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Aladine A. Elsamadicy, Andrew B. Koo, Megan Lee, Adam J. Kundishora, Christopher S. Hong, Astrid C. Hengartner, Joaquin Camara-Quintana, Kristopher T. Kahle, and Michael L. DiLuna

from an average 5.0 to 3.7 days also decreased costs from $18,360 to $23,640 per patient. 18 Thus, finding ways to reduce length of stay while maintaining patient safety would be beneficial in managing rising healthcare costs. Overall, in AIS patients undergoing deformity correction involving 4 or more levels, the influence that affective disorders have on outcomes may not be as impactful in these complicated cases, as they may be for in adults. Nonetheless, understanding how affective disorders affect AIS patients may improve the provider approach in caring for

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Era D. Mikkonen, Markus B. Skrifvars, Matti Reinikainen, Stepani Bendel, Ruut Laitio, Sanna Hoppu, Tero Ala-Kokko, Atte Karppinen, and Rahul Raj

the most severe injuries are admitted to neurosurgical units and ICUs for resource-intensive but potentially lifesaving treatment. There are some data on the cost of ICU-treated pediatric TBI; however, these data usually account for hospital costs only. 5–8 After intensive care, some TBI patients need long rehabilitation periods to regain independence. Little is known about the total healthcare costs of ICU-treated pediatric TBI patients. Finland has a public tax-funded healthcare and social insurance system covering all inhabitants. 9 This system allows for the

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Sebastian Salas-Vega, Vikram B. Chakravarthy, Robert D. Winkelman, Matthew M. Grabowski, Ghaith Habboub, Jason W. Savage, Michael P. Steinmetz, and Thomas E. Mroz

function was used to identify the model that best fit the training data and minimized the cross-validation error term. The best-fitting model was then used to make predictions on test samples and estimate LOS residuals. A final classifier was then estimated by retraining the best-fitting model on the entire data set. Total (direct + indirect) healthcare costs associated with each episode of care were obtained from hospital records and adjusted for inflation (2020 US dollars) by using the producer price index for inpatient services from the US Bureau of Labor Statistics

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


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.


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).


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.


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.

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Marcel R. Wiley, Leah Y. Carreon, Mladen Djurasovic, Steven D. Glassman, Yehia H. Khalil, Michelle Kannapel, and Jeffrey L. Gum

T he Centers for Medicare and Medicaid Services (CMS) has made decreasing hospital readmissions within the 30- to 90-day postoperative period a priority to curb rapidly increasing healthcare costs. From 2003 to 2004, 20% of Medicare patients were readmitted within 30 days of their hospitalization and 34% within 90 days. 1 Around half (51.5%) of the patients who were discharged after elective surgical procedures were readmitted or deceased 1 year after discharge, with total costs to Medicare estimated to be $17.4 billion in 2004. Up to 90% of these visits were

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Ethan A. Winkler, John K. Yue, Hansen Deng, Kunal P. Raygor, Ryan R. L. Phelps, Caleb Rutledge, Alex Y. Lu, Roberto Rodriguez Rubio, Jan-Karl Burkhardt, and Adib A. Abla

-payer hospital-based database, the National (Nationwide) Inpatient Sample (NIS), to characterize national trends in cerebral bypass surgery from 2002 to 2014 in the United States (US). Unlike prior reports, we show that there has been a modest increase in the number of cerebral bypasses performed nationally, a finding largely attributed to a rise in the surgical treatment of moyamoya disease. The changing indications for cerebral vascularization are characterized, and we explore whether these changes influence patient outcomes or the national healthcare costs attributed to

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Kunal Varshneya, Adrian J. Rodrigues, Zachary A. Medress, Martin N. Stienen, Gerald A. Grant, John K. Ratliff, and Anand Veeravagu

characteristics and clinical outcomes of pediatric skull fracture patients with and without CSF leaks, and we longitudinally assessed the healthcare costs associated with the care of these patients. Methods Data Source This study obtained a sample of the MarketScan Commercial Claims and Encounters Database (Truven Health Analytics) from January 1, 2007, to December 31, 2015, inclusive. This database is a collection of commercial inpatient, outpatient, and pharmaceutical claims of more than 75 million employees, retirees, and dependents representing a substantial portion of the

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Katrina Ducis, R. Dianne Seibold, Tylyn Bremer, and Andrew Jea

, including coagulopathy, impaired immune function, suboptimal wound healing capacity, 6 decreased clearance of anesthetic agents, 7 and prolonged hospitalization, 8 thereby increasing healthcare costs. Patients undergoing spine surgery were observed by an operating room nurse to have marked decreased core body temperatures prior to surgery onset. This led to the institution of a nurse-driven quality improvement initiative with the goal of reducing the severity and duration of hypothermia, as defined by a temperature less than 36.0°C prior to the start of the operation

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Timothy J. Yee, Yamaan S. Saadeh, Michael J. Strong, Ayobami L. Ward, Clay M. Elswick, Sudharsan Srinivasan, Paul Park, Mark E. Oppenlander, Daniel E. Spratt, William C. Jackson, and Nicholas J. Szerlip

T he spine is the most common site of osseous metastatic disease, 1 and spinal metastases result in substantial pain, disability, and healthcare costs. 2 , 3 While the benefits of circumferential spinal cord decompression with adjuvant radiotherapy have been well established, 2 , 4–6 those of bony fusion in this population are incompletely understood. In nononcological populations, attainment of solid fusion is associated with superior functional outcomes and lower reoperation rates compared with pseudarthrosis. 7–10 Especially in the absence of fusion

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Predicting nonroutine discharge after elective spine surgery: external validation of machine learning algorithms

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Brittany M. Stopa, Faith C. Robertson, Aditya V. Karhade, Melissa Chua, Marike L. D. Broekman, Joseph H. Schwab, Timothy R. Smith, and William B. Gormley

healthcare costs and improve outcomes and patient satisfaction by reducing length of stay, complications, and readmission rates. While the evidence to support the use of individualized discharge planning has had mixed success, 10 it is clearly possible to improve patient education and patient selection, and to streamline the entire discharge planning process in a standardized manner for certain elective surgical procedures that have a predictable postoperative recovery. Our group, for example, successfully implemented a Transitional Care Program (TCP) for neurosurgical