Comparison of Quality Metrics for Pediatric Shunt Surgery and Proposal of the Negative Shunt Revision Rate

2018 ◽  
Vol 109 ◽  
pp. e404-e408 ◽  
Author(s):  
Thomas Beez ◽  
Hans-Jakob Steiger
Keyword(s):  
Revision Rate ◽  
Quality Metrics ◽  
Shunt Revision ◽  
Shunt Surgery

scholarly journals The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery

2016 ◽  
Vol 18 (1) ◽  
pp. 7-15 ◽  
Author(s):  
Garrett T. Venable ◽  
Nicholas B. Rossi ◽  
G. Morgan Jones ◽  
Nickalus R. Khan ◽  
Zachary S. Smalley ◽  
...  
Keyword(s):  
Risk Factors ◽  
Operating Room ◽  
Revision Surgery ◽  
Revision Rate ◽  
Catheter Placement ◽  
Shunt Revision ◽  
Shunt Failure ◽  
Shunt Surgery ◽  
Distal Catheter ◽  
Quality Metric

OBJECTIVE Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of “quality outcome measures,” some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric. METHODS An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each “index” shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes. RESULTS During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression. CONCLUSIONS With economic and governmental pressures to identify and implement “quality measures” for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with “poor” or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and—hopefully—modifiable quality metric for shunt surgery in children.

scholarly journals Predicting shunt failure in children: should the global shunt revision rate be a quality measure?

2016 ◽  
Vol 17 (3) ◽  
pp. 249-259 ◽  
Author(s):  
Nicholas B. Rossi ◽  
Nickalus R. Khan ◽  
Tamekia L. Jones ◽  
Jacob Lepard ◽  
Joseph H. McAbee ◽  
...  
Keyword(s):  
Risk Factors ◽  
Revision Rate ◽  
Shunt Revision ◽  
Failure Rates ◽  
Shunt Failure ◽  
Shunt Surgery ◽  
Shunt System ◽  
Pediatric Hydrocephalus ◽  
Model Selection Approach ◽  
Negative Findings

OBJECT Ventricular shunts for pediatric hydrocephalus continue to be plagued with high failure rates. Reported risk factors for shunt failure are inconsistent and controversial. The raw or global shunt revision rate has been the foundation of several proposed quality metrics. The authors undertook this study to determine risk factors for shunt revision within their own patient population. METHODS In this single-center retrospective cohort study, a database was created of all ventricular shunt operations performed at the authors’ institution from January 1, 2010, through December 2013. For each index shunt surgery, demographic, clinical, and procedural variables were assembled. An “index surgery” was defined as implantation of a new shunt or the revision or augmentation of an existing shunt system. Bivariate analyses were first performed to evaluate individual effects of each independent variable on shunt failure at 90 days and at 180 days. A final multivariate model was chosen for each outcome by using a backward model selection approach. RESULTS There were 466 patients in the study accounting for 739 unique (“index”) operations, for an average of 1.59 procedures per patient. The median age for the cohort at the time of the first shunt surgery was 5 years (range 0–35.7 years), with 53.9% males. The 90- and 180-day shunt failure rates were 24.1% and 29.9%, respectively. The authors found no variable—demographic, clinical, or procedural—that predicted shunt failure within 90 or 180 days. CONCLUSIONS In this study, none of the risk factors that were examined were statistically significant in determining shunt failure within 90 or 180 days. Given the negative findings and the fact that all other risk factors for shunt failure that have been proposed in the literature thus far are beyond the control of the surgeon (i.e., nonmodifiable), the use of an institution’s or individual’s global shunt revision rate remains questionable and needs further evaluation before being accepted as a quality metric.

scholarly journals Effect of electromagnetic-navigated shunt placement on failure rates: a prospective multicenter study

2010 ◽  
Vol 113 (6) ◽  
pp. 1273-1278 ◽  
Author(s):  
Caroline Hayhurst ◽  
Tjemme Beems ◽  
Michael D. Jenkinson ◽  
Patricia Byrne ◽  
Simon Clark ◽  
...  
Keyword(s):  
Revision Rate ◽  
Shunt Revision ◽  
Standard Group ◽  
Fisher Exact Test ◽  
Anatomical Landmarks ◽  
Failure Rates ◽  
Shunt Failure ◽  
Catheter Position ◽  
Optimal Position ◽  
Shunt Placement

Object As many as 40% of shunts fail in the first year, mainly due to proximal obstruction. The role of catheter position on failure rates has not been clearly demonstrated. The authors conducted a prospective cohort study of navigated shunt placement compared with standard blind shunt placement at 3 European centers to assess the effect on shunt failure rates. Methods All adult and pediatric patients undergoing de novo ventriculoperitoneal shunt placement were included (patients with slit ventricles were excluded). The first cohort underwent standard shunt placement using anatomical landmarks. All centers subsequently adopted electromagnetic (EM) navigation for routine shunt placements, forming the second cohort. Catheter position was graded on postoperative CT in both groups using a 3-point scale developed for this study: (1) optimal position free-floating in CSF; (2) touching choroid or ventricular wall; or (3) intraparenchymal. Episodes and type of shunt revision were recorded. Early shunt failure was defined as that occurring within 30 days of surgery. Patients with shunts were followed-up for 12 months in the standard group, for a median of 6 months in the EM-navigated group, or until shunt failure. Results A total of 75 patients were included in the study, 41 with standard shunts and 34 with EM-navigated shunts. Seventy-four percent of navigated shunts were Grade 1 compared with 37% of the standard shunts (p = 0.001, chi-square test). There were no Grade 3 placements in the navigated group, but 8 in the standard group, and 75% of these failed. Early shunt failure occurred in 9 patients in the standard group and in 2 in the navigated group, reducing the early revision rate from 22 to 5.9% (p = 0.048, Fisher exact test). Early shunt failures were due to proximal obstruction in 78% of standard shunts (7 of 9) and in 50% of EM-navigated shunts (1 of 2). Conclusions Noninvasive EM image guidance in shunt surgery reduces poor shunt placement, resulting in a significant decrease in the early shunt revision rate.

A MULTI-INSTITUTIONAL, 5-YEAR ANALYSIS OF INITIAL AND MULTIPLE VENTRICULAR SHUNT REVISIONS IN CHILDREN

Neurosurgery ◽  
2008 ◽  
Vol 62 (2) ◽  
pp. 445-454 ◽  
Author(s):  
Jay G. Berry ◽  
Matthew A. Hall ◽  
Vidya Sharma ◽  
Liliana Goumnerova ◽  
Anthony D. Slonim ◽  
...  
Keyword(s):  
Multivariate Regression ◽  
Hospital Volume ◽  
Revision Rate ◽  
Shunt Revision ◽  
Children's Hospitals ◽  
Shunt Placement ◽  
Hospital Variation ◽  
Children’S Hospitals ◽  
Year 2000

Abstract OBJECTIVE To evaluate risk factors and predictors of cerebrospinal ventricular shunt revisions in children. METHODS A retrospective, longitudinal cohort of 1307 children ages 0 to 18 years undergoing initial ventricular shunt placement in the year 2000, with follow-up through 2005, from 32 freestanding children's hospitals within the Pediatric Health Information Systems database was studied. Rates of ventricular shunt revision were compared with patient demographic, clinical, and hospital characteristics with use of bivariate and multivariate regression accounting for hospital clustering. RESULTS Thirty-seven percent of children required at least one shunt revision within 5 years of initial shunt placement; 20% of children required two or more revisions. Institutional rates of first shunt revision ranged from 20 to 70% of initial shunts placed among the 32 hospitals in the cohort. Hospitals where one to 20 initial shunt placements per year experienced the highest initial shunt revision rate (42%). Hospitals performing over 83 initial shunt placements per year experienced the lowest revision rate (22%). We found that children undergoing shunt placement in the Midwest were more likely to experience multiple shunt revisions (odds ratio, 1.25; 95% confidence interval, 1.06–1.47) after controlling for hospital volume, shunt type, age, and diagnosis associated with initial shunt placement. CONCLUSION Higher hospital volume of initial shunt placement was associated with lower revision rates. Substantial hospital variation in the rates of ventricular shunt revision exists among children's hospitals. Future prospective studies are needed to examine the reasons for the variability in shunt revision rates among hospitals, including differences in specific processes of care.

Abstract 16: Early Use of Aspirin is Critical for Improving Outcomes Following Systemic to Pulmonary Artery Shunting

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Sayna Norouzi ◽  
Giv Heidari Bateni ◽  
Matthew Hall ◽  
Pirooz Eghtesady
Keyword(s):  
Mortality Rate ◽  
Pulmonary Artery ◽  
Congenital Heart ◽  
Critical Role ◽  
Health Information System ◽  
Perioperative Period ◽  
Shunt Revision ◽  
Shunt Surgery ◽  
Shunt Procedure ◽  
Artificial Graft

Objective: Systemic to pulmonary artery shunting (BT) is a common palliative procedure used in children with congenital heart disease. Despite the relatively simple nature of the procedure, the BT shunt procedure is associated with significant morbidity and mortality that is believed to be related perhaps to thrombosis of the artificial graft. The optimal postoperative anticoagulation regimen for this procedure is unknown. We compared the effectiveness of various anticoagulation regimens in patients undergoing BT shunt procedure, evaluating in particular the time of aspirin (ASA) initiation on BT shunt outcomes. Methods: The Pediatric Health Information System database (PHIS) was retrospectively queried (2000-2011) to identify patients (<30 days old) who underwent isolated BT shunts procedures. Postoperative anticoagulation regimens were categorized into: Heparin only, ASA and Heparin and ASA only regimens. The primary end point was mortality; secondary endpoints included the need for shunt revision, catheter-based investigation or intervention post procedure. The effect of aspirin supplementation on heparin regimen on the day of surgery and the day after was evaluated using GEE logistic regression to account for hospital clustering. All confounding factors were adjusted between groups. Cox proportional hazard analysis was performed in order to compare anticoagulation regimens after BT shunt surgery. Results: A total of 1746 patients were identified. Survival analysis revealed that ASA plus heparin is the best anticoagulation regimen after BT shunt surgery (p =0.001). Patients who survived to discharged, started ASA earlier than those died during hospitalization (mean day of start of 3.7±0.2 vs. 14.6±6.3 with interquartile range of 3 vs. 11 respectively, p= 0.001). Based on GEE modeling, administration of aspirin even on day one significantly decreased mortality rate (adjusted OR=0.21, CI 95%=0.04-0.97, p =0.04 compared to heparin only group). Conclusion: Our results demonstrate a critical role for ASA in lowering rates of mortality and complications in the immediate perioperative period after BT shunt surgery. Administration of ASA as early as first postoperative day can reduce the mortality rate for this common congenital heart procedure.

Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges

Neurosurgery ◽  
2019 ◽  
Vol 85 (4) ◽  
pp. E765-E770 ◽  
Author(s):  
Sonia Ajmera ◽  
Mustafa Motiwala ◽  
Nickalus R Khan ◽  
Lydia J Smith ◽  
Kim Giles ◽  
...  
Keyword(s):  
Revision Surgery ◽  
Image Guidance ◽  
De Novo ◽  
Hospital Charges ◽  
Shunt Revision ◽  
Postanesthesia Care Unit ◽  
Shunt Surgery ◽  
Clinical Scenarios ◽  
The Difference ◽  
The Cost

Abstract BACKGROUND Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery. OBJECTIVE To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN). METHODS Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department. RESULTS Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively. CONCLUSION From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.

Ventriculoperitoneal Shunt Surgery Outcome in Adult Transition Patients With Pediatric-Onset Hydrocephalus

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. 380-389 ◽  
Author(s):  
G. Kesava Reddy ◽  
Papireddy Bollam ◽  
Gloria Caldito ◽  
Bharat Guthikonda ◽  
Anil Nanda
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Shunt Revision ◽  
Shunt Failure ◽  
Shunt Surgery ◽  
Shunt Placement ◽  
Adult Transition ◽  
Shunt Survival ◽  
Pediatric Onset

Abstract BACKGROUND: Ventriculoperitoneal shunting remains the most widely used neurosurgical procedure for the management of hydrocephalus, albeit with many complications. OBJECTIVE: To review and assess the long-term clinical outcome of ventriculoperitoneal shunt surgery in adult transition patients with pediatric-onset hydrocephalus. METHODS: Patients 17 years or older who underwent ventriculoperitoneal shunt placement for hydrocephalus during their pediatric years (younger than 17 years) were included. Medical charts, operative reports, imaging studies, and clinical follow- up evaluations were reviewed and analyzed retrospectively. RESULTS: A total of 105 adult patients with pediatric-onset hydrocephalus were included. The median age of the patients was 25.9 years. The median age at the time of the initial ventriculoperitoneal shunt placement was 1.0 year. The median follow-up time for all patients was 17.7 years. The incidence of shunt failure at 6 months was 15.2%, and the overall incidence of shunt failure was 82.9%. Single shunt revision occurred in 26.7% of the patients, and 56.2% had multiple shunt revisions. The cause of hydrocephalus was significantly associated with shunt survival for patients who had shunt failure before the age of 17 years. Being pediatric at first shunt revision, infection, proximal shunt complication, and other causes were independently associated with multiple shunt failures. CONCLUSION: The findings of this retrospective study show that the long-term ventriculoperitoneal shunt survival remains low in adult transition patients with pediatric-onset hydrocephalus.

The Impact of Endoscopic Third Ventriculostomy on Shunt Revision Rate: A 14-Year Experience at a Single Institution

2015 ◽  
Vol 84 (3) ◽  
pp. 677-680.e1 ◽  
Author(s):  
Ran Xu ◽  
Heather J. McCrea ◽  
Caitlin E. Hoffman ◽  
Mark M. Souweidane ◽  
Jeffrey P. Greenfield
Keyword(s):  
Endoscopic Third Ventriculostomy ◽  
Revision Rate ◽  
Shunt Revision ◽  
Third Ventriculostomy ◽  
Single Institution ◽  
The Impact

scholarly journals Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004–2013)

2019 ◽  
Vol 90 (7) ◽  
pp. 747-754 ◽  
Author(s):  
Rocío Fernández-Méndez ◽  
Hugh K Richards ◽  
Helen M Seeley ◽  
John D Pickard ◽  
Alexis J Joannides
Keyword(s):  
Cerebrospinal Fluid ◽  
Intraventricular Haemorrhage ◽  
Normal Pressure ◽  
Incidence Rates ◽  
Shunt Revision ◽  
Csf Shunt ◽  
First Year ◽  
Shunt Surgery ◽  
Potential Risks ◽  
The Uk

ObjectivesTo determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions.MethodsA retrospective, multicentre, registry-based study was conducted based on 10 years’ data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation.Results41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems.ConclusionsOur report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.

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