Randy L. Jensen, Gmaan Alzhrani, John R. W. Kestle, Douglas L. Brockmeyer, Sara M. Lamb and William T. Couldwell
Jian Guan, Michael Karsy, Andrea A. Brock, William T. Couldwell, John R. W. Kestle, Randy L. Jensen, Andrew T. Dailey, Erica F. Bisson and Richard H. Schmidt
Overlapping surgery remains a controversial topic in the medical community. Although numerous studies have examined the safety profile of overlapping operations, there are few data on its financial impact. The authors assessed direct hospital costs associated with neurosurgical operations during periods before and after a more stringent overlapping surgery policy was implemented.
The authors retrospectively reviewed the records of nonemergency neurosurgical operations that took place during the periods from June 1, 2014, to October 31, 2014 (pre–policy change), and from June 1, 2016, to October 31, 2016 (post–policy change), by any of the 4 senior neurosurgeons authorized to perform overlapping cases during both periods. Cost data as well as demographic, surgical, and hospitalization-related variables were obtained from an institutional tool, the Value-Driven Outcomes database.
A total of 625 hospitalizations met inclusion criteria for cost analysis; of these, 362 occurred prior to the policy change and 263 occurred after the change. All costs were reported as a proportion of the average total hospitalization cost for the entire cohort. There was no significant difference in mean total hospital costs between the prechange and postchange period (0.994 ± 1.237 vs 1.009 ± 0.994, p = 0.873). On multivariate linear regression analysis, neither the policy change (p = 0.582) nor the use of overlapping surgery (p = 0.273) was significantly associated with higher total hospital costs.
A more restrictive overlapping surgery policy was not associated with a reduction in the direct costs of hospitalization for neurosurgical procedures.
Jian Guan, Andrea A. Brock, Michael Karsy, William T. Couldwell, Meic H. Schmidt, John R. W. Kestle, Randy L. Jensen, Andrew T. Dailey and Richard H. Schmidt
Overlapping surgery—the performance of parts of 2 or more surgical procedures at the same time by a single lead surgeon—has recently come under intense scrutiny, although data on the effects of overlapping procedures on patient outcomes are lacking. The authors examined the impact of overlapping surgery on complication rates in neurosurgical patients.
The authors conducted a retrospective review of consecutive nonemergent neurosurgical procedures performed during the period from May 12, 2014, to May 12, 2015, by any of 5 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Overlapping surgery was defined as any case in which 2 patients under the care of a single lead surgeon were under anesthesia at the same time for any duration. Information on patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed. Primary outcome was the occurrence of any complication from the beginning of surgery to 30 days after discharge. A secondary outcome was the occurrence of a serious complication—defined as a life-threatening or life-ending event—during this same period.
One thousand eighteen patients met the inclusion criteria for the study. Of these patients, 475 (46.7%) underwent overlapping surgery. Two hundred seventy-one patients (26.6%) experienced 1 or more complications, with 134 (13.2%) suffering a serious complication. Fourteen patients in the cohort died, a rate of 1.4%. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%, p = 0.837), nor was the rate of serious complications (14.7% vs 11.8%, p = 0.168). After adjustments for surgery type, surgery duration, body mass index, American Society of Anesthesiologists (ASA) physical classification grade, and intraoperative blood loss, overlapping surgery remained unassociated with overall complications (OR 0.810, 95% CI 0.592–1.109, p = 0.189). Similarly, after adjustments for surgery type, surgery duration, body mass index, ASA grade, and neurological comorbidity, there was no association between overlapping surgery and serious complications (OR 0.979, 95% CI 0.661–1.449, p = 0.915).
In this cohort, patients undergoing overlapping surgery did not have an increased risk for overall complications or serious complications. Although this finding suggests that overlapping surgery can be performed safely within the appropriate framework, further investigation is needed in other specialties and at other institutions.
James K. Liu, Michael S. Tenner, Oren N. Gottfried, Edwin A. Stevens, Joshua M. Rosenow, Neel Madan, Joel D. Macdonald, John R. W. Kestle and William T. Couldwell
Object. Cerebral vasospasm that is caused by aneurysmal subarachnoid hemorrhage and that is refractory to maximal medical management can be treated with selective intraarterial papaverine infusions. The effects of single papaverine treatments on cerebral circulation time are well known. The purpose of this study was to assess the efficacy of multiple, repeated papaverine infusions on the cerebral circulation time in patients with recurrent vasospasm.
Methods. A retrospective study was conducted in 17 patients who received multiple intraarterial papaverine infusions in 91 carotid artery (CA) territories for the treatment of cerebral vasospasm. Cerebral circulation times were measured from the first angiographic image, in which peak contrast was seen above the supraclinoid internal CA, to the peak filling of cortical veins. Glasgow Outcome Scale (GOS) scores assessed 12 months after discharge were reviewed. Cerebral circulation times in 16 CA territories were measured in a control group of 11 patients.
Seventeen patients received a total of 91 papaverine treatments. Prolonged cerebral circulation times improved after 90 (99%) of 91 papaverine treatments. The prepapaverine mean cerebral circulation time was 6.54 seconds (range 3.35–27 seconds) and the immediate postpapaverine mean cerebral circulation time was 4.19 seconds (range 2.1–12.6 seconds), an overall mean decrease of 2.35 seconds (36%, p < 0.001). Recurrent vasospasm reflected by prolonged cerebral circulation times continued to improve with subsequent papaverine infusions. Repeated infusions were just as successful quantitatively as the primary treatment (mean change 2.06 seconds). The mean cerebral circulation time in the control group was 5.21 seconds (range 4–6.8 seconds). In five patients a dramatic reversal of low-attenuation changes was detected on computerized tomography scans. The mean GOS score at 12 months after discharge was 3.4.
Conclusions. The preliminary results indicate that multiple intraarterial papaverine treatments consistently improve cerebral circulation times, even with repeated infusions in cases of recurrent vasospasm.
Jian Guan, Michael Karsy, Andrea A. Brock, William T. Couldwell, John R. W. Kestle, Randy L. Jensen, Andrew T. Dailey and Richard H. Schmidt
Recently, overlapping surgery has been a source of controversy both in the popular press and within the academic medical community. There have been no studies examining the possible effects of more stringent overlapping surgery restrictions. At the authors’ institution, a new policy was implemented that restricts attending surgeons from starting a second case until all critical portions of the first case that could require the attending surgeon’s involvement are completed. The authors examined the impact of this policy on complication rates, neurosurgical resident education, and wait times for neurosurgical procedures.
The authors performed a retrospective chart review of nonemergency neurosurgical procedures performed over two periods—from June 1, 2014, to October 31, 2014 (pre–policy change) and from June 1, 2016, to October 31, 2016 (post–policy change)—by any of 4 senior neurosurgeons at a single institution who were authorized to schedule overlapping cases. Information on preoperative evaluation, patient demographics, premorbid conditions, surgical variables, and postoperative course were collected and analyzed.
Six hundred fifty-three patients met inclusion criteria for complications analysis. Of these, 378 (57.9%) underwent surgery before the policy change. On multivariable regression analysis, neither overlapping surgery (odds ratio [OR] 1.072, 95% confidence interval [CI] 0.710–1.620) nor the overlapping surgery policy change (OR 1.057, 95% CI 0.700–1.596) was associated with overall complication rates. Similarly, neither overlapping surgery (OR 1.472, 95% CI 0.883–2.454) nor the overlapping surgery policy change (OR 1.251, 95% CI 0.748–2.091) was associated with numbers of serious complications. After the policy change, the percentage of procedures in which the senior assistant was a postresidency fellow increased significantly, from 11.9% to 34.2% (p < 0.001). In a multiple linear regression analysis of surgery wait times, patients undergoing surgery after the policy change had significantly longer delays from the decision to operate until the actual neurosurgical procedure (p < 0.001).
At the authors’ institution, further restriction of overlapping surgery was not associated with a reduction in overall or serious complications. Resident involvement in neurosurgical procedures decreased significantly after the policy change, and this study suggests that wait times for neurosurgical procedures also significantly lengthened.
Michael Karsy, Fraser Henderson Jr., Steven Tenny, Jian Guan, Jeremy W. Amps, Allan H. Friedman, Alejandro M. Spiotta, Sunil Patel, John R. W. Kestle, Randy L. Jensen and William T. Couldwell
The analysis of resident research productivity in neurosurgery has gained significant recent interest. Resident scholarly output affects departmental productivity, recruitment of future residents, and likelihood of future research careers. To maintain and improve opportunities for resident research, the authors evaluated factors that affect resident attitudes toward neurosurgical research on a national level.
An online survey was distributed to all US neurosurgical residents. Questions assessed interest in research, perceived departmental support of research, and resident-perceived limitations in pursuing research. Residents were stratified based on number of publications above the median (AM; ≥ 14) or below the median (BM; < 14) for evaluation of factors influencing productivity.
A total of 278 resident responses from 82 US residency programs in 30 states were included (a 20% overall response rate). Residents predominantly desired future academic positions (53.2%), followed by private practice with some research (40.3%). Residents reported a mean ± SD of 11 ± 14 publications, which increased with postgraduate year level. The most common type of research involved retrospective cohort studies (24%) followed by laboratory/benchtop (19%) and case reports (18%). Residents as a group spent on average 14.1 ± 18.5 hours (median 7.0 hours) a week on research. Most residents (53.6%) had ≥ 12 months of protected research time. Mentorship (92.4%), research exposure (89.9%), and early interest in science (78.4%) had the greatest impact on interest in research while the most limiting factors were time (91.0%), call scheduling (47.1%), and funding/grants (37.1%). AM residents cited research exposure (p = 0.003), neurosurgery conference exposure (p = 0.02), formal research training prior to residency (p = 0.03), internal funding sources (p = 0.05), and software support (p = 0.02) as most important for their productivity. Moreover, more productive residents applied and received a higher number of < $10,000 and ≥ $10,000 grants (p < 0.05). A majority of residents (82.4%) agreed or strongly agreed with pursuing research throughout their professional careers. Overall, about half of residents (49.6%) were encouraged toward continued neurosurgical research, while the rest were neutral (36.7%) or discouraged (13.7%). Free-text responses helped to identify solutions on a departmental, regional, and national level that could increase interest in neurosurgical research.
This survey evaluates various factors affecting resident views toward research, which may also be seen in other specialties. Residents remain enthusiastic about neurosurgical research and offer several solutions to the ever-scarce commodities of time and funding within academic medicine.