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Jonathan Awori, Jennifer Strahle, Humphrey Okechi and Matthew C. Davis

OBJECTIVE

Pediatric neurosurgery can be highly cost-effective even in the developing world, but delivery of these services is hampered by resource limitations at the levels of both health care infrastructure and individual patients. Few studies have evaluated costs borne by neurosurgical patients in the developing world and their potential implications for efficient and effective delivery of care in this population.

METHODS

The families of 40 pediatric neurosurgery patients were surveyed in February 2015 at the AIC Kijabe Hospital in Kijabe, Kenya. Costs associated with obtaining inpatient care were assessed.

RESULTS

Patient families were charged an average of US $539.44 for neurosurgical services, representing 132% of their annual income. Indirect expenses (transport, food and lodging, lost wages) constituted US $79.37, representing 14.7% of the overall cost and 19.5% of their annual income.

CONCLUSIONS

Expansion of pediatric neurosurgical services throughout the developing world necessitates increased attention to seemingly insignificant expenses that are absorbed by patients and their families. Even when all direct costs are covered at the institutional or national level, without additional assistance, some patients may be too poor to obtain even “free” neurosurgical care.

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Elizabeth N. Kuhn, Matthew C. Davis, Bonita S. Agee, Robert A. Oster and James M. Markert

OBJECT

Handoffs and services changes are potentially modifiable sources of medical error and delays in transition of care. This cohort study assessed the relationship between resident service handoffs and length of stay for neurosurgical patients.

METHODS

All patients admitted to the University of Alabama at Birmingham neurosurgical service between July 1, 2012, and July 1, 2014, were retrospectively identified. A service handoff was defined as any point when a resident handed off coverage of a service for longer than 1 weekend. A conditional probability distribution was constructed to adjust length of stay for the increasing probability of a random handoff. The Student t-test and ANCOVA were used to assess relationships between resident service handoffs and length of hospital stay, adjusted for potential confounders.

RESULTS

A total of 3038 patients met eligibility criteria and were included in the statistical analyses. Adjusted length of hospital stay (5.32 vs 3.53 adjusted days) and length of ICU stay (4.38 vs 2.96 adjusted days) were both longer for patients who experienced a service handoff, with no difference in mortality. In the ANCOVA model, resident service handoff remained predictive of both length of hospital stay (p < 0.001) and length of ICU stay (p < 0.001).

CONCLUSIONS

Occurrence of a resident service handoff is an independent predictor of length of hospital and ICU stay in neurosurgical patients. This finding is novel in the neurosurgical literature. Future research might identify mechanisms for improving continuity of care and mitigating the effect of resident handoffs on patient outcomes.

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Matthew C. Davis, Elizabeth N. Kuhn, Bonita S. Agee, Robert A. Oster and James M. Markert

OBJECTIVE

Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital.

METHODS

The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders.

RESULTS

A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35).

CONCLUSIONS

This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

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Galal Elsayed, Samuel G. McClugage III, Matthew S. Erwood, Matthew C. Davis, Esther B. Dupépé, Paul Szerlip, Beverly C. Walters and Mark N. Hadley

OBJECTIVE

Insurance disparities can have relevant effects on outcomes after elective lumbar spinal surgery. The aim of this study was to evaluate the association between private/public payer status and patient-reported outcomes in adult patients who underwent decompression surgery for lumbar spinal stenosis.

METHODS

A sample of 100 patients who underwent surgery for lumbar spinal stenosis from 2012 to 2014 was evaluated as part of the prospectively collected Quality Outcomes Database at a single institution. Outcome measures were evaluated at 3 months and 12 months, analyzed in regard to payer status (private insurance vs Medicare/Veterans Affairs insurance), and adjusted for potential confounders.

RESULTS

At baseline, patients had similar visual analog scale back and leg pain, Oswestry Disability Index, and EQ-5D scores. At 3 months postintervention, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.11, p < 0.001) and more leg pain (mean difference 1.26, p = 0.05). At 12 months, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.14, p < 0.001). There were no significant differences at 3 months or 12 months between groups for back pain (p = 0.14 and 0.43) or disability (p = 0.19 and 0.15). Across time points, patients in both groups showed improvement at 3 months and 12 months in all 4 functional outcomes compared with baseline (p < 0.001).

CONCLUSIONS

Both private and public insurance patients had significant improvement after elective lumbar spinal surgery. Patients with public insurance had slightly less improvement in quality of life after surgery than those with private insurance but still benefited greatly from surgical intervention, particularly with respect to functional status.

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Matthew C. Davis, Brandon G. Rocque, Ash Singhal, Thomas Ridder, Jogi V. Pattisapu and James M. Johnston Jr.

OBJECTIVE

Neurosurgical services are increasingly recognized as essential components of surgical care worldwide. The degree of interest among neurosurgeons regarding international work, and the barriers to involvement in global neurosurgical outreach, are largely unexplored. The authors distributed a survey to members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Pediatric Neurosurgery to assess the state of global outreach among its members and to identify barriers to involvement.

METHODS

An internet-based questionnaire was developed by the International Education Subcommittee of the AANS/CNS Joint Section on Pediatric Neurosurgery and distributed to pediatric neurosurgeons via the AANS/CNS Joint Section email contact list. Participants were surveyed on their involvement in global neurosurgical outreach, geographic location, nature of the participation, and barriers to further involvement.

RESULTS

A 35.3% response rate was obtained, with 116 respondents completing the survey. Sixty-one percent have performed or taught neurosurgery in a developing country, and 49% travel at least annually. Africa was the most common region (54%), followed by South America (30%), through 29 separate organizing entities. Hydrocephalus was the most commonly treated condition (88%), followed by spinal dysraphism (74%), and tumor (68%). Most respondents obtained follow-up through communications from local surgeons (77%). Seventy-one percent believed the international experience improved their practice, and 74% were very or extremely interested in working elsewhere. Interference with current practice (61%), cost (44%), and difficulty identifying international partners (43%) were the most commonly cited barriers to participation.

CONCLUSIONS

Any coordinated effort to expand global neurosurgical capacity begins with appreciation for the current state of outreach efforts. Increasing participation in global outreach will require addressing both real and perceived barriers to involvement. Creation and curation of a centralized online database of ongoing projects to facilitate coordination and involvement may be beneficial.

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Galal Elsayed, Matthew S. Erwood, Matthew C. Davis, Esther C. Dupépé, Samuel G. McClugage III, Paul Szerlip, Beverly C. Walters and Mark N. Hadley

OBJECTIVE

This study defines the association of preoperative physical activity level with functional outcomes at 3 and 12 months following surgical decompression for lumbar spinal stenosis.

METHODS

Data were collected as a prospective observational registry at a single institution from 2012 through 2015, and then analyzed with a retrospective cohort design. Patients who were able to participate in activities outside the home preoperatively were compared to patients who did not participate in such activities, with respect to 3-month and 12-month functional outcomes postintervention, adjusted for relevant confounders.

RESULTS

Ninety-nine patients were included. At baseline, sedentary/inactive patients (n = 55) reported greater back pain, lower quality of life, and higher disability than similarly treated patients who were active preoperatively. Both cohorts experienced significant improvement from baseline in back pain, leg pain, disability, and quality of life at both 3 and 12 months after lumbar decompression surgery. At 3 months postintervention, sedentary/inactive patients reported more leg pain and worse disability than patients who performed activities outside the home preoperatively. However, at 12 months postintervention, there were no statistically significant differences between the two cohorts in back pain, leg pain, quality of life, or disability. Multivariate analysis revealed that sedentary/inactive patients had improved disability and higher quality of life after surgery compared to baseline. Active patients experienced greater overall improvement in disability compared to inactive patients.

CONCLUSIONS

Sedentary/inactive patients have a more protracted recovery after lumbar decompression surgery for spinal stenosis, but at 12 months postintervention can expect to reach similar long-term outcomes as patients who are active/perform activities outside the home preoperatively.

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Galal Elsayed, Samuel G. McClugage III, Matthew S. Erwood, Matthew C. Davis, Esther B. Dupépé, Paul Szerlip, Beverly C. Walters and Mark N. Hadley

OBJECTIVE

Insurance disparities can have relevant effects on outcomes after elective lumbar spinal surgery. The aim of this study was to evaluate the association between private/public payer status and patient-reported outcomes in adult patients who underwent decompression surgery for lumbar spinal stenosis.

METHODS

A sample of 100 patients who underwent surgery for lumbar spinal stenosis from 2012 to 2014 was evaluated as part of the prospectively collected Quality Outcomes Database at a single institution. Outcome measures were evaluated at 3 months and 12 months, analyzed in regard to payer status (private insurance vs Medicare/Veterans Affairs insurance), and adjusted for potential confounders.

RESULTS

At baseline, patients had similar visual analog scale back and leg pain, Oswestry Disability Index, and EQ-5D scores. At 3 months postintervention, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.11, p < 0.001) and more leg pain (mean difference 1.26, p = 0.05). At 12 months, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.14, p < 0.001). There were no significant differences at 3 months or 12 months between groups for back pain (p = 0.14 and 0.43) or disability (p = 0.19 and 0.15). Across time points, patients in both groups showed improvement at 3 months and 12 months in all 4 functional outcomes compared with baseline (p < 0.001).

CONCLUSIONS

Both private and public insurance patients had significant improvement after elective lumbar spinal surgery. Patients with public insurance had slightly less improvement in quality of life after surgery than those with private insurance but still benefited greatly from surgical intervention, particularly with respect to functional status.

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Galal A. Elsayed, Esther B. Dupépé, Matthew S. Erwood, Matthew C. Davis, Samuel G. McClugage III, Paul Szerlip, Beverly C. Walters and Mark N. Hadley

OBJECTIVE

The goal of this study was to analyze the effect of patient education level on functional outcomes following decompression surgery for symptomatic lumbar spinal stenosis.

METHODS

Patients with surgically decompressed symptomatic lumbar stenosis were collected in a prospective observational registry at a single institution between 2012 and 2014. Patient education level was compared to surgical outcomes to elucidate any relationships. Outcomes were defined using the Oswestry Disability Index score, back and leg pain visual analog scale (VAS) score, and the EuroQol–5 Dimensions questionnaire score.

RESULTS

Of 101 patients with symptomatic lumbar spinal stenosis, 27 had no college education and 74 had a college education (i.e., 2-year, 4-year, or postgraduate degree). Preoperatively, patients with no college education had statistically significantly greater back and leg pain VAS scores when compared to patients with a college education. However, there was no statistically significant difference in quality of life or disability between those with no college education and those with a college education. Postoperatively, patients in both cohorts improved in all 4 patient-reported outcomes at 3 and 12 months after treatment for symptomatic lumbar spinal stenosis.

CONCLUSIONS

Despite their education level, both cohorts showed improvement in their functional outcomes at 3 and 12 months after decompression surgery for symptomatic lumbar spinal stenosis.

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Darryl Lau, Abdulrahman M. El-Sayed, John E. Ziewacz, Priya Jayachandran, Farhan S. Huq, Grettel J. Zamora-Berridi, Matthew C. Davis and Stephen E. Sullivan

Object

Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage.

Methods

A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality.

Results

Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29–25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13–9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status.

Conclusions

The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.

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Dagoberto Estevez-Ordonez, Matthew C. Davis, Betsy Hopson, MSHA, Anastasia Arynchyna, Brandon G. Rocque, Graham Fieggen, Gail Rosseau, Godfrey Oakley, MSPM and Jeffrey P. Blount

Neural tube defects (NTDs) are one of the greatest causes of childhood mortality and disability-adjusted life years worldwide. Global prevalence at birth is approximately 18.6 per 10,000 live births, with more than 300,000 infants with NTDs born every year. Substantial strides have been made in understanding the genetics, pathophysiology, and surgical treatment of NTDs, yet the natural history remains one of high morbidity and profound impairment of quality of life. Direct and indirect costs of care are enormous, which ensures profound inequities and disparities in the burden of disease in countries of low and moderate resources. All indices of disease burden are higher for NTDs in developing countries. The great tragedy is that the majority of NTDs can be prevented with folate fortification of commercially produced food. Unequivocal evidence of the effectiveness of folate to reduce the incidence of NTDs has existed for more than 25 years. Yet, the most comprehensive surveys of effectiveness of implementation strategies show that more than 100 countries fail to fortify, and consequently only 13% of folate-preventable spina bifida is actually prevented. Neurosurgeons harbor a disproportionate, central, and fundamental role in the management of NTDs and enjoy high standing in society. No organized group in medicine can speak as authoritatively or convincingly. As a result, neurosurgeons and organized neurosurgery harbor disproportionate potential to advocate for more comprehensive folate fortification, and thereby prevent the most common and severe birth defect to impact the human nervous system. Assertive, proactive, informed advocacy for folate fortification should be a central and integral part of the neurosurgical approach to NTDs. Only by making the prevention of dysraphism a priority can we best address the inequities often observed worldwide.