Geographic variation and regional trends in adoption of endovascular techniques for cerebral aneurysms

2011 ◽  
Vol 114 (6) ◽  
pp. 1768-1777 ◽  
Author(s):  
Gabriel A. Smith ◽  
Phillip Dagostino ◽  
Mitchell G. Maltenfort ◽  
Aaron S. Dumont ◽  
John K. Ratliff
Keyword(s):  
Endovascular Procedures ◽  
Hospital Costs ◽  
Cerebral Aneurysms ◽  
Academic Medical Centers ◽  
Endovascular Techniques ◽  
Unruptured Aneurysms ◽  
Medical Centers ◽  
Academic Medical ◽  
Hospital Deaths ◽  
Unruptured Cerebral Aneurysms

Object Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed. Methods The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored. Results The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%–92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations. Conclusions The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.

scholarly journals Characteristics of Academic Medical Centers Associated with Ischemic Stroke Outcome

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 382-382
Author(s):  
S. Claiborne Johnston ◽  
Leslie A Gillum
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Academic Medical Centers ◽  
Administrative Database ◽  
Hospital Death ◽  
Improvement Project ◽  
Medical Centers ◽  
Academic Medical ◽  
Hospital Deaths

P235 Background: Data supporting the efficacy of stroke center characteristics are limited. Methods: A questionnaire detailing stroke treatment practices was sent to 42 academic medical centers in the University Health Systems Consortium participating in a quality improvement project. In-hospital mortality of all emergency-department admissions for ischemic stroke at these institutions was evaluated in a large administrative database from 1997 through 1999. We used a multivariable method called generalized estimating equations, which broadens confidence intervals to adjust for clustering of variables at institutions. Using this technique, institutional characteristics were evaluated as predictors of in-hospital mortality after adjusting for age, gender, race, hospital treatment volume of ischemic stroke, and admission status (emergent, urgent, elective). Results: Thirty-two institutions completed the questionnaire and 29 of these were included in the administrative database. In-hospital deaths occurred in 758 (7.0%) of the 10,880 ischemic strokes admitted through the emergency department. In-hospital deaths were less frequent at hospitals with a vascular neurologist (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.36–0.74, p<0.001), and at those with guidelines stating that only neurologists could administer tPA (OR 0.65, 95% CI 0.49–0.88, p=0.004). There was a trend toward fewer deaths at hospitals with a dedicated stroke team available by pager (OR 0.76, 95% CI 0.56–1.04, p=0.09). The presence of a dedicated neurological intensive care unit, stroke unit, and written clinical pathway for stroke were not significantly associated with in-hospital death. Conclusions: Academic medical centers with a vascular neurologist and those with written guidelines limiting tPA administration to neurologists had lower rates of in-hospital mortality for ischemic stroke patients.

Unplanned Reoperation and Implant Revision After Total Wrist Arthroplasty

Hand ◽  
2020 ◽  
pp. 155894471989881 ◽  
Author(s):  
Taylor M. Pong ◽  
Wouter F. van Leeuwen ◽  
Kamil Oflazoglu ◽  
Philip E. Blazar ◽  
Neal Chen
Keyword(s):  
Risk Factors ◽  
Implant Removal ◽  
Academic Medical Centers ◽  
Implant Design ◽  
Factors Associated ◽  
Medical Centers ◽  
Total Wrist Arthroplasty ◽  
Academic Medical ◽  
Related Risk ◽  
Wrist Arthroplasty

Background: Total wrist arthroplasty (TWA) is a treatment option for many debilitating wrist conditions. With recent improvements in implant design, indications for TWA have broadened. However, despite these improvements, there are still complications associated with TWA, such as unplanned reoperation and eventual implant removal. The goal of this study was to identify risk factors for an unplanned reoperation or implant revision after a TWA at 2 academic medical centers between 2002 and 2015. Methods: In this retrospective study, 24 consecutive TWAs were identified using CPT codes. Medical records were manually reviewed to identify demographic, patient- or disease-related, and surgery-related risk factors for reoperation and implant removal after a primary TWA. Results: Forty-six percent of wrists (11 of 24 TWAs performed) had a reoperation after a median of 3.4 years, while 29% (7 of 24) underwent implant revision after a median of 5 years. Two patients had wrist surgery prior to their TWA, both eventually had their implant removed ( P = .08). There were no risk factors associated with reoperation or implant removal. Conclusion: Unplanned reoperation and implant removal after a primary TWA are common. Approximately 1 in 3 wrists are likely to undergo revision surgery. We found no factors associated with reoperation or implant removal; however, prior wrist surgery showed a trend toward risk of implant removal after TWA.

Abstract 1122‐000145: Impact of Age on Outcomes Following Endovascular vs Clipping of Ruptured and Unruptured Cerebral Aneurysms

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Hamidreza Saber ◽  
Naoki Kaneko ◽  
David Kimball ◽  
Jose Morales ◽  
Satoshi Tateshima ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Endovascular Therapy ◽  
Age Groups ◽  
Cerebral Aneurysms ◽  
Unruptured Aneurysm ◽  
Favorable Outcome ◽  
Hospital Length Of Stay ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
Unruptured Cerebral Aneurysms

Introduction : Age is an important determinant of outcome in patients with unruptured or ruptured cerebral aneurysms. Advancements in endovascular therapies have significantly impacted patient selection and treatment of patients with cerebral aneurysm. Recent release of the National claims data for 2017–2018 provides the opportunity to explore novel population‐level outcomes following clipping vs endovascular treatment of ruptured and unruptured cerebral aneurysms in different age groups. Methods : Analysis of US National Inpatient Sample of hospitalizations with aneurysmal subarachnoid hemorrhage (aSAH) or unruptured aneurysms treated with clipping or endovascular therapy from January 1, 2017 to December 31, 2018. Pre‐defined age strata included: younger than 50 years; 50–64 years; 65–79 years; and 80 years or older. Primary outcomes included in‐hospital mortality and favorable outcome defined as discharge to home. Results : Overall, 34,955 hospitalizations with unruptured aneurysm treatment, (26,695 endovascular and 8,260 surgical clipping), and 17,525 hospitalizations with aSAH were identified in the study period. In unruptured aneurysm group, endovascular therapy was associated with significantly higher favorable outcome across all age groups, and lower mortality in those 65 years or older (all P<0.001) when compared to clipping. Median hospital length‐of‐stay was 1 day (IQR 1–4) in endovascular vs 4 days (IQR 3–8) in clipping group (P<0.001). In aSAH group, endovascular therapy was associated with higher favorable outcome in 50–80 years age groups when compared to clipping, with no significant differences for in‐hospital mortality outcome (Table). Significantly more favorable outcomes were achieved with coiling vs clipping in those aged 65 or above with unruptured aneurysms. Conclusions : In 2017–2018 in US, unruptured aneurysm patients treated with endovascular therapy had significantly lower morbidity and mortality compared to those treated with surgical clipping, and differences were more pronounced with age. Similar but less strong association was observed in patients with aSAH.

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