Unchanged safety outcomes in deep brain stimulation surgery for Parkinson disease despite a decentralization of care

Clinical article

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Object

Early work on deep brain stimulation (DBS) surgery, when procedures were mostly carried out in a small number of high-volume centers, demonstrated a relationship between surgical volume and procedural safety. However, over the past decade, DBS has become more widely available in the community rather than solely at academic medical centers. The authors examined the Nationwide Inpatient Sample (NIS) to study the safety of DBS surgery for Parkinson disease (PD) in association with this change in practice patterns.

Methods

The NIS is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified patients with a primary diagnosis of PD (332.0) and a primary procedure code for implantation/replacement of intracranial neurostimulator leads (02.93) who underwent surgery between 2002 and 2009. They analyzed outcomes using univariate and hierarchical, logistic regression analyses.

Results

The total number of DBS cases remained stable from 2002 through 2009. Despite older and sicker patients undergoing DBS, procedural safety (rates of non-home discharges, complications) remained stable. Patients at low-volume hospitals were virtually indistinguishable from those at high-volume hospitals, except that patients at low-volume hospitals had slightly higher comorbidity scores (0.90 vs 0.75, p < 0.01). Complications, non-home discharges, length of hospital stay, and mortality rates did not significantly differ between low- and high-volume hospitals when accounting for hospital-related variables (caseload, teaching status, location).

Conclusions

Prior investigations have demonstrated a robust volume-outcome relationship for a variety of surgical procedures. However, the present study supports safety of DBS at smaller-volume centers. Prospective studies are required to determine whether low-volume centers and higher-volume centers have similar DBS efficacy, a critical factor in determining whether DBS is comparable between centers.

Abbreviations used in this paper:CI = confidence interval; DBS = deep brain stimulation; HCUP = Healthcare Cost and Utilization Project; ICD-9 = International Classification of Diseases, 9th edition; LOS = length of stay; NIS = Nationwide Inpatient Sample; OR = odds ratio; PD = Parkinson disease.

Article Information

Address correspondence to: Robert A. McGovern, M.D., Department of Neurological Surgery, Neurological Institute, Columbia University Medical Center, 710 West 168th St., New York, NY 10032. email: ram2140@columbia.edu.

Please include this information when citing this paper: published online September 27, 2013; DOI: 10.3171/2013.8.JNS13475.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Total number of discharges for patients treated with DBS for PD between 2002 and 2009.

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    Mean age in years and modified comorbidity score of patients discharged after DBS surgery for PD between 2002 and 2009.

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    Yearly caseload at the hospital of discharge for patients treated with with DBS for PD between 2002 and 2009.

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    Percentage of non-home discharges for patients treated with DBS for PD between 2002 and 2009. Non-home discharges exclude routine discharges and discharges including home health care.

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    Percentage of discharges for patients treated with DBS for PD with any complication between 2002 and 2009. Complications include hematoma complicating a procedure, hemorrhage, infarction, infectious complications related to a mechanical device, mechanical complications related to a neurological device, lead removal, and urinary tract infections.

  • View in gallery

    Average LOS for patients discharged after DBS surgery for PD between 2002 and 2009.

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