Cranial surgery among Medicare beneficiaries

BACKGROUND: This article examines the incidence of inpatient cranial surgery among Medicare beneficiaries. Many of these surgeries are trauma related or reflect chronic disabilities. The costs of care and the mortality rates are high for these patients. METHODS: A retrospective study examined the inpatient discharge data on Medicare fee-for-service beneficiaries during FY 1997 for diagnosis-related groups 1, 2, and 484. Incidence patterns, length of hospital stay, and mortality were examined by age, race, sex, source of admission, and discharge destination. RESULTS: Approximately 86% of the Medicare cranial surgery patients were 65 years of age or older, but only 10.2% were 85 years of age or older. The average patient age was 72 years. Nearly 51% of the patients were male, and 86.3% were white. Approximately 35% of the patients were admitted from the emergency room. The average length of stay was 9.6 days, and the average intensive care unit stay was 3.5 days. Whereas 42.3% of the patients were discharged to home, 44.6% were discharged to postacute care, and 10.9% died in the hospital. The average inpatient charge was $30,746. CONCLUSIONS: Cranial surgery in the Medicare population results in high inpatient mortality and high rates of postacute care use, especially as patient age increases.     

Influence of shunt type on ventricular volume changes in children with hydrocephalus

OBJECT: The goal of this study was twofold: to investigate the change in ventricular volume in children with hydrocephalus in response to shunt placement and to assess the effects of two different valve types (Medium Pressure [MP] cylindrical valve and Delta [model 1.5] valve). METHODS: Ventricular volume was measured using segmentation techniques on computerized tomography scans and magnetic resonance images obtained in 40 children with hydrocephalus who ranged in age from 4 days to 16 years. Imaging was performed preoperatively and at 5 days and 3, 6, and 12 months postoperatively. The results were compared with measurements obtained in 71 healthy children ranging in age from 1 month to 15 years. Each ventricular volume that was measured was divided by the corresponding sex and age-related mean normal volume to calculate the "x normal" ventricular volume, indicating how many times larger than normal the ventricle was. The mean preoperative ventricular volume was 232 cm3 (range 50-992 cm3). The mean postoperative volumes were 147, 102, 68, and 61 cm3 at 5 days and at 3, 6, and 12 months posttreatment, respectively. The mean preoperative x normal ventricular volume was 14.5 (range 2.2-141.7), and the mean postoperative x normal volumes were 7.9, 5.6, 3.5, and 2.9 at 5 days and 3, 6, and 12 months postimplantation, respectively. The rate of volume reduction was consistently higher in patients who received the MP valve in comparison with those who received the Delta valve, both for new shunt insertions and for shunt revisions. The difference between the two valve groups did not reach statistical significance. Two patients in whom ventricular volumes increased during the study period experienced shunt obstruction at a later time. CONCLUSIONS: Preoperative ventricular volume in children with hydrocephalus can be up to 14 times greater than normal. In response to shunt placement, the ventricular volume continues to fall during the first 6 months after operation. The effect is more profound in children who receive the MP valve than in those who receive the Delta valve, although in this study the authors did not demonstrate statistical significance in the difference between the two valves. Nevertheless, this may indicate that the MP valve produces overdrainage in comparison with the Delta valve, even within the first few months after insertion. There is some indication that sequential ventricular volume measurement may be used to identify impending shunt failure.     

High-intensity end-of-life care among Medicare beneficiaries with bladder cancer

ObjectivesTo quantify the proportion of patients receiving high-intensity end-of-life care, identify associated risk factors, and assess how receipt of palliative care impact end-of-life care; as the delivery of such care, and how it relates to palliative care, has not been reported in bladder cancerSubjects and MethodsWe conducted a retrospective cohort study of patients with bladder cancer who died within 1 year of diagnosis using Surveillance, Epidemiology, and End Results linked Medicare data. The primary outcome was a composite measure of high-intensity end-of-life care (>1 hospital admission, >1 ED visit, or ≥1 ICU admission within the last month of life; receipt of chemotherapy within the last 2 weeks of life; or acute care in-hospital death). Secondary outcomes included the use of such care over time and any association with the use of palliative care. A generalized linear mixed model assessed for independent determinants.ResultsOverall, 45% of patients received high-intensity end-of-life care. This proportion decreased over time. Patients receiving high-intensity care had higher rates of comorbidities, advanced bladder cancer, and nonbladder cancer cause of death. These patients more often received palliative care but, compared to those not receiving high-intensity care, this occurred farther removed from bladder cancer diagnosis and closer to death.ConclusionsNearly half of Medicare beneficiaries with bladder cancer who die within 1 year of diagnosis receive high-intensity care at the end of life. Palliative care was seldom used and only very near the time of death.     

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Background context

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies.

Purpose

To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions.

Study design

Retrospective cohort study.

Patient sample

Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to 2007.

Outcome measures

Readmissions within 30 days of discharge, excluding readmissions for rehabilitation.

Methods

Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software).

Results

Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%–33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions.

Conclusions

Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.     

Does the shunt opening pressure influence the effect of shunt surgery in normal pressure hydrocephalus?

Summary Thirteen patients with normal pressure hydrocephalus were operated upon with an externally manoeuvrable shunt system (Sophy SU8) in order to investigate its influence on clinical outcome, intracranial pressure and cranial CT parameters. The opening pressure was set at high at surgery and lowered stepwise at intervals of three months to medium and low. The clinical condition, intracranial pressure and cranial CT parameters were examined at the end of the 3 months interval on each pressure level.The patients improved within the first 3 months inspite of an unchanged mean intracranial pressure and remained in a stable clinical condition during the rest of the study period. The intracranial pressure was significantly reduced at 9 months. The ventricular index, Evans index, temporal horn and third ventricle width were reduced 3 months post-operatively and did not change significantly during the rest of the study. The pre-operative third ventricle width was correlated to high psychometric test results after shunt surgery. Reduction in ventricular index, Evans index and third ventricle width after surgery correlated to improvement in psychometric scoring.The clinical improvement after shunt surgery for normal pressure hydrocephalus is seen within 3 months and is independent of the adjusted valve pressure.     

CSF shunt removal in children with hydrocephalus

Summary The possibility to remove a previously inserted CSF shunt device in hydrocephalic children is a well known though rare event for paediatric neurosurgeons. A retrospective analysis of our experience with a series of 850 children affected by non tumoral hydrocephalus shows that obvious shunt independence could be demonstrated in 3.2% of the patients (27 cases). The time interval between the CSF shunt insertion and removal ranged between 8 months and 12 years (mean: 8 years).Parameters analysed to search for any predictive elements were age at surgery, aetiology, type of prosthesis utilised, time interval between insertion and removal of the shunt, number of the possible revisions. The results of the study suggest that the highest incidence of shunt independence is reached in subjects operated on in early infancy, as 24 of 27 removed shunts were in patients operated on under 6 months of age, and the remaining in 2 children treated when less than 2 years old. Such a finding could be explained on the grounds of a delay in maturation of the CSF absorption mechanisms followed by a late normalisation in these patients.As regards to aetiology, 41% of the 27 patients considered in this series were affected by a post-haemorrhagic hydrocephalus, which was progressive, as demonstrated by serial neuroradiological examinations and echo-Doppler cerebral studies at the time of the surgical treatment. In six children the hydrocephalus was associated with myelomeningocele. Five patients had aqueduct stenosis and 2 communicating hydrocephalus.The types of CSF shunting system we utilised did not play any role in determining or facilitating shunt independence. No correlation was observed with the need and the number of shunt revisions. The role of the interval time between the insertion and the removal of the shunt was not analysable, because of the possible acquisition of the shunt independence prior to its demonstration at the moment of the surgical revision of the CSF shunt (elective lengthening because of the physiological body growth) or to the radiological demonstration of CSF shunt device disconnection. The same constraint prevents the evaluation of the actual overall incidence of shunt independence in shunted hydrocephalic children, as some of them could have harboured a non-functioning CSF shunt device, though unnoticed.     

Fungal meningitic hydrocephalus with repeated shunt malfunction

A 33-year-old female presented with a rare case of fungal meningitis caused by Aspergillus detected for the first time at 15 years after onset. The meningitis repeatedly occurred over a period of 15 years. On admission, cerebrospinal fluid examination found cell count 1340/high-power field, protein 158 mg/dl, and sugar 8 mg/dl, indicating meningitis, although no bacterial or fungal species were detected. Cerebral computed tomography demonstrated hydrocephalus and cervical computed tomography demonstrated a mass lesion on the ventral side of the spinal cord from C4 to C6. Fungal meningitis was suspected and treated with amphotericin B. Her symptoms improved and she was eventually discharged. She was readmitted for recurrence of meningitis and hydrocephalus 2 months later. Amphotericin B was administered and a ventriculoperitoneal (VP) shunt was placed. Shunt malfunction recurred seven times. Aspergillus was detected for the first time from the atrium side of the ventriculoatrial shunt tube at 15 years after onset. Fluconazole was administered. She had narrowing of the cisterna magna, and underwent foramen magnum decompression. The VP shunt was finally reconstructed. Fluconazole administration was continued. Combination of foramen magnum decompression and long-term administration of fluconazole was effective in this case.     

Ventriculoperitoneal shunt in cryptococcal meningitis with hydrocephalus

Fourteen patients with cryptococcal meningitis were reviewed. All patients had a ventriculoperitoneal shunt for hydrocephalus. Early recognitions and prompt relief of hydrocephalus were useful for eight patients who showed rapid deterioration of consciousness or signs of cerebral herniation. There was no surgical response in four patients who had had weeks of confusion or mental change. It seems, therefore, that the duration of disturbance of consciousness or change of mentality before shunting is critical in determination of the outcome of the treatment. Ventricular shunting was effective in relieving papilledema in five patients. However, the surgery did not prevent the development of papilledema to optic atrophy and subsequent blindness in two patients. Hence, in addition to hydrocephalus with increased intracranial pressure, conditions such as direct invasion of the optic pathways by Cryptococcus neoformans or optochiasmatic arachnoiditis may be responsible for the visual failure. Ventricular shunting was also helpful in restoring paraparesis in one patient. Of the cerebrospinal fluid determinations, low protein concentration was a favorable indicator for surgery. Of the seven patients who received the surgical procedure before the start of antifungal therapy, four showed a significant improvement despite active infection of the central nervous system. None of the seven patients deteriorated because of the surgical operation. Thus, active stage of cryptococcal meningitis does not contraindicate the necessity of shunting, and premedication with antifungal drugs is unnecessary. Also, no shunt-related morbidity and mortality was seen in this study.     

Ventriculoatrial shunt in tuberculous meningitis with hydrocephalus

Raised intracranial tension affects the course of tuberculous meningitis adversely. The development of hydrocephalus may account for the raised intracranial pressure. Insertion of a ventriculoatrial shunt significantly alters the course of the disease. The results in seven cases have been detailed and discussed. The levels of consciousness improved, hemiplegia and aphasia practically cleared up, and vision returned even in children who were blind for 4 to 6 weeks. Operation could be performed even in an active stage of the disease without much fear of miliary dissemination.     

Pathophysiology of shunt dysfunction in shunt treated hydrocephalus

Background

We hypothesized that shunt dysfunction in the ventricular catheter and the shunt valve is caused by different cellular responses. We also hypothesized that the cellular responses depend on different pathophysiological mechanisms.

Methods

Removed shunt material was collected. Macroscopic tissue in the catheters was paraffin-embedded and HE-stained. Valves were incubated with trypsin-EDTA in order to detach macroscopically invisible biomaterial, which was then cytospinned and HE-stained. Associated aetiological and surgical data were collected by reviewing patient files, and ventricular catheter position was examined using preoperative radiology (CT scans).

Results

We examined eleven ventricular catheters and ten shunt valves. Catheters: 6/11 catheters contained intraluminal tissue consisting of vascularised glial tissue and inflammatory cells (macrophages/giant cells and a few eosinophils). Catheter adherence correlated with the presence of intraluminal tissue, and all tissue containing catheters had some degree of ventricle wall contact. All obstructed catheters contained intraluminal tissue, except one catheter that was dysfunctional because of lost ventricular contact. Valves: Regardless of intraoperative confirmation of valve obstruction, all ten valves contained an almost uniform cellular response of glial cells (most likely ependymal cells), macrophages/giant cells, and lymphomonocytic cells. Some degree of ventricle wall catheter contact was present in all examined valves with available radiology (9/10).

Conclusions

The same cellular responses (i.e., glial cells and inflammatory cells) cause both catheter obstruction and valve obstruction. We propose two synergistic pathophysiological mechanisms. (1) Ventricle wall/parenchymal contact by the catheter causes mechanical irritation of the parenchyma including ependymal exfoliation. (2) The shunt material provokes an inflammatory reaction, either nonspecific or specific. In combination, these mechanisms cause obstructive tissue ingrowth (glial and inflammatory) in the catheter and clogging of the valve by exfoliated glial cells and reactive inflammatory cells.     

Systematic review of the outcome of shunt surgery in idiopathic normal-pressure hydrocephalus

Introduction

Early surgical series of shunt insertion for idiopathic normal-pressure hydrocephalus reported a low rate of short-term improvement with a relatively high rate of mortality and morbidity; subsequently shunt insertion was recommended for patients in whom there is favourable risk-to-benefit ratio.

Methods

Bibliographic search for studies that objectively assessed the outcome following shunt insertion in idiopathic normal-pressure hydrocephalus was done; the aim was to estimate the outcome of shunt insertion in terms of improvement rates and associated mortality and morbidity.

Results

A total of 64 studies of 3,063 patients were reviewed. Positive improvement following shunt insertion was reported in an average of 71 % of patients with an average 1 % mortality. Results from studies published in the last 5 years showed 82 % improvement following shunt insertion, mortality of 0.2 %, and combined common complications rate of 8.2 %.

Conclusion

When patients are properly selected, shunt insertion is a safe and effective management of idiopathic normal-pressure hydrocephalus with a prolonged positive outcome.     

Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer

BackgroundWe sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer.MethodsStandard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition.ResultsAmong 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76–0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82–0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06–1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10–1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21–1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90–1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98–1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes.ConclusionQuality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.     

Epidemiology of carotid endarterectomies among Medicare beneficiaries.

Extensive debates exist in the literature on the indications, effectiveness, and risks of carotid endarterectomy. However, no investigations analyze the procedure's epidemiology. Medicare paid for essentially all carotid endarterectomies on patients over 65 years old, more than two thirds of all such surgery. Accordingly, we identified all 1985 to 1989 Medicare bills for ICD-9-CM code 38.12. This report found an average annual decrease of 6.4% in the frequency of carotid endarterectomies. Higher proportions and incidence rates occurred among 65- to 79-year-old people, men, and whites. Larger, urban, and nonprofit hospitals performed the procedure more often. The number of hospitals performing this procedure has increased over time. Mortality rates within 30 days decreased from 3.0% of procedures in 1985 to 2.5% in 1989. Higher than average death rates occurred among older, male, and black patients, and in low volume hospitals. Clinical trials undertaken in large, urban, teaching, high-volume institutions reported only 1% deaths. The institutions actually performing carotid endarterectomies differ from the clinical trials in their demography and perioperative mortality rates. This difference in community practice may limit the applicability of the clinical trials.     

The impact of individual surgeon on the likelihood of minimal invasive surgery among Medicare beneficiaries undergoing pancreatic resection

BackgroundThe objective of the current study was to evaluate the impact of the individual surgeon on the use of minimally invasive pancreatic resection.MethodsThe Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent pancreatic resection between 2013 and 2017. The impact of patient- and procedure-related factors on the likelihood of minimally invasive pancreatic resection was investigated.ResultsA total of 12,652 (85.4%) patients underwent open pancreatic resection, whereas minimally invasive pancreatic resection was performed in 2,155 (14.6%) patients. Unadjusted rates of minimally invasive pancreatic resection ranged from 0% in the bottom volume tertile to 35.3% in the top tertile. Although patients with emergency admission were less likely to undergo minimally invasive pancreatic resection (odds ratio = 0.43, 95% confidence interval 0.32–0.58), patients operated on more recently had a higher chance of minimally invasive pancreatic resection (year 2017; odds ratio = 1.51, 95% confidence interval 1.28–1.79). On multivariable analysis, there was over a 3-fold variation in the odds that a patient underwent minimally invasive versus open pancreatic resection based on the individual surgeon (median odds ratio = 3.27, 95% confidence interval 2.98–3.56). Patients who underwent pancreatectomy by a low-volume, minimally invasive pancreatic resection surgeon had higher odds of 90-day mortality after surgery (odds ratio = 1.33, 95% confidence interval: 1.16–1.59), as well as higher observed/expected mortality compared with individuals treated by high-volume surgeons.ConclusionThe likelihood of undergoing minimally invasive pancreatic resection among Medicare beneficiaries was markedly influenced by the individual treating surgeon rather than patient- or procedure-level factors.