National trend in prevalence, cost, and discharge after subdural hematoma from 1998-2007

Neuroscience Intensive Care Unit, Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA.
Critical care medicine (Impact Factor: 6.31). 03/2011; 39(7):1619-25. DOI: 10.1097/CCM.0b013e3182186ed6
Source: PubMed


Subdural hematoma is a common type of intracranial hemorrhage, particularly among the elderly, yet, despite the aging U.S. population, little has been published in the last 10 yrs. This study aimed to determine national trends in prevalence, discharge disposition, length of stay, and cost of subdural hematoma over time.
Retrospective cohort study.
Adult patients hospitalized in the United States between 1998 and 2007 identified in the Nationwide Inpatient Sample.
Seven hundred twenty thousand, two hundred ninety-seven adult patients hospitalized in subdural hematoma.
Discharge disposition, hospital length of stay, and national cost (adjusted to 2007 dollars) were examined. Hospitalizations for subdural hematoma increased from 59,373 (30 per 100,000 hospitalizations) in 1998 to 91,935 (42 per 100,000) in 2007, constituting a 39% per-capita increase. The prevalence of subdural hematoma increased with age (p < .001), particularly among those >80 yrs of age (36% of subdural hematoma cohort), in lower income patients, in patients with acquired abnormalities of the coagulation cascade, and in patients with trauma. Inhospital mortality decreased from 15% to 12% (p = .001), but unsatisfactory discharge disposition increased from 17% to 20% (p < .001). National cost increased from $1.0 to $1.6 billion (p < .001). Unsatisfactory discharge disposition and cost were both independently predicted by higher comorbidity index, alcohol abuse, history of trauma, and acquired abnormal coagulation or platelet factors (p < .05). Neurosurgical intervention for subdural hematoma decreased from 41% in 1998 to 31% in 2007 (p < .001). Subdural hematoma evacuation was associated with decreased mortality but did not significantly protect against poor discharge disposition and was associated with significantly higher cost.
The prevalence and total cost for subdural hematoma has increased significantly in the last decade nationwide. Health resource consumption for subdural hematoma is increasing without clear evidence that management practices are leading to improved outcomes.

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    • "Previous research on subdural hematomas (especially chronic subdural hematomas) within the elderly typically focus on the type of surgical treatment,[11121314] the role of anticoagulant[1516] and epidemiology.[117] However, the long-term outcome of elderly patients and the role of conservative management versus surgery cannot be determined based on the limited data available.[3418] "
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    ABSTRACT: Subdural hematoma (SDH) is a common disease entity treated by neurosurgical intervention. Although the incidence increases in the elderly population, there is a paucity of studies examining their surgical outcomes. To determine the neurological and functional outcomes of patients over 70 years of age undergoing surgical decompression for subdural hematoma. We retrospectively reviewed data on 45 patients above 70 years who underwent craniotomy or burr holes for acute, chronic or mixed subdural hematomas. We analyzed both neurological and functional status before and after surgery. Forty-five patients 70 years of age or older were treated in our department during the study period. There was a significant improvement in the neurological status of patients from admission to follow up as assessed using the Markwalder grading scale (1.98 vs. 1.39; P =0.005), yet no improvement in functional outcome was observed as assessed by Glasgow Outcome Score. Forty-one patients were admitted from home, however only 20 patients (44%) were discharged home, 16 (36%) discharged to nursing home or rehab, 6 (13%) to hospice and 3 (7%) died in the postoperative period. Neurological function improved in patients who were older, had a worse pre-operative neurological status, were on anticoagulation and had chronic or mixed acute and chronic hematoma. However, no improvement in functional status was observed. Surgical management of SDH in patients over 70 years of age provides significant improvement in neurological status, but does not change functional status.
    07/2013; 4(3):250-6. DOI:10.4103/0976-3147.118760
  • Critical care medicine 07/2011; 39(7):1822-3. DOI:10.1097/CCM.0b013e31821e83a2 · 6.31 Impact Factor
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    ABSTRACT: Background: Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time. Methods: Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures. Results: The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006. Conclusions: From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.
    Thyroid: official journal of the American Thyroid Association 11/2012; 23(6). DOI:10.1089/thy.2012.0218 · 4.49 Impact Factor
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