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Kent D. Yundt, Ralph G. Dacey Jr. and Michael N. Diringer

cerebral aneurysms is one such area. The challenge of health care reform is to reduce expenditures without compromising quality of care. This requires a collaborative effort between the managers of the health care delivery system and the providers of health care. It is important for physicians and other health care providers to participate in reducing health care expenditures because their practice patterns determine use of many resources and because they can best assess the impact of changes in resource utilization on outcome. The first step in a rational approach

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Andrew S. Little, Kristina Chapple, Heidi Jahnke and William L. White

H ealth care resource utilization is becoming an increasingly important metric and health economics concern. Resource utilization is particularly important to study in the context of emerging technologies that gain popularity and begin to replace traditional techniques, such as endoscopic endonasal transsphenoidal surgery. Use of this technique is growing, and over the past decade, many surgeons have been transitioning their practice from microscopic speculum-based approaches to endoscopic approaches. 3 , 6 , 7 , 13 , 14 The endoscopic pituitary approach

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Andrew S. Little and Kristina Chapple

patient during their inpatient epoch, which included radiology, pharmacy, clinical laboratory, pathology, supplies, surgical/operative, anesthesia, room charges, and recovery room/postanesthetic care unit. We analyzed hospital charges in 454 transsphenoidal surgery admissions for Cushing disease performed at 116 nonfederal hospitals from 2007 to 2009 using a national database to gain a better understanding of the predictors of health care resource utilization. We learned that the mean hospital charge was $48,272 ± $32,060 per patient. After accounting for confounders in

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Jonathan Pindrik, Jay Riva-Cambrin, Abhaya V. Kulkarni, Jessica S. Alvey, Ron W. Reeder, Ian F. Pollack, John C. Wellons III, Eric M. Jackson, Curtis J. Rozzelle, William E. Whitehead, David D. Limbrick Jr., Robert P. Naftel, Chevis Shannon, Patrick J. McDonald, Mandeep S. Tamber, Todd C. Hankinson, Jason S. Hauptman, Tamara D. Simon, Mark D. Krieger, Richard Holubkov, John R. W. Kestle and for the Hydrocephalus Clinical Research Network

utilization—the number of surgical revisions and hospital admission days related to surgical management of hydrocephalus—between initial treatment strategies. Conducted by members of the HCRN, this study investigated differences in surgical resource utilization between CSF shunt insertion and ETV with or without CPC as initial treatment strategies for permanent CSF diversion in infant hydrocephalus. Methods This study analyzed prospectively collected data within the HCRN’s Core Data Project (Hydrocephalus Registry). Pediatric patients with a corrected age of 24 months or

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Sara Anne Wilkins, Chevis N. Shannon, Steven T. Brown, E. Haley Vance, Drew Ferguson, Kimberly Gran, Marshall Crowther, John C. Wellons III and James M. Johnston Jr.

, and successfully implemented a dedicated sports concussion clinic to serve our community. The next challenge was to conduct a retrospective study to determine how effective our solutions were in the short run. In this paper we present our experience, quantifying the significant variation in management of pediatric sports-related concussion prior to protocol standardization, as well as the impact of an institution-wide protocol on patient care and institutional resource utilization. Methods Study Design We conducted a retrospective cohort study of pediatric

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Doniel Drazin, Miriam Nuño, Chirag G. Patil, Kimberly Yan, John C. Liu and Frank L. Acosta Jr.


The objective of this study was to determine factors associated with admission to the hospital through the emergency room (ER) for patients with a primary diagnosis of low-back pain (LBP). The authors further evaluated the impact of ER admission and patient characteristics on mortality, discharge disposition, and hospital length of stay.


The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. Univariate comparisons of patient characteristics according to the type of admission (ER versus non-ER) were conducted. Multivariate analysis evaluated factors associated with an ER admission, risk of mortality, and nonroutine discharge.


According to the NIS, approximately 183,151 patients with a primary diagnosis of LBP were discharged from US hospitals between 1998 and 2007. During this period, an average of 65% of these patients were admitted through the ER, with a significant increase from 1998 (54%) to 2005 (71%). Multivariate analysis revealed that uninsured patients (OR 2.1, 95% CI 1.7–2.6, p < 0.0001) and African American patients (OR 1.5, 95% CI 1.2–1.7, p < 0.0001) were significantly more likely to be admitted through the ER than private insurance patients or Caucasian patients, respectively. Additionally, a moderate but statistically significant increase in the likelihood of ER admission was noted for patients with more preexisting comorbidities (OR 1.1, 95% CI 1.0–1.2, p < 0.001). An 11% incremental increase in the odds of admission through the ER was observed with each year increment (OR 1.1, 95% CI 1.0–1.2, p < 0.001). Highest income patients ($45,000+) were more likely to be admitted through the ER (OR 1.3, 95% CI 1.1–1.6, p = 0.007) than the lowest income cohort. While ER admission did not impact the risk of mortality (OR 0.95, 95% CI 0.60–1.51, p = 0.84), it increased the odds of a nonroutine discharge (OR 1.39, 95% CI 1.26–1.53, p < 0.0001).


A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.

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Stacey J. Ackerman, David W. Polly Jr., Tyler Knight, Tim Holt and John Cummings Jr.

is unclear how often lumbar fusion is being performed in patients who really have SI pathology, but an occurrence of at least 5% of the time has been suggested. 24 In addition, the lumbar spinal fusion subgroup analysis was conducted because lumbar spinal fusion patients with sacroiliac diagnoses may represent a group requiring greater medical resource utilization to treat than patients with the same diagnosis, but who have not had lumbar spinal fusion. TABLE 2: International Classification of Disease procedure codes used to identify patients who underwent

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Odette A. Harris, Carl A. Bruce, Marvin Reid, Randolph Cheeks, Kirk Easley, Monique C. Surles, Yi Pan, Donnahae Rhoden-Salmon, Dwight Webster and Ivor Crandon

(measured as GOS and FIM scores). Another area of concern includes hospital resource utilization. It is difficult, however, to fully evaluate the varying treatment strategies in randomized clinical controlled trials, given that these treatment strategies are well established and their evaluation in such a setting would be unlikely to meet institutional review criteria. An observational study design is more feasible because it has the unique ability to capture the dynamic nature and relationships of the many factors associated with trauma. In addition, it has been

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D. Ryan Ormond, Joseph Kahamba, Kevin O. Lillehei and Nicephorus Rutabasibwa

Tanzania sits on the Indian Ocean in East Africa and has a population of over 53 million people. While the gross domestic product has been increasing in recent years, distribution of wealth remains a problem, and challenges in the distribution of health services abound. Neurosurgery is a unique case study of this problem. The challenges facing the development of neurosurgery in Tanzania are many and varied, built largely out of the special needs of modern neurosurgery. Task shifting (training nonphysician surgical providers) and 2-tiered systems (fast-track certification of general surgeons to perform basic neurosurgical procedures) may serve some of the immediate need, but these options will not sustain the development of a comprehensive neurosurgical footprint. Ultimately, long-term solutions to the need for neurosurgical care in Tanzania can only be fulfilled by local government investment in capacity building (infrastructure and neurosurgical training), and the commitment of Tanzanians trained in neurosurgery. With this task in mind, Tanzania developed an independent neurosurgery training program in Dar es Salaam. While significant progress has been made, a number of training deficiencies remain. To address these deficiencies, the Muhimbili Orthopedic Institute (MOI) Division of Neurosurgery and the University of Colorado School of Medicine Department of Neurosurgery set up a Memorandum of Understanding in 2016. This relationship was developed with the perspective of a “collaboration of equals.” Through this collaboration, faculty members and trainees from both institutions have the opportunity to participate in international exchange, join in collaborative research, experience the culture and friendship of a new country, and share scholarship through presentations and teaching. Ultimately, through this international partnership, mutual improvement in the care of the neurosurgical patient will develop, bringing programs like MOI out of isolation and obscurity. From Dar es Salaam, a center of excellence is developing to train neurosurgeons who can go well equipped throughout Tanzania to improve the care of the neurosurgical patient everywhere. The authors encourage further such exchanges to be developed between partnership training programs throughout the world, improving the scholarship, subspecialization, and teaching expertise of partner programs throughout the world.

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Michael D. Taylor and Mark Bernstein

anesthesia. 8 Results have been variable for the identification of the rolandic fissure on MR imaging. 6, 36 Functional MR imaging has also been used to determine the relationship between functional areas and intraaxial brain tumors. 28, 36 Resource Utilization and Awake Craniotomy Awake craniotomy is a time-efficient procedure with a median OR duration of 3.25 hours. There is a learning curve to the procedure, as shown by the reduction in OR time as this study progressed. In many neurosurgical centers all postcraniotomy patients are sent to the ICU. 5 The principal