechanical thrombectomy procedures among stroke patients existed according to race, expected payer, population density, and wealth of the patient's zip code (P < .0001). White, Hispanic, and Asian/Pacific Islander patients received endovascular treatment at higher rates than black and Native American patients. Compared with the white stroke patients, black (P < .001), Hispanic (P < .001), Asian/Pacific Islander (P < .001), and Native American stroke patients (P < .001) all demonstrated decreased frequency of admission to hospitals performing mechanical thrombectomy procedures at high volumes. Among treated patients, blacks (P = .0876), Hispanics (P = .0335), and Asian/Pacific Islanders (P < .001) demonstrated decreased frequency in mechanical thrombectomy procedures performed at high-volume centers when compared with whites. While present, socioeconomic disparities were not as consistent or pronounced as racial differences.
We demonstrate variances in endovascular acute stroke treatment allocation according to racial and socioeconomic factors in 2008. Efforts should be made to monitor and address potential disparities in treatment utilization.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 05/2013; 23(2). DOI:10.1016/j.jstrokecerebrovasdis.2013.03.036 · 1.67 Impact Factor
Available from: atsjournals.org
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ABSTRACT: Proponents of the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) propose that in this era of EBUS-TBNA, training for conventional transbronchial needle aspiration (C-TBNA) should be abandoned. The authors of this editorial provide the opposing view. C-TBNA has a short and a steep learning curve and adds to the diagnostic yield of flexible bronchoscopy in a cost-effective fashion. Considering its simplicity, availability, affordability, safety, and several unique indications, C-TBNA continues to contribute to the welfare of patients worldwide. It should remain as an integral part of pulmonary fellowship training programs.
Annals of the American Thoracic Society 12/2013; 10(6):685-9. DOI:10.1513/AnnalsATS.201308-272ED
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ABSTRACT: Patients with cerebrovascular disease undergo complex surgical procedures, often requiring prolonged inpatient hospitalization. Prior studies have demonstrated associations between racial/demographic factors and clinical outcomes in patients undergoing cerebrovascular procedures (CVPs). The Centers for Medicare and Medicaid Services (CMS) have published a series of 11 hospital-acquired conditions (HACs) deemed "reasonably preventable" for which related costs of treatment are not reimbursed. We hypothesize that race and payer status disparities impact HAC frequency in patients undergoing CVPs and that HAC incidence is associated with length of stay and hospital costs.
To assess health disparities in HACs among the cerebrovascular neurosurgical patient population.
Data were collected from the Nationwide Inpatient Sample (NIS) database from 2002-2010. CVPs and HACs were identified by ICD-9CM diagnostic and procedure codes. HAC incidence was evaluated according to demographics including race, payer status, and median zip code income via multivariable analysis. Secondary outcomes of interest included length of stay and resulting inpatient charges.
From 2002-2010, there were 1,290,883 CVP discharges with an HAC rate of 0.5%. Significant disparities in HAC frequency existed according to ethnicity and insurance provider. Minorities and Medicaid patients had increased frequency of HACs (p<0.05), as well as prolonged length of stay and higher inpatient costs (p<0.05).
HAC incidence is associated with racial and socioeconomic factors in patients who undergo CVPs. Awareness of these disparities may lead to improved processes and protocol implementation, which might help to decrease the frequency of these potentially avoidable events.
Neurosurgery 03/2014; 75(1). DOI:10.1227/NEU.0000000000000352 · 3.62 Impact Factor
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