scholarly journals Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work

Neurosurgery ◽  
2017 ◽  
Vol 82 (3) ◽  
pp. 329-334 ◽  
Author(s):  
Kimon Bekelis ◽  
Symeon Missios ◽  
Todd A MacKenzie
Keyword(s):  
Length Of Stay ◽  
Cerebral Aneurysm ◽  
New York State ◽  
Cerebral Aneurysms ◽  
Work Hours ◽  
Endovascular Coiling ◽  
Emergency Procedures ◽  
Aneurysm Treatment ◽  
Unruptured Cerebral Aneurysm ◽  
Unruptured Cerebral Aneurysms

Abstract BACKGROUND The association between long work hours and outcomes among attending surgeons remains an issue of debate. OBJECTIVE To investigate whether operating emergently the night before an elective case was associated with inferior outcomes among attending neurosurgeons. METHODS We executed a cohort study with unruptured cerebral aneurysm patients, who underwent endovascular coiling or surgical clipping from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. We investigated the association of treatment by surgeons performing emergency procedures the night before with outcomes of elective cerebral aneurysm treatment using an instrumental variable analysis. RESULTS Overall, 4700 patients underwent treatment for unruptured cerebral aneurysms. There was no difference in inpatient mortality (adjusted difference, –0.7%; 95% confidence interval [CI], –1.4% to 0.02%), discharge to a facility (adjusted difference, –0.1%; 95% CI, –1.2% to 1.2%), or length of stay (adjusted difference, –0.58; 95% CI, –1.66 to 0.50) between patients undergoing elective cerebral aneurysm treatment by surgeons who performed emergency procedures the night before, and those who did not. CONCLUSION Using a comprehensive patient cohort in New York State for elective treatment of unruptured cerebral aneurysms, we did not identify an association of treatment by surgeons performing emergency procedures the night before, with mortality, discharge to a facility, or length of stay. Our study had 80% power to detect differences in mortality (our primary outcome), as small as 4.1%. The results of the present study do not support the argument for regulation of attending work hours.

scholarly journals The impact of hybrid neurosurgeons on the outcomes of endovascular coiling for unruptured cerebral aneurysms

2017 ◽  
Vol 126 (1) ◽  
pp. 29-35 ◽  
Author(s):  
Kimon Bekelis ◽  
Dan Gottlieb ◽  
Nicos Labropoulos ◽  
Yin Su ◽  
Stavropoula Tjoumakaris ◽  
...  
Keyword(s):  
Propensity Score ◽  
Cerebral Aneurysm ◽  
Readmission Rate ◽  
Cerebral Aneurysms ◽  
Endovascular Coiling ◽  
Unruptured Cerebral Aneurysm ◽  
Hospital Referral ◽  
Unruptured Cerebral Aneurysms ◽  
The Impact ◽  
Aneurysm Coiling

OBJECTIVE The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. The authors investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding, the authors used propensity score conditioning, with mixed effects to account for clustering at the hospital referral region level. RESULTS During the study period, there were 11,716 patients who underwent endovascular coiling for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 1186 (10.1%) underwent treatment performed by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR 0.84; 95% CI 0.58–1.23), discharge to rehabilitation (OR 1.0; 95% CI 0.66–1.51), 30-day readmission rate (OR 1.07; 95% CI 0.83–1.38), and length of stay (adjusted difference, 0.41; 95% CI −0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. CONCLUSIONS In a cohort of Medicare patients, the authors did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons and proceduralists performing only endovascular coiling.

Continuity of care and 30-day readmission for patients evaluated in the emergency room after cerebral aneurysm treatment

2016 ◽  
Vol 8 (11) ◽  
pp. 1203-1206 ◽  
Author(s):  
Kimon Bekelis ◽  
Symeon Missios ◽  
Todd A MacKenzie
Keyword(s):  
Propensity Score ◽  
Cerebral Aneurysm ◽  
Continuity Of Care ◽  
New York State ◽  
Multivariable Analysis ◽  
Mixed Effects ◽  
Endovascular Coiling ◽  
Aneurysm Treatment ◽  
Original Procedure ◽  
Adjusted Model

BackgroundThe association between continuity of care and the rate of 30-day readmissions after surgical procedures continues to be debated.ObjectiveTo investigate the association of 30-day readmissions with evaluation in the hospital where the original procedure was performed for patients presenting to the emergency department (ED) after cerebral aneurysm treatment.MethodsWe performed a cohort study of patients with cerebral aneurysms, who were evaluated in the ED within 30 days after discharge following surgical clipping or endovascular coiling between 2009 and 2013, and were registered in the Statewide Planning and Research Cooperative System database. A propensity score adjusted model was used to control for confounding, whereas mixed effects accounted for clustering at the hospital level.ResultsOf the 452 patients presenting to the ED, 218 (48.2%) were evaluated in a different hospital from that in which the original procedure was performed (7.7% readmitted), and 234 (51.8%) were evaluated at the original hospital (18.4% readmitted). In a multivariable analysis, we showed that evaluation in the ED of the original hospital was associated with decreased rate of 30-day readmission (OR=0.41; 95% CI 0.22 to 0.78). We found similar associations in a mixed-effects logistic regression model (OR=0.46; 95% CI 0.35 to 0.84) and a propensity score adjusted model (OR=0.41; 95% CI 0.22 to 0.77). This corresponds to10 patients needing to be evaluated in the hospital at which the original procedure was performed to prevent one readmission.ConclusionsUsing a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ED after cerebral aneurysm treatment, we identified an association between assessment in the hospital at which the original procedure was performed and a lower rate of 30-day readmissions. This underlines the potential importance of continuity of care for surgical patients to prevent readmission.

scholarly journals Unruptured cerebral aneurysm clipping: association of combined open and endovascular expertise with outcomes

2015 ◽  
Vol 8 (9) ◽  
pp. 977-981 ◽  
Author(s):  
Kimon Bekelis ◽  
Dan Gottlieb ◽  
George Bovis ◽  
Yin Su ◽  
Stavropoula Tjoumakaris ◽  
...  
Keyword(s):  
Propensity Score ◽  
Cerebral Aneurysm ◽  
Readmission Rate ◽  
Cerebral Aneurysms ◽  
Postoperative Mortality ◽  
Fee For Service ◽  
Aneurysm Clipping ◽  
Unruptured Cerebral Aneurysm ◽  
Procedural Volume ◽  
Unruptured Cerebral Aneurysms

BackgroundIt is often questioned if one physician can conduct both open and endovascular techniques successfully and safely.ObjectiveTo investigate the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping.MethodsWe performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms between 2007 and 2012. To control for confounding we used propensity score conditioning, and controlled for clustering at the physician level.ResultsDuring the study, 3247 patients underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2481 (76.4%) by proceduralists, who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated a lack of association of combined practice with 1-year postoperative mortality (OR=0.81; 95% CI 0.51 to 1.28), discharge to rehabilitation (OR=0.95; 95% CI 0.72 to 1.25), length of stay (adjusted difference 0.85 days; 95% CI −0.31 to 2.00), or 30-day readmission rate (OR=1.05; 95% CI 0.80 to 1.39). Higher procedural volume was independently associated with improved outcomes.ConclusionsIn a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons performing only clipping.

Size is the Most Important Predictor of Aneurysm Rupture Among Multiple Cerebral Aneurysms: Post Hoc Subgroup Analysis of Unruptured Cerebral Aneurysm Study Japan

Neurosurgery ◽  
2017 ◽  
Vol 82 (6) ◽  
pp. 864-869 ◽  
Author(s):  
Masaaki Shojima ◽  
Akio Morita ◽  
Hirofumi Nakatomi ◽  
Shinjiro Tominari
Keyword(s):  
Cerebral Aneurysm ◽  
Cerebral Aneurysms ◽  
Aneurysm Rupture ◽  
Ruptured Aneurysm ◽  
Clinical Value ◽  
Total Cohort ◽  
Unruptured Cerebral Aneurysm ◽  
Specific Factors ◽  
Unruptured Cerebral Aneurysms ◽  
Post Hoc

Abstract BACKGROUND Multiple cerebral aneurysms are encountered in approximately 15% to 35% of patients harboring unruptured cerebral aneurysms. It would be of clinical value to determine which of them is most likely to rupture. OBJECTIVE To characterize features of the ruptured aneurysm relative to other concomitant fellow aneurysms in patients with multiple cerebral aneurysms. METHODS From a total of 5720 patients who were prospectively registered in the Unruptured Cerebral Aneurysm Study in Japan, a subgroup of patients with multiple cerebral aneurysms who developed subarachnoid hemorrhage was extracted for this post hoc analysis. Intrapatient comparisons of each aneurysm were carried out using aneurysm-specific factors such as size, location, and shape to identify predictors of rupture among the fellow aneurysms in a patient with multiple cerebral aneurysms. RESULTS Twenty-five patients with 62 aneurysms were identified from the total cohort of 5720 patients. With the distinctiveness in size, which means the aneurysm was the single largest among the multiple aneurysms, the ruptured aneurysm in each case was discriminated from the other coexisting aneurysms with a sensitivity of 0.76 and specificity of 0.86. CONCLUSION Our results suggest that the largest aneurysm is likely to rupture among coexisting aneurysms in a patient with multiple cerebral aneurysms.

scholarly journals Unruptured Cerebral Aneurysms Presenting with Ischemic Events

2008 ◽  
Vol 35 (5) ◽  
pp. 588-592 ◽  
Author(s):  
Nancy McLaughlin ◽  
Michel W. Bojanowski
Keyword(s):  
Cerebral Aneurysms ◽  
Superior Cerebellar Artery ◽  
Anterior Circulation ◽  
Ischemic Lesion ◽  
Aneurysm Treatment ◽  
Unruptured Cerebral Aneurysm ◽  
Cerebellar Artery ◽  
Study Population ◽  
Unruptured Cerebral Aneurysms ◽  
Ischemic Events

Background:Patients harboring an unruptured cerebral aneurysm may present with ischemic events. The goal of this study is to assess the clinical and radiological characteristics and the outcome following treatment of these patients.Methods:The study population included 463 patients with unruptured cerebral aneurysms treated between January 2000 and November 2006. Patients with aneurysms manifesting with ischemic events were included. Outcome was assessed 12 months following aneurysm treatment using the modified Rankin scale.Results:Eleven patients were included in this series. An acute ischemic lesion in the symptomatic territory was demonstrated in six patients. The aneurysms were located on the internal carotid artery (n=4), middle cerebral artery (n=4), superior cerebellar artery (n=2) and basilar artery (n=1). They measured 10mm or less (n=7); 11-20mm (n=2); more than 21mm (n=2). Five aneurysms were partially thrombosed on imaging. Five patients were referred for coiling. Of these, one patient had an unsuccessful coiling attempt, one had a residual neck, and three presented an aneurysm recurrence. Six patients were treated surgically. Symptomatic thromboembolism occurred after surgery in three patients. Complete aneurysm exclusion was documented in five of six operated patients. Nine of the ten treated patients had a favorable outcome.Conclusion:Even though aneurysms presenting with ischemic events are often small and located on the anterior circulation, in this series the risk of thromboembolic events following aneurysm treatment is noteworthy. This information is relevant given the possible benign natural history in terms of stroke and risk of bleeding for some of these aneurysms.

scholarly journals Relationship between patient safety indicator events and comprehensive stroke center volume status in the treatment of unruptured cerebral aneurysms

2018 ◽  
Vol 129 (2) ◽  
pp. 471-479 ◽  
Author(s):  
Chad W. Washington ◽  
L. Ian Taylor ◽  
Robert J. Dambrino ◽  
Paul R. Clark ◽  
Gregory J. Zipfel
Keyword(s):  
Patient Safety ◽  
Cerebral Aneurysm ◽  
Cerebral Aneurysms ◽  
Volume Status ◽  
Patient Safety Indicators ◽  
Poor Outcome ◽  
Unruptured Cerebral Aneurysm ◽  
Unruptured Cerebral Aneurysms ◽  
Comprehensive Stroke Center ◽  
Stroke Center

OBJECTIVEThe Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification.METHODSUsing the 2002–2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission’s annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms.RESULTSA total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1–1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2–1.6). The relationship was not significant in the endovascularly treated patients.CONCLUSIONSIn the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.

scholarly journals Recurrent or New Symptomatic Cerebral Aneurysm after Previous Treatment

2005 ◽  
Vol 11 (4) ◽  
pp. 341-348 ◽  
Author(s):  
S. Rothemeyer ◽  
D. Lefeuvre ◽  
A. Taylor
Keyword(s):  
Treatment Failure ◽  
Cerebral Aneurysm ◽  
Nerve Palsy ◽  
Cerebral Aneurysms ◽  
Previous Treatment ◽  
Primary Treatment ◽  
The Other ◽  
Endovascular Coiling ◽  
Previously Treated ◽  
Third Cranial Nerve Palsy

With the establishment of endovascular coiling as a successful treatment for symptomatic cerebral aneurysms, attention is now being directed at the durability of this treatment. If this is to be accurately done it will be important to understand the causes of symptomatic aneurysm presentation after previous treatment. In order to assess this we undertook a retrospective review, covering the four year period from 2000 to 2004, of all patients re-presenting with a symptomatic saccular aneurysm after previous treatment. Seven patients were identified, six presenting with subarachnoid haemorrhage (SAH) and one with a third cranial nerve palsy. Three patients had incomplete clipping of their aneurysms and all presented within months of their initial treatment. The other four patients presented between five and 20 years after primary treatment and all were felt to have new cerebral aneurysms. Two of these patients had aneurysms develop at the same location as their previously treated lesions, however these were still felt to be new aneurysms rather than re-growth or recurrence because of their morphology. Based on our findings it would appear that development of a new cerebral aneurysm after clipping is more of a risk than aneurysm recurrence from treatment failure. This will need to be considered when evaluating re-presentation after treatment by either coiling or clipping and more importantly, perhaps we should be directing more attention to preventing disease progression rather than treatment failure.

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