Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes

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  • 1 School of Medicine, University of Missouri–Kansas City, Missouri;
  • 2 Department of Neurosurgery, Baylor College of Medicine, Houston;
  • 3 Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas;
  • 4 Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
  • 5 Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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OBJECTIVE

Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms.

METHODS

The Nationwide Readmissions Database (NRD) was queried for the years 2010–2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes.

RESULTS

In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1–2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1–1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1–3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction).

CONCLUSIONS

Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.

ABBREVIATIONS EC-IC = extracranial-intracranial; HCUP = Healthcare Cost and Utilization Project; HVC = high-volume center; ICAD = intracranial arteriosclerotic disease; LOS = length of stay; MMD = moyamoya disease; NIS = National Inpatient Sample; NRD = Nationwide Readmissions Database; 30dRA = 1- to 30-day readmission; 90dRA = 1- to 90-day readmission.

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Contributor Notes

Correspondence Jan-Karl Burkhardt: Hospital of the University of Pennsylvania, Philadelphia, PA. jan.burkhardt@pennmedicine.upenn.edu.

INCLUDE WHEN CITING Published online November 6, 2020; DOI: 10.3171/2020.6.JNS202117.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Burkhardt J-K, Lawton MT. Practice trends in intracranial bypass surgery in a 21-year experience. World Neurosurg. 2019;125:e717e722.

    • Search Google Scholar
    • Export Citation
  • 2

    Lawton MT. Seven Bypasses: Tenets and Techniques for Revascularization. Thieme; 2018.

  • 3

    Powers WJ, Clarke WR, Grubb RL Jr, Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA. 2011;306(18):19831992.

    • Search Google Scholar
    • Export Citation
  • 4

    EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med. 1985;313(19):11911200.

    • Search Google Scholar
    • Export Citation
  • 5

    Hoffman H, Protas M, Chin LS. A nationwide analysis of 30-day and 90-day readmissions after elective cerebral aneurysm clipping in the United States: causes, predictors, and trends. World Neurosurg. 2019;128:e873e883.

    • Search Google Scholar
    • Export Citation
  • 6

    Donoho DA, Wen T, Babadjouni RM, Predictors of 30- and 90-day readmission following craniotomy for malignant brain tumors: analysis of nationwide data. J Neurooncol. 2018;136(1):8794.

    • Search Google Scholar
    • Export Citation
  • 7

    Babadjouni R, Wen T, Donoho DA, Increased hospital surgical volume reduces rate of 30- and 90-day readmission after acoustic neuroma surgery. Neurosurgery. 2019;84(3):726732.

    • Search Google Scholar
    • Export Citation
  • 8

    Rumalla K, Smith KA, Arnold PM, Schwartz TH. Readmission following surgical resection for intractable epilepsy: nationwide rates, causes, predictors, and outcomes. Oper Neurosurg (Hagerstown). 2019;16(3):374382.

    • Search Google Scholar
    • Export Citation
  • 9

    Amin-Hanjani S, Butler WE, Ogilvy CS, 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. 2005;103(5):794804.

    • Search Google Scholar
    • Export Citation
  • 10

    Winkler EA, Yue JK, Deng H, National trends in cerebral bypass surgery in the United States, 2002–2014. Neurosurg Focus. 2019;46(2):E4.

    • Search Google Scholar
    • Export Citation
  • 11

    Sun H, Kalakoti P, Sharma K, Proposing a validated clinical app predicting hospitalization cost for extracranial-intracranial bypass surgery. PLoS One. 2017;12(10):e0186758.

    • Search Google Scholar
    • Export Citation
  • 12

    Hoffman H, Protas M, Chin LS. Causes, predictors, and trends of unplanned readmissions after elective endovascular embolization of cerebral aneurysms. J Stroke Cerebrovasc Dis. 2019;28(11):104396.

    • Search Google Scholar
    • Export Citation
  • 13

    Buchanan IA, Donoho DA, Patel A, Predictors of surgical site infection after nonemergent craniotomy: a Nationwide Readmission Database analysis. World Neurosurg. 2018;120:e440e452.

    • Search Google Scholar
    • Export Citation
  • 14

    Koo AB, Elsamadicy AA, David WB, Thirty- and 90-day readmissions after treatment of traumatic subdural hematoma: national trend analysis. World Neurosurg. 2020;139:e212e219.

    • Search Google Scholar
    • Export Citation
  • 15

    Adhikari S, Hossein MZ, Das A, Etiology and outcome of acute intestinal obstruction: a review of 367 patients in Eastern India. Saudi J Gastroenterol. 2010;16(4):285287.

    • Search Google Scholar
    • Export Citation
  • 16

    Janjua N, Nasar A, Lynch JK, Qureshi AI. Thrombolysis for ischemic stroke in children: data from the nationwide inpatient sample. Stroke. 2007;38(6):18501854.

    • Search Google Scholar
    • Export Citation
  • 17

    Tang AM, Bakhsheshian J, Ding L, Nonindex readmission after ruptured brain aneurysm treatment is associated with higher morbidity and repeat readmission. World Neurosurg. 2019;130:e753e759.

    • Search Google Scholar
    • Export Citation
  • 18

    Akbarian-Tefaghi H, Kalakoti P, Sun H, Impact of hospital caseload and elective admission on outcomes after extracranial-intracranial bypass surgery. World Neurosurg. 2017;108:716728.

    • Search Google Scholar
    • Export Citation
  • 19

    Davies JM, Lawton MT. Improved outcomes for patients with cerebrovascular malformations at high-volume centers: the impact of surgeon and hospital volume in the United States, 2000–2009. J Neurosurg. 2017;127(1):6980.

    • Search Google Scholar
    • Export Citation
  • 20

    Kazumata K, Ito M, Tokairin K, The frequency of postoperative stroke in moyamoya disease following combined revascularization: a single-university series and systematic review. J Neurosurg. 2014;121(2):432440.

    • Search Google Scholar
    • Export Citation
  • 21

    Saber H, Rajah G, Palla M, Sheth SA. Utilization and safety of extracranial-intracranial bypass surgery in symptomatic steno-occlusive disorders. Brain Circ. 2019;5(1):3235.

    • Search Google Scholar
    • Export Citation
  • 22

    von Weitzel-Mudersbach P, Andersen G, Rosenbaum S. Low morbidity after extracranial-intracranial bypass operation. The Danish Extracranial-Intracranial Bypass Study: a nationwide survey. Cerebrovasc Dis. 2018;45(5-6):252257.

    • Search Google Scholar
    • Export Citation
  • 23

    Yoon S, Burkhardt J-K, Lawton MT. Long-term patency in cerebral revascularization surgery: an analysis of a consecutive series of 430 bypasses. J Neurosurg. 2018;131(1):8087.

    • Search Google Scholar
    • Export Citation
  • 24

    Nomura S, Yamaguchi K, Ishikawa T, Clinical factors influencing the development of extracranial-intracranial bypass graft for steno-occlusive cerebrovascular disease. Neurosurg Focus. 2019;46(2):E5.

    • Search Google Scholar
    • Export Citation
  • 25

    Takanari K, Araki Y, Okamoto, Operative wound-related complications after cranial revascularization surgeries. J Neurosurg. 2015;123(5):11451150.

    • Search Google Scholar
    • Export Citation
  • 26

    Basu J, Friedman B, Burstin H. Preventable hospitalization and Medicaid managed care: does race matter? J Health Care Poor Underserved. 2006;17(1):101115.

    • Search Google Scholar
    • Export Citation
  • 27

    Wei W, Chen X, Yu J, Li X-Q. Risk factors for postoperative stroke in adults patients with moyamoya disease: a systematic review with meta-analysis. BMC Neurol. 2019;19(1):98.

    • Search Google Scholar
    • Export Citation

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