Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011

ArticleinJournal of Neurosurgery 120(3) · November 2013with10 Reads
DOI: 10.3171/2013.10.JNS122419 · Source: PubMed
Object: Surgical complications increase the cost of health care worldwide and directly contribute to patient morbidity and mortality. In an effort to mitigate morbidity and incentivize best practices, stakeholders such as health insurers and the US government are linking reimbursement to patient outcomes. In this study the authors analyzed a national database to determine basic metrics of how comorbidities specifically affect the subspecialty of neurosurgery. Methods: Data on 1,777,035 patients for the years 2006-2011 were acquired from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Neurosurgical cases were extracted by querying the data for which the surgical specialty was listed as "neurological surgery." Univariate statistics were calculated using the chi-square test, and 95% confidence intervals were determined for the resultant risk ratios. A multivariate model was constructed using significant variables from the univariate analysis (p < 0.05) with binary logistic regression. Results: Over 38,000 neurosurgical cases were analyzed, with complications occurring in 14.3%. Cranial cases were 2.6 times more likely to have complications than spine cases, and African Americans and Asians/Pacific Islanders were also at higher risk. The most frequent complications were bleeding requiring transfusion (4.5% of patients) and reoperation within 30 days of the initial operation (4.3% of patients), followed by failure to wean from mechanical ventilation postoperatively (2.5%). Significant predictors of complications included preoperative stroke, sepsis, blood transfusion, and chronic steroid use. Conclusions: Understanding the landscape of neurosurgical complications will allow better targeting of the most costly and harmful complications of preventive measures. Data from the ACS NSQIP database provide a starting point for developing paradigms of improved care of neurosurgical patients.
    • "In our study, there was a lower rate of perioperative complications associated with lumbar microdecompression than what has been reported in studies that involve laminectomy procedures (3.2 vs. 10.4 %) [9]. Moreover, this rate is clearly lower than what has previously been reported for fusion pro- cedures [20, 26]. Interestingly, the rate of unintentional durotomies was very low and there were no major complications such as nerve injury, DVT, PE, and deep-wound infec- tions [9, 16, 24, 27] . "
    [Show abstract] [Hide abstract] ABSTRACT: To assess outcomes and complications in patients undergoing microsurgical decompression for central lumbar spinal stenosis (LSS) without radiologic instability. Prospective data for patients operated at the Department of Neurosurgery, St. Olavs University Hospital, Norway, were obtained from the Norwegian Registry for Spine Surgery (NORspine) from 2007 to 2012. The primary outcome was change in Oswestry disability index (ODI) at 1 year. The secondary endpoint was perioperative complications. Complications were graded according to the Ibanez classification system. For all patients (n = 125), the mean improvement in ODI at 1 year was 16.9 points (95 % CI 13.5-20.2, p < 0.001). Seventy-six (71.7 %) patients achieved a minimal clinically important difference in ODI (defined as ≥8 points improvement). The total number of complications within 3 months of surgery was 22 (17.6 %). There were 14 medical and eight surgical complications, and all were Ibanez grade I or II (mild or moderate) complications. Four (3.2 %) complications occurred while being admitted to the hospital and 18 (14.4 %) occurred within 3 months following hospital discharge. The most common complication was urinary tract infection (n = 11, 8.8 %). Microsurgical decompression for central LSS in the absence of radiological instability is an effective and safe treatment.
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    • "The convenience and accessibility of the Taiwan national health insurance system may increase the likelihood of treatment for MV patients [1, 2]. Improved medical techniques may also increase the number of patients with co-morbidities who are willing to receive invasive MV [14]. The prevalence of MV patients younger than 65 years has also increased, and patients in this age group tend to prefer treatment in high-volume hospitals or medical centers [1, 2]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To investigate the relationship between changes in patient attributes and hospital attributes over time and to explore predictors of medical utilization and mortality rates in mechanical ventilation (MV) patients in Taiwan. Background: Providing effective medical care for MV patients is challenging and requires good planning and effective clinical decision making policies. Most studies of MV, however, have only analyzed a single regional ventilator weaning center or respiratory care unit, high-quality population-based studies of MV trends and outcomes are scarce. Methods: This population-based cohort study retrospectively analyzed 213,945 MV patients treated during 2004-2009. Results: During the study period, the percentages of MV patients with the following characteristics significantly increased: age ≦ 65 years, treatment at a medical center, and treatment by a high-volume physician. In contrast, the percentages of MV patients treated at local hospitals and by low-volume physicians significantly decreased (P<0.001). Age, gender, Deyo-Charlson co-morbidity index, teaching hospital, hospital level, hospital volume, and physician volume were significantly associated with MV outcome (P<0.001). Over the 6-year period analyzed in this study, the estimated mean hospital treatment cost increased 48.8% whereas mean length of stay decreased 13.9%. The estimated mean overall survival time for MV patients was 16.4 months (SD 0.4 months), and the overall in-hospital 1-, 3-, and 5-year survival rates were 61.0%, 36.7%, 17.3%, and 9.6%, respectively. Conclusions: These population-based data revealed increases in the percentages of MV patients treated at medical centers and by high-volume physicians, especially in younger patients. Notably, although LOS for MV patients decreased, hospital treatment costs increased. Healthcare providers and patients should recognize that attributes of both the patient and the hospital may affect outcomes.
    Full-text · Article · Apr 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Repeated cerebrospinal fluid (CSF) shunt failures in pediatric patients are common, and they are a significant cause of morbidity and, occasionally, of death. To date, the risk factors for repeated failure have not been established. By performing survival analysis for repeated events, the authors examined the effects of patient characteristics, shunt hardware, and surgical details in a large cohort of patients. During a 10-year period all pediatric patients with hydrocephalus requiring CSF diversion procedures were included in a prospective single-institution observational study. Patient characteristics were defined as age, gender, weight, head circumference, American Society of Anesthesiology class, and cause of hydrocephalus. Surgical details included whether the procedure was performed on an emergency or nonemergency basis, use of antibiotic agents, concurrent surgical procedures, and duration of the surgical procedure. Details on shunt hardware included: the type of shunt, the valve system, whether the shunt system included multiple or complex components, the type of distal catheter, the site of the shunt, and the side on which the shunt was placed. Repeated shunt failures were assessed using multivariable time-to-event analysis (by using the Cox regression model). Conditional models (as established by Prentice, et al.) were formulated for gap times (that is, times between successive shunt failures). There were 1183 shunt failures in 839 patients. Failure time from the first shunt procedure was an important predictor for the second and third episodes of failure, thus establishing an association between the times to failure within individual patients. An age younger than 40 weeks gestation at the time of the first shunt implantation carried a hazard ratio (HR) of 2.49 (95% confidence interval [CI] 1.68-3.68) for the first failure, which remained high for subsequent episodes of failure. An age from 40 weeks gestation to 1 year (at the time of the initial surgery) also proved to be an important predictor of first shunt malfunctions (HR 1.77, 95% CI 1.29-2.44). The cause of hydrocephalus was significantly associated with the risk of initial failure and, to a lesser extent, later failures. Concurrent other surgical procedures were associated with an increased risk of failure. The patient's age at the time of initial shunt placement and the time interval since previous surgical revision are important predictors of repeated shunt failures in the multivariable model. Even after adjusting for age at first shunt insertion as well as the cause of hydrocephalus, there is significant association between repeated failure times for individual patients.
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