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 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 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.

scholarly journals Small vs. Large Unruptured Cerebral Aneurysm: Concerns With the Age of Patient

2021 ◽  
Vol 12 ◽  
Author(s):  
Jianfeng Zheng ◽  
Ru Xu ◽  
Xiaochuan Sun ◽  
Xiaodong Zhang
Keyword(s):  
Older Patients ◽  
Multivariable Analysis ◽  
Cerebral Aneurysms ◽  
Preventive Treatment ◽  
Maximum Diameter ◽  
Poor Outcome ◽  
Clinical Complications ◽  
Unruptured Cerebral Aneurysm ◽  
Unruptured Cerebral Aneurysms ◽  
The Impact

Objective: The coiling and clipping of unruptured cerebral aneurysms (UCAs) in older patients has increased rapidly, and aneurysm size was a significant factor for decision-making in the treatment of UCAs. The purpose of the study was to investigate the impact of age on the functional outcomes of patients between the small versus large UCAs.Methods: We conducted a retrospective study for consecutive cases of UCAs admitted from May 2011 to December 2020. According to the maximum diameter of UCA, patients were divided into small UCAs (≤ 5 mm) group and large UCAs (&gt;5 mm) group. Baseline characteristics, clinical complications, and outcomes of patients between the two groups were analyzed.Results: A total of 564 UCA patients received preventive treatment, including 165 small UCAs and 399 large UCAs. Compared with the small UCA group, the incidence of ischemia event in the large UCA group was significantly higher (7.3 vs. 2.4%; p = 0.029). Multivariable analysis demonstrating age (p = 0.006) and treatment modality (p &lt; 0.001) were independent risk factors associated with poor outcome for patients with large UCAs.Conclusions: Preventive treatment of small UCAs is safe and effective, but older patients with large UCAs are at high risk of poor outcome, and the operations should be more cautious.

Prevalence of patient safety indicators and hospital-acquired conditions in those treated for unruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database

2013 ◽  
Vol 119 (4) ◽  
pp. 966-973 ◽  
Author(s):  
Kyle M. Fargen ◽  
Maryam Rahman ◽  
Dan Neal ◽  
Brian L. Hoh
Keyword(s):  
Health Care ◽  
Adverse Event ◽  
Patient Safety ◽  
Nationwide Inpatient Sample ◽  
Cerebral Aneurysms ◽  
Patient Safety Indicators ◽  
Hospital Acquired Conditions ◽  
Unruptured Cerebral Aneurysms ◽  
Hospital Acquired

Object The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are metrics used to gauge the quality of health care provided by health care institutions. The PSIs and HACs are publicly reported metrics and are directly linked to reimbursement for services. To better understand the prevalence of these adverse events in hospitalized patients treated for unruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of unruptured aneurysm in the Nationwide Inpatient Sample (NIS) database. Methods The NIS, part of the AHRQ's Healthcare Cost and Utilization Project, was queried for all hospitalizations between 2002 and 2010 involving coiling or clipping of unruptured cerebral aneurysms. The incidence rate for each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The SAS statistical software package was used to calculate incidences and perform multivariate analyses to determine the effects of patient variables on the probability of each indicator developing. Results There were 54,589 hospitalizations involving unruptured cerebral aneurysms in the NIS database for the years 2002–2010; 8314 patients (15.2%) underwent surgical clipping and 9916 (18.2%) were treated with endovascular coiling. One thousand four hundred ninety-two PSI and HAC events occurred among the 8314 patients treated with clipping; at least 1 PSI or HAC occurred in 14.6% of these patients. There were 1353 PSI and HAC events among the 9916 patients treated with coiling; at least 1 PSI or HAC occurred in 10.9% of these patients. Age, sex, and comorbidities had statistically significant associations with an adverse event. Compared with the patients having no adverse event, those having at least 1 PSI during their hospitalizations had significantly longer hospital stays (p < 0.0001), higher hospital costs (p < 0.0001), and higher mortality rates (p < 0.0001). Conclusions These results estimate baseline national rates of PSIs and HACs in patients with unruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

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.

Abstract WP94: Clinical Outcomes of Unruptured Cerebral Aneurysms Treated With Clipping or Coiling in Japan: The J-aspect Study

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ataru Nishimura ◽  
Kunihiro Nishimura ◽  
Akiko Kada ◽  
Satoru Kamitani ◽  
Ryota Kurogi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Postoperative Complications ◽  
Clinical Outcomes ◽  
Brain Infarction ◽  
Cerebral Aneurysms ◽  
Nationwide Survey ◽  
Mortality Rates ◽  
Lower Number ◽  
Patient Safety Indicators ◽  
Unruptured Cerebral Aneurysms

Background: Evaluation of the overall clinical outcomes of stroke care is important for improving institutional quality of care. We performed a nationwide survey in Japan to analyze cases of unruptured cerebral aneurysms using the diagnostic procedure combination (DPC). Methods and Results: Certified neurosurgical training institutions in Japan provided data from the DPC database on patients hospitalized with neurosurgical diseases between April 1, 2012 and March 31, 2013. Patients hospitalized owing to unruptured cerebral aneurysms were identified from the DPC database based on the International Classification of Diseases (ICD)-10 diagnosis code (I671). We excluded patients with emergency admissions. We compared the mortality rates, modified Rankin Scale (mRS) scores, postoperative complications of patients who underwent clipping and coiling. With respect to postoperative complications, we evaluated the ratio of an event of complication (brain infarction, brain hemorrhage and cardiac infarction) and the number of complications (scored using patient safety indicators: PSIs and hospital-acquired conditions: HACs). We used hierarchical logistic regression models to estimate the odds ratios (ORs) for in-hospital mortality and complications. We identified 6329 patients with unruptured cerebral aneurysms (3710 clipping, 2619 coiling). Patient characteristics, mortality rates, and mRS were similar between groups. Patients who underwent coiling had a significantly lower number of complications than patients who underwent clipping (PSIs: OR = 0.40; P < 0.001, HACs: OR = 0.47; P = 0.001). Adversely, there was an increased likelihood of ischemic stroke in coiling patients compared with clipping patients (coiling: 7.2%; clipping: 4.7%; OR = 1.37; P = 0.011). 83.2% of coiling patients underwent MRI after the operation, compared with 37.3% of clipping patients. Conclusions: Our data demonstrated that coiling patients had lower number of post-operative complications and higher number of ischemic stroke than clipping patients. But the cause that higher number of coiling patients had ischemic stroke than clipping patients because higher number of coiling patients were underwent MRI after operation compared with clipping patients.

Comprehensive Stroke Center Treatment and Outcomes for Elderly Adults with Cerebral Aneurysms and Subarachnoid Hemorrhage

2012 ◽  
Vol 60 (10) ◽  
pp. 1984-1986 ◽  
Author(s):  
Paul T. Akins ◽  
Yekaterina Axelrod ◽  
Syed Arshad ◽  
Jonathan Hartman ◽  
Cheng Ji ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Aneurysms ◽  
Elderly Adults ◽  
Comprehensive Stroke Center ◽  
Stroke Center

scholarly journals Risk of unruptured aneurysm treatment in California

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 381-381
Author(s):  
S. Claiborne Johnston ◽  
Shoujun Zhao ◽  
R. Adams Dudley ◽  
Daryl R Gress
Keyword(s):  
Adverse Events ◽  
Cerebral Aneurysm ◽  
Endovascular Therapy ◽  
Odds Ratio ◽  
Cerebral Aneurysms ◽  
Hospital Treatment ◽  
Hospital Death ◽  
Hospital Deaths ◽  
The Difference ◽  
Unruptured Cerebral Aneurysms

P230 Background. Few studies have directly compared the risk of cerebral aneurysm repair with surgery and with endovascular coil embolization. Since the vast majority of patients with unruptured cerebral aneurysms are non-disabled prior to treatment, this diagnosis provides an opportunity to compare risks of treatment. Methods. Discharge abstracts for all patients with a primary diagnosis of unruptured cerebral aneurysm were retrieved from a statewide database of non-Federal hospital discharges in California from January 1990 through December 1998. Admissions for initial treatment and all follow-up care were combined to reflect the entire course of therapy. An adverse event was defined as an in-hospital death or discharge to nursing home or rehabilitation hospital at any point during the treatment course. Results. A total of 2069 patients were treated for unruptured aneurysms. Adverse outcomes were more frequent in the 1699 patients treated with surgery than in the 370 treated with endovascular therapy (25% vs. 10%; p<0.0001 by chi-square test). The difference persisted after adjustment for age, gender, race, source of admission, and year of treatment (odds ratio 3.5 for adverse events surgery vs. endovascular therapy, 95% confidence interval 2.4–5.2, p<0.0001 by logistic regression). In-hospital deaths occurred in 3.5% of surgical cases and 0.5% of endovascular cases (p=0.003), and the difference remained significant after adjustment in multivariable models (odds ratio 6.3, 1.5–26.2, p=0.01). Adverse events were less likely at hospitals treating a larger portion of patients with endovascular therapy after adjustment for case characteristics, hospital treatment volume, and clustering of observations using generalized estimating equations (p=0.006). Conclusions. In California, endovascular repair of unruptured cerebral aneurysms is associated with fewer adverse events and in-hospital deaths than surgery.

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