The impact of patient age and comorbidities on the occurrence of “never events” in cerebrovascular surgery: an analysis of the Nationwide Inpatient Sample

Clinical article

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Object

As health care administrators focus on patient safety and cost-effectiveness, methodical assessment of quality outcome measures is critical. In 2008 the Centers for Medicare and Medicaid Services (CMS) published a series of “never events” that included 11 hospital-acquired conditions (HACs) for which related costs of treatment are not reimbursed. Cerebrovascular procedures (CVPs) are complex and are often performed in patients with significant medical comorbidities.

Methods

This study examines the impact of patient age and medical comorbidities on the occurrence of CMS-defined HACs, as well as the effect of these factors on the length of stay (LOS) and hospitalization charges in patients undergoing common CVPs.

Results

The HACs occurred at a frequency of 0.49% (1.33% in the intracranial procedures and 0.33% in the carotid procedures). Falls/trauma (n = 4610, 72.3% HACs, 357 HACs per 100,000 CVPs) and catheter-associated urinary tract infections (n = 714, 11.2% HACs, 55 HACs per 100,000 CVPs) were the most common events. Age and the presence of ≥ 2 comorbidities were strong independent predictors of HACs (p < 0.0001). The occurrence of HACs negatively impacts both LOS and hospital costs. Patients with at least 1 HAC were 10 times more likely to have prolonged LOS (≥ 90th percentile) (p < 0.0001), and 8 times more likely to have high inpatient costs (≥ 90th percentile) (p < 0.0001) when adjusting for patient and hospital factors.

Conclusions

Improved quality protocols focused on individual patient characteristics might help to decrease the frequency of HACs in this high-risk population. These data suggest that risk adjustment according to underlying patient factors may be warranted when considering reimbursement for costs related to HACs in the setting of CVPs.

Abbreviations used in this paper:AHRQ = Agency for Healthcare Research and Quality; AVM = arteriovenous malformation; CAS = carotid artery stenting; CEA = carotid endarterectomy; CMS = Centers for Medicaid and Medicare Services; CVP = cerebrovascular procedure; EC-IC = extracranial-intracranial; HAC = hospital-acquired condition; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LOS = length of stay; NIS = Nationwide Inpatient Sample; UTI = urinary tract infection.
Article Information

Contributor Notes

Address correspondence to: Shuhan He, B.S., Keck School of Medicine of USC, 1200 North State St., Ste. 5046, Los Angeles, CA 90089. email: Shuhanhe@usc.edu.Please include this information when citing this paper: published online June 27, 2014; DOI: 10.3171/2014.4.JNS131253.

© AANS, except where prohibited by US copyright law.

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References
  • 1

    AbuRahma AFStone PASrivastava MHass SMMousa AYDean LS: The effect of surgeon's specialty and volume on the perioperative outcome of carotid endarterectomy. J Vasc Surg 58:6666722013

    • Search Google Scholar
    • Export Citation
  • 2

    Adamczyk PAttenello FWen GHe SRussin JSanossian N: Mechanical thrombectomy in acute stroke: utilization variances and impact of procedural volume on inpatient mortality. J Stroke Cerebrovasc Dis 22:126312692013

    • Search Google Scholar
    • Export Citation
  • 3

    Aizawa HAzuma NKatayama THasebe NInaba MSasajima T: Cerebrovascular disease and intracranial artery stenosis in patients with symptomatic peripheral artery disease. J Stroke Cerebrovasc Dis 21:8258312012

    • Search Google Scholar
    • Export Citation
  • 4

    Alaraj AWallace AMander NAletich VCharbel FTAmin-Hanjani S: Outcome following symptomatic cerebral vasospasm on presentation in aneurysmal subarachnoid hemorrhage: coiling vs. clipping. World Neurosurg 74:1381422010

    • Search Google Scholar
    • Export Citation
  • 5

    Allman RMGoode PSBurst NBartolucci AAThomas DR: Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care 12:22301999

    • Search Google Scholar
    • Export Citation
  • 6

    Amin-Hanjani SButler WEOgilvy CSCarter BSBarker FG II: Extracranial-intracranial bypass in the treatment of occlusive cerebrovascular disease and intracranial aneurysms in the United States between 1992 and 2001: a population-based study. J Neurosurg 103:7948042005

    • Search Google Scholar
    • Export Citation
  • 7

    Barker FG IIAmin-Hanjani SButler WEHoh BLRabinov JDPryor JC: Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996–2000. Neurosurgery 54:18302004

    • Search Google Scholar
    • Export Citation
  • 8

    Berman MFSolomon RAMayer SAJohnston SCYung PP: Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke 34:220022072003

    • Search Google Scholar
    • Export Citation
  • 9

    Brinjikji WLanzino GRabinstein AAKallmes DFCloft HJ: Age-related trends in the treatment and outcomes of ruptured cerebral aneurysms: a study of the nationwide inpatient sample 2001–2009. AJNR Am J Neuroradiol 34:102210272013

    • Search Google Scholar
    • Export Citation
  • 10

    Brott TGHobson RW IIHoward GRoubin GSClark WMBrooks W: Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 363:11232010

    • Search Google Scholar
    • Export Citation
  • 11

    Calvillo-King LXuan LZhang STuhrim SHalm EA: Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: derivation and validation of a clinical risk score. Stroke 41:278627942010

    • Search Google Scholar
    • Export Citation
  • 12

    Centers for Medicare and Medicaid Services: Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals Fact Sheet Washington, DCDepartment of Health and Human Services2012

    • Search Google Scholar
    • Export Citation
  • 13

    Chung RYCarter BSNorbash ABudzik RPutnam COgilvy CS: Management outcomes for ruptured and unruptured aneurysms in the elderly. Neurosurgery 47:8278332000

    • Search Google Scholar
    • Export Citation
  • 14

    Cowan JA JrDimick JBWainess RMUpchurch GR JrThompson BG: Outcomes after cerebral aneurysm clip occlusion in the United States: the need for evidence-based hospital referral. J Neurosurg 99:9479522003

    • Search Google Scholar
    • Export Citation
  • 15

    Davies JMYanamadala VLawton MT: Comparative effectiveness of treatments for cerebral arteriovenous malformations: trends in nationwide outcomes from 2000 to 2009. Neurosurg Focus 33:1E112012

    • Search Google Scholar
    • Export Citation
  • 16

    Eslami MHMcPhee JTSimons JPSchanzer AMessina LM: National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 53:3073152011

    • Search Google Scholar
    • Export Citation
  • 17

    Fargen KMRahman MNeal DHoh BL: Prevalence of patient safety indicators and hospital-acquired conditions in those treated for unruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database. Clinical article. J Neurosurg 119:9669732013

    • Search Google Scholar
    • Export Citation
  • 18

    Fleischmann KEGoldman LYoung BLee TH: Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay. Am J Med 115:5155202003

    • Search Google Scholar
    • Export Citation
  • 19

    Frontera JAFernandez AClaassen JSchmidt MSchumacher HCWartenberg K: Hyperglycemia after SAH: predictors, associated complications, and impact on outcome. Stroke 37:1992032006

    • Search Google Scholar
    • Export Citation
  • 20

    Goldstein LBSamsa GPMatchar DBHorner RD: Charlson Index comorbidity adjustment for ischemic stroke outcome studies. Stroke 35:194119452004

    • Search Google Scholar
    • Export Citation
  • 21

    Haines TPLee DCO'Connell BMcDermott FHoffmann T: Why do hospitalized older adults take risks that may lead to falls?. Health Expect 29:120262012

    • Search Google Scholar
    • Export Citation
  • 22

    Halm EATuhrim SWang JJRockman CRiles TSChassin MR: Risk factors for perioperative death and stroke after carotid endarterectomy: results of the New York Carotid Artery Surgery Study. Stroke 40:2212292009

    • Search Google Scholar
    • Export Citation
  • 23

    Hannan ELPopp AJTranmer BFuestel PWaldman JShah D: Relationship between provider volume and mortality for carotid endarterectomies in New York state. Stroke 29:229222971998

    • Search Google Scholar
    • Export Citation
  • 24

    Hauck EFWohlfeld BWelch BGWhite JASamson D: Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study. Clinical article. J Neurosurg 109:101210182008

    • Search Google Scholar
    • Export Citation
  • 25

    Heafner LSuda DCasalenuovo NLeach LSErickson VGawlinski A: Development of a tool to assess risk for falls in women in hospital obstetric units. Nurs Womens Health 17:981072013

    • Search Google Scholar
    • Export Citation
  • 26

    Hoh BLKleinhenz DTChi YYMocco JBarker FG II: Incidence of ventricular shunt placement for hydrocephalus with clipping versus coiling for ruptured and unruptured cerebral aneurysms in the Nationwide Inpatient Sample database: 2002 to 2007. World Neurosurg 76:5485542011

    • Search Google Scholar
    • Export Citation
  • 27

    Joice GADeibert CMKates MSpencer BAMcKiernan JM: “Never events”: Centers for Medicare and Medicaid Services complications after radical cystectomy. Urology 81:5275322013

    • Search Google Scholar
    • Export Citation
  • 28

    Khatri RChaudhry SAVazquez GRodriguez GJHassan AESuri MFK: Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice. J Vasc Surg 55:72782012

    • Search Google Scholar
    • Export Citation
  • 29

    Krishna VWalsh KTurner RDChalela JTurk APatel SJ: Impact of integrated cerebrovascular program on outcomes in patients with intracranial aneurysms. J Neurointerv Surg 5:2642682013

    • Search Google Scholar
    • Export Citation
  • 30

    Latorre JGChou SHNogueira RGSinghal ABCarter BSOgilvy CS: Effective glycemic control with aggressive hyperglycemia management is associated with improved outcome in aneurysmal subarachnoid hemorrhage. Stroke 40:164416522009

    • Search Google Scholar
    • Export Citation
  • 31

    Lee MKDodson TBKarimbux NYNalliah RPAllareddy V: Effect of occurrence of infection-related never events on length of stay and hospital charges in patients undergoing radical neck dissection for head and neck cancer. Oral Surg Oral Med Oral Pathol Oral Radiol 116:1471582013

    • Search Google Scholar
    • Export Citation
  • 32

    McPhee JTSchanzer AMessina LMEslami MH: Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 48:14421450e12008

    • Search Google Scholar
    • Export Citation
  • 33

    Milstein A: Ending extra payment for “never events”—stronger incentives for patients' safety. N Engl J Med 360:238823902009

  • 34

    Morello RTBarker ALHaines TZavarsek SWatts JJHill K: In-hospital falls and fall-related injuries: a protocol for a cost of fall study. Inj Prev 19:3632013

    • Search Google Scholar
    • Export Citation
  • 35

    Morse BCBoland BNBlackhurst DWRoettger RH: Analysis of Centers for Medicaid and Medicare Services ‘never events' in elderly patients undergoing bowel operations. Am Surg 76:8418452010

    • Search Google Scholar
    • Export Citation
  • 36

    Nakai AAkeda MKawabata I: Incidence and risk factors for inpatient falls in an academic acute-care hospital. J Nippon Med Sch 73:2652702006

    • Search Google Scholar
    • Export Citation
  • 37

    Ogilvy CSCarter BS: Stratification of outcome for surgically treated unruptured intracranial aneurysms. Neurosurgery 52:82882003

  • 38

    Pronovost PJGoeschel CAWachter RM: The wisdom and justice of not paying for “preventable complications”. JAMA 299:219721992008

    • Search Google Scholar
    • Export Citation
  • 39

    Rajamani KKennedy KFRuggiero NJRosenfield KSpertus JChaturvedi S: Outcomes of carotid endarterectomy in the elderly: report from the National Cardiovascular Data Registry. Stroke 44:117211742013

    • Search Google Scholar
    • Export Citation
  • 40

    Rohde JMMyers AHVlahov D: Variation in risk for falls by clinical department: implications for prevention. Infect Control Hosp Epidemiol 11:5215241990

    • Search Google Scholar
    • Export Citation
  • 41

    Rosenthal MB: Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med 357:157315752007

  • 42

    Setacci Fde Donato GChisci ESirignano PGalzerano GCastriota F: Economic impact of endarterectomy vs carotid artery stenting: a one year, single centre study. EuroIntervention 3:3403442007

    • Search Google Scholar
    • Export Citation
  • 43

    Siracuse JJOdell DDGondek SPOdom SRKasper EMHauser CJ: Health care and socioeconomic impact of falls in the elderly. Am J Surg 203:3353382012

    • Search Google Scholar
    • Export Citation
  • 44

    Stansbury JPJia HWilliams LSVogel WBDuncan PW: Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes. Stroke 36:3743862005

    • Search Google Scholar
    • Export Citation
  • 45

    Sun BCEmond JACamargo CA Jr: Direct medical costs of syncope-related hospitalizations in the United States. Am J Cardiol 95:6686712005

    • Search Google Scholar
    • Export Citation
  • 46

    Teufack SGCampbell PJabbour PMaltenfort MEvans JRatliff JK: Potential financial impact of restriction in “never event” and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study. Clinical article. J Neurosurg 112:2492562010

    • Search Google Scholar
    • Export Citation
  • 47

    Titsworth WLHester JCorreia TReed RGuin PArchibald L: The effect of increased mobility on morbidity in the neurointensive care unit. Clinical article. J Neurosurg 116:137913882012

    • Search Google Scholar
    • Export Citation
  • 48

    Tutuarima JAvan der Meulen JHde Haan RJvan Straten ALimburg M: Risk factors for falls of hospitalized stroke patients. Stroke 28:2973011997

    • Search Google Scholar
    • Export Citation
  • 49

    Vogel TRDombrovskiy VYGraham AM: Carotid artery stenting in the nation: the influence of hospital and physician volume on outcomes. Vasc Endovascular Surg 44:89942010

    • Search Google Scholar
    • Export Citation
  • 50

    Whitehouse JDFriedman NDKirkland KBRichardson WJSexton DJ: The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 23:1831892002

    • Search Google Scholar
    • Export Citation
  • 51

    Wiebers DOWhisnant JPHuston J IIIMeissner IBrown RD JrPiepgras DG: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:1031102003

    • Search Google Scholar
    • Export Citation
  • 52

    Wimmer NJYeh RWCutlip DEMauri L: Risk prediction for adverse events after carotid artery stenting in higher surgical risk patients. Stroke 43:321832242012

    • Search Google Scholar
    • Export Citation
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