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Kimon Bekelis, Symeon Missios, Shannon Coy and Jeremiah N. Johnson

OBJECTIVE

The accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion.

METHODS

The authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons.

RESULTS

During the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72–1.31), length of stay (adjusted difference −0.1, 95% CI −0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49–1.55), and hospitalization charges (adjusted difference $18,735, 95% CI −$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score–adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients.

CONCLUSIONS

After merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.

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Symeon Missios and Kimon Bekelis

OBJECTIVE

Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.

METHODS

A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.

RESULTS

Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

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Symeon Missios and Kimon Bekelis

OBJECTIVE

The accuracy of public reporting in health care is an issue of debate. The authors investigated the association of patient satisfaction measures from a public reporting platform with objective outcomes for patients undergoing spine surgery.

METHODS

The authors performed a cohort study involving patients undergoing elective spine surgery from 2009 to 2013 who were registered in the New York Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. A mixed-effects regression analysis, controlling for clustering at the hospital level, was used to investigate the association of patient satisfaction metrics with outcomes.

RESULTS

During the study period, 160,235 patients underwent spine surgery. Using a mixed-effects multivariable regression analysis, the authors demonstrated that undergoing elective spine surgery in hospitals with a higher percentage of patient-assigned high satisfaction scores was not associated with a decreased rate of discharge to rehabilitation (OR 0.77, 95% CI 0.57–1.06), mortality (OR 0.96, 95% CI 0.90–1.01), or hospitalization charges (β 0.04, 95% CI −0.16 to 0.23). However, it was associated with decreased length of stay (LOS; β −0.19, 95% CI −0.33 to −0.05). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others.

CONCLUSIONS

Merging a comprehensive all-payer cohort of spine surgery patients in New York state with data from the CMS Hospital Compare website, the authors were not able to demonstrate an association of improved performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, and hospitalization charges. Increased patient satisfaction was associated with decreased LOS.

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Kimon Bekelis, Symeon Missios and Robert J. Spinner

OBJECT

Despite the growing epidemic of falls, the true incidence of peripheral nerve injuries (PNIs) in this patient population remains largely unknown.

METHODS

The authors performed a retrospective cohort study of 839,210 fall-injured patients who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011 and fulfilled the inclusion criteria. Regression techniques were used to investigate the association of demographic and socioeconomic factors with the rate of PNIs in this patient population. The association of age with the incidence of PNIs was also investigated.

RESULTS

Overall, 3151 fall-injured patients (mean age 39.1 years, 33.3% females) sustained a PNI (0.4% of all falls). The respective incidence of PNIs was 2.7 per 1000 patients for ground-level falls, 4.9 per 1000 patients for multilevel falls, and 4.5 per 1000 patients for falls involving force. This demonstrated a rapid increase in the first 2 decades of life, with a maximum rate of 1.1% of all falls in the 3rd decade, followed by a slower decline and eventual plateau in the 7th decade. In a multivariable analysis, the association of PNIs with age followed a similar pattern with patients 20–29 years of age, demonstrating the highest association (OR 2.34 [95% CI 2.0–2.74] in comparison with the first decade of life). Falls involving force (OR 1.25 [95% CI 1.14–1.37] in comparison with multilevel falls) were associated with a higher incidence of PNIs. On the contrary, female sex (OR 0.87 [95% CI 0.80–0.84]) and ground-level falls (OR 0.79 [95% CI 0.72–0.86]) were associated with a lower rate of PNIs.

CONCLUSIONS

Utilizing a comprehensive national database, the authors demonstrated that PNIs are more common than previously described in fall-injured patients and identified their age distribution. These injuries are associated with young adults and falls of high kinetic energy.

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Symeon Missios, Kimon Bekelis and Gene H. Barnett

Laser interstitial thermal therapy (LITT) is a minimally invasive technique for treating intracranial tumors, originally introduced in 1983. Its use in neurosurgical procedures was historically limited by early technical difficulties related to the monitoring and control of the extent of thermal damage. The development of magnetic resonance thermography and its application to LITT have allowed for real-time thermal imaging and feedback control during laser energy delivery, allowing for precise and accurate provision of tissue hyperthermia. Improvements in laser probe design, surgical stereotactic targeting hardware, and computer monitoring software have accelerated acceptance and clinical utilization of LITT as a neurosurgical treatment alternative. Current commercially available LITT systems have been used for the treatment of neurosurgical soft-tissue lesions, including difficult to access brain tumors, malignant gliomas, and radiosurgery-resistant metastases, as well as for the ablation of such lesions as epileptogenic foci and radiation necrosis. In this review, the authors aim to critically analyze the literature to describe the advent of LITT as a neurosurgical, laser excision tool, including its development, use, indications, and efficacy as it relates to neurosurgical applications.

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Symeon Missios, Kimon Bekelis and Robert J. Spinner

Object

Despite the negative effects of peripheral nerve injuries (PNIs) on long-term population health, their true prevalence among pediatric trauma patients is under debate. The authors investigated the prevalence of PNIs among children involved in trauma and investigated associations between PNIs and several patient characteristics.

Methods

The authors performed a retrospective cohort study of pediatric trauma patients who were registered in the National Trauma Data Bank from 2009 through 2011 and who fulfilled the study inclusion criteria. They used regression techniques to investigate the association of demographic and socioeconomic factors with the rate of PNIs among these patients.

Results

Of the 245,470 study patients, 50,211 were involved in motor vehicle crashes, 3380 in motorcycle crashes, 20,491 in bicycle crashes, 18,262 in pedestrian accidents, 26,294 in other crashes (mainly involving all-terrain vehicles and snowmobiles), and 126,832 in falls. The respective prevalence of PNIs was 0.66% for motor vehicle crashes, 1% for motorcycle crashes, 0.38% for bicycle crashes, 0.42% for pedestrian accidents, 0.79% for other crashes, and 0.52% for falls. Multivariate logistic regression analysis demonstrated that the following were associated with an increased incidence of PNIs: increased patient age (OR 1.10, 95% CI 1.01–1.20), higher Injury Severity Score (OR 1.10, 95% CI 1.01–1.20), elevated systolic blood pressure at arrival at the emergency room (OR 1.10, 95% CI 1.01–1.20), and increased number of trauma surgeons at the institution (OR 1.10, 95% CI 1.01–1.20). The following were associated with lower incidence of PNIs: female sex (OR 0.94, 95% CI 0.87–1.02), rural hospitals (OR 0.94, 95% CI 0.87–1.02), and urban nonteaching hospitals (OR 0.94, 95% CI 0.87–1.02).

Conclusions

PNIs are more common than previously identified for the pediatric trauma population. These injuries are associated with older age and increased severity of the overall injury.

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Symeon Missios, Kimon Bekelis, Gasser Al-Shyal, Peter A. Rasmussen and Gene H. Barnett

Object

The appropriate dose during stereotactic radiosurgery (SRS) of cerebral arteriovenous malformations (AVMs) remains a matter of debate. In the present study, the authors retrospectively evaluated the association of using a prescribed dose calculated utilizing the K index with the obliteration rate of cerebral AVMs after SRS.

Methods

The authors performed a retrospective analysis of the Cleveland Clinic SRS database. All patients undergoing Gamma Knife radiosurgery for cerebral AVMs from 1997 to 2010 were selected. Regression techniques and Kaplan-Meier analyses were used to investigate the effect of divergence from the optimal K index dose on the rate of AVM obliteration.

Results

In the study period 152 patients (mean age 43.6 years; 53.9% of treatments were performed in females) underwent 165 Gamma Knife radiosurgery treatments for AVMs. In a univariate analysis Spetzler-Martin grade (OR 0.63 [95% CI 0.42–0.93]), higher AVM score (OR 0.43 [95% CI 0.27–0.70]), larger AVM volume (OR 0.88 [95% CI 0.82–0.94]), and higher maximum diameter (OR 0.56 [95% CI 0.41–0.77]) were associated with a lower rate of AVM obliteration. Higher margin dose (OR 1.16 [95% CI 1.08–1.24]) and higher maximum dose (OR 1.08 [95% CI 1.04–1.13]) were associated with a higher obliteration rate. To further examine the effect of prescribed dose divergence from the calculated K index dose, cases were classified to groups depending on the AVM volume and dose variance from the ideal K index dose. Contingency tables and Kaplan-Meier curves were then created, and no significant differences in rates of obliteration were noted among the different groups.

Conclusions

Gamma Knife radiosurgery for cerebral AVMs remains an effective and safe treatment modality. Smaller AVMs may receive doses less than the calculated K index dose without an apparent effect on obliteration rates.

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Kimon Bekelis, Symeon Missios, Todd A. MacKenzie, Atman Desai, Adina Fischer, Nicos Labropoulos and David W. Roberts

Object

Precise delineation of individualized risks of morbidity and mortality is crucial in decision making in cerebrovascular neurosurgery. The authors attempted to create a predictive model of complications in patients undergoing cerebral aneurysm clipping (CAC).

Methods

The authors performed a retrospective cohort study of patients who had undergone CAC in the period from 2005 to 2009 and were registered in the Nationwide Inpatient Sample (NIS) database. A model for outcome prediction based on preoperative individual patient characteristics was developed.

Results

Of the 7651 patients in the NIS who underwent CAC, 3682 (48.1%) had presented with unruptured aneurysms and 3969 (51.9%) with subarachnoid hemorrhage. The respective inpatient postoperative risks for death, unfavorable discharge, stroke, treated hydrocephalus, cardiac complications, deep vein thrombosis, pulmonary embolism, and acute renal failure were 0.7%, 15.3%, 5.3%, 1.5%, 1.3%, 0.6%, 2.0%, and 0.1% for those with unruptured aneurysms and 11.5%, 52.8%, 5.5%, 39.2%, 1.7%, 2.8%, 2.7%, and 0.8% for those with ruptured aneurysms. Multivariate analysis identified risk factors independently associated with the above outcomes. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated using the area under the receiver operating characteristic curve, and it was found to have good discrimination.

Conclusions

The featured model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and can potentially be used as an adjunct in decision making in cerebrovascular neurosurgery.

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Symeon Missios, Kimon Bekelis and David W. Roberts

Paul of Aegina (625–690 AD) was born on the island of Aegina and was one of the most prominent physician-writers of the Byzantine Empire. His work Epitome of Medicine, comprised of 7 books, was a comprehensive compendium of the medical and surgical knowledge of his time and was subsequently translated into multiple languages. Paul of Aegina made valuable contributions to neurosurgical subjects and described procedures for the treatment of nerve injuries, hydrocephalus, and fractures of the skull and spine. His work combined the ancient knowledge of Hippocrates and Galen with contemporary medical observations and served as a bridge between Byzantine and Arabic medicine. He is considered to be one of the great ancient Greek medical writers and his work has influenced the subsequent evolution of Western European and Arab medicine. This paper provides an account of his contribution to the management of neurosurgical pathologies during the Byzantine era, as described in his medical compendium, Epitome of Medicine.