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Oliver Y. Tang, James S. Yoon, Anna R. Kimata and Michael T. Lawton

OBJECTIVE

Previous research has demonstrated the association between increased hospital volume and improved outcomes for a wide range of neurosurgical conditions, including adult neurotrauma. The authors aimed to determine if such a relationship was also present in the care of pediatric neurotrauma patients.

METHODS

The authors identified 106,146 pediatric admissions for traumatic intracranial hemorrhage (tICH) in the National Inpatient Sample (NIS) for the period 2002–2014 and 34,017 admissions in the National Trauma Data Bank (NTDB) for 2012–2015. Hospitals were stratified as high volume (top 20%) or low volume (bottom 80%) according to their pediatric tICH volume. Then the association between high-volume status and favorable discharge disposition, inpatient mortality, complications, and length of stay (LOS) was assessed. Multivariate regression modeling was used to control for patient demographics, severity metrics, hospital characteristics, and performance of neurosurgical procedures.

RESULTS

In each database, high-volume hospitals treated over 60% of pediatric tICH admissions. In the NIS, patients at high-volume hospitals presented with worse severity metrics and more frequently underwent neurosurgical intervention over medical management (all p < 0.001). After multivariate adjustment, admission to a high-volume hospital was associated with increased odds of a favorable discharge (home or short-term facility) in both databases (both p < 0.001). However, there were no significant differences in inpatient mortality (p = 0.208). Moreover, high-volume hospital patients had lower total complications in the NIS and lower respiratory complications in both databases (all p < 0.001). Although patients at high-volume hospitals in the NTDB had longer hospital stays (β-coefficient = 1.17, p < 0.001), they had shorter stays in the intensive care unit (β-coefficient = 0.96, p = 0.024). To determine if these findings were attributable to the trauma center level rather than case volume, an analysis was conducted with only level I pediatric trauma centers (PTCs) in the NTDB. Similarly, treatment at a high-volume level I PTC was associated with increased odds of a favorable discharge (OR 1.28, p = 0.009), lower odds of pneumonia (OR 0.60, p = 0.007), and a shorter total LOS (β-coefficient = 0.92, p = 0.024).

CONCLUSIONS

Pediatric tICH patients admitted to high-volume hospitals exhibited better outcomes, particularly in terms of discharge disposition and complications, in two independent national databases. This trend persisted when examining level I PTCs exclusively, suggesting that volume alone may have an impact on pediatric neurotrauma outcomes. These findings highlight the potential merits of centralizing neurosurgery and pursuing regionalization policies, such as interfacility transport networks and destination protocols, to optimize the care of children affected by traumatic brain injury.

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Andrew Y. Powers, Mauricio B. Pinto, Oliver Y. Tang, Jia-Shu Chen, Cody Doberstein and Wael F. Asaad

OBJECTIVE

Traumatic intracranial hemorrhage (tICH) is a significant source of morbidity and mortality in trauma patients. While prognostic models for tICH outcomes may assist in alerting clinicians to high-risk patients, previously developed models face limitations, including low accuracy, poor generalizability, and the use of more prognostic variables than is practical. This study aimed to construct a simpler and more accurate method of risk stratification for all tICH patients.

METHODS

The authors retrospectively identified a consecutive series of 4110 patients admitted to their institution’s level 1 trauma center between 2003 and 2013. For each admission, they collected the patient’s sex, age, systolic blood pressure, blood alcohol concentration, antiplatelet/anticoagulant use, Glasgow Coma Scale (GCS) score, Injury Severity Score, presence of epidural hemorrhage, presence of subdural hemorrhage, presence of subarachnoid hemorrhage, and presence of intraparenchymal hemorrhage. The final study population comprised 3564 patients following exclusion of records with missing data. The dependent variable under study was patient death. A k-fold cross-validation was carried out with the best models selected via the Akaike Information Criterion. These models risk stratified the study partitions into grade I (< 1% predicted mortality), grade II (1%–10% predicted mortality), grade III (10%–40% predicted mortality), or grade IV (> 40% predicted mortality) tICH. Predicted mortalities were compared with actual mortalities within grades to assess calibration. Concordance was also evaluated. A final model was constructed using the entire data set. Subgroup analysis was conducted for each hemorrhage type.

RESULTS

Cross-validation demonstrated good calibration (p < 0.001 for all grades) with a mean concordance of 0.881 (95% CI 0.865−0.898). In the authors’ final model, older age, lower blood alcohol concentration, antiplatelet/anticoagulant use, lower GCS score, and higher Injury Severity Score were all associated with greater mortality. Subgroup analysis showed successful stratification for subarachnoid, intraparenchymal, grade II–IV subdural, and grade I epidural hemorrhages.

CONCLUSIONS

The authors developed a risk stratification model for tICH of any GCS score with concordance comparable to prior models and excellent calibration. These findings are applicable to multiple hemorrhage subtypes and can assist in identifying low-risk patients for more efficient resource allocation, facilitate family conversations regarding goals of care, and stratify patients for research purposes. Future work will include testing of more variables, validation of this model across institutions, as well as creation of a simplified model whose outputs can be calculated mentally.

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Oliver Y. Tang, Krissia M. Rivera Perla, Rachel K. Lim, James S. Yoon, Robert J. Weil and Steven A. Toms

OBJECTIVE

Research has documented significant growth in neurosurgical expenditures and practice consolidation. The authors evaluated the relationship between interhospital competition and inpatient charges or costs in patients undergoing cranial neurosurgery.

METHODS

The authors identified all admissions in 2006 and 2009 from the National Inpatient Sample. Admissions were classified into 5 subspecialties: cerebrovascular, tumor, CSF diversion, neurotrauma, or functional. Hospital-specific interhospital competition levels were quantified using the Herfindahl-Hirschman Index (HHI), an economic metric ranging continuously from 0 (significant competition) to 1 (monopoly). Inpatient charges (hospital billing) were multiplied with reported cost-to-charge ratios to calculate costs (actual resource use). Multivariate regressions were used to assess the association between HHI and inpatient charges or costs separately, controlling for 17 patient, hospital, severity, and economic factors. The reported β-coefficients reflect percentage changes in charges or costs (e.g., β-coefficient = 1.06 denotes a +6% change). All results correspond to a standardized −0.1 change in HHI (increase in competition).

RESULTS

In total, 472,938 nationwide admissions for cranial neurosurgery treated at 896 unique hospitals met inclusion criteria. Hospital HHIs ranged from 0.099 to 0.724 (mean 0.298 ± 0.105). Hospitals in more competitive markets had greater charge/cost markups (β-coefficient = 1.10, p < 0.001) and area wage indices (β-coefficient = 1.04, p < 0.001). Between 2006 and 2009, average neurosurgical charges and costs rose significantly ($62,098 to $77,812, p < 0.001; $21,385 to $22,389, p < 0.001, respectively). Increased interhospital competition was associated with greater charges for all admissions (β-coefficient = 1.07, p < 0.001) as well as cerebrovascular (β-coefficient = 1.08, p < 0.001), tumor (β-coefficient = 1.05, p = 0.039), CSF diversion (β-coefficient = 1.08, p < 0.001), neurotrauma (β-coefficient = 1.07, p < 0.001), and functional neurosurgery (β-coefficient = 1.11, p = 0.037) admissions. However, no significant associations were observed between HHI and costs, except for CSF diversion surgery (β-coefficient = 1.03, p = 0.021). Increased competition was not associated with important clinical outcomes, such as inpatient mortality, favorable discharge disposition, or complication rates, except for lower mortality for brain tumors (OR 0.78, p = 0.026), but was related to greater length of stay for all admissions (β-coefficient = 1.06, p < 0.001). For a sensitivity analysis adjusting for outcomes, all findings for charges and costs remained the same.

CONCLUSIONS

Hospitals in more competitive markets exhibited higher charges for admissions of patients undergoing an in-hospital cranial procedure. Despite this, interhospital competition was not associated with increased inpatient costs except for CSF diversion surgery. There was no corresponding improvement in outcomes with increased competition, with the exception of a potential survival benefit for brain tumor surgery.