Impact of frailty on short-term outcomes in patients undergoing transsphenoidal pituitary surgery

2020 ◽  
Vol 132 (2) ◽  
pp. 360-370 ◽  
Author(s):  
Anthony O. Asemota ◽  
Gary L. Gallia
Keyword(s):  
Propensity Score ◽  
Vascular Complications ◽  
Pituitary Surgery ◽  
Pulmonary Insufficiency ◽  
Median Income ◽  
Short Term ◽  
Electrolyte Disorders ◽  
Frail Patients ◽  
Transsphenoidal Pituitary Surgery ◽  
The Impact

OBJECTIVEFrailty, a state of decreased physiological reserve, has been shown to significantly impact outcomes of surgery. The authors sought to examine the impact of frailty on the short-term outcomes of patients undergoing transsphenoidal pituitary surgery.METHODSWeighted data from the 2000–2014 National (Nationwide) Inpatient Sample were studied. Patients diagnosed with pituitary tumors or disorders who had undergone transsphenoidal pituitary surgery were identified. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Standard descriptive techniques and matched propensity score analyses were used to explore the odds ratios of postoperative complications, discharge dispositions, and costs.RESULTSA total of 115,317 cases were included in the analysis. Frailty was present in 1.48% of cases. The mean age of frail versus non-frail patients was 57.14 ± 16.96 years (mean ± standard deviation) versus 51.91 ± 15.88 years, respectively (p < 0.001). A greater proportion of frail compared to non-frail patients had an age ≥ 65 years (37.08% vs 24.08%, respectively, p < 0.001). Frail patients were more likely to be black or Hispanic (p < 0.001), possess Medicare or Medicaid insurance (p < 0.001), belong to lower-median-income groups (p < 0.001), and have greater comorbidity (p < 0.001). Results of propensity score–matched multivariate analysis revealed that frail patients were more likely to develop fluid and electrolyte disorders (OR 1.61, 95% CI 1.07–2.43, p = 0.02), intracranial vascular complications (OR 2.73, 95% CI 1.01–7.49, p = 0.04), mental status changes (OR 3.60, 95% CI 1.65–7.82, p < 0.001), and medical complications including pulmonary insufficiency (OR 2.01, 95% CI 1.13–4.05, p = 0.02) and acute kidney failure (OR 4.70, 95% CI 1.88–11.74, p = 0.01). The mortality rate was higher among frail patients (1.46% vs 0.37%, p < 0.001). Frail patients also demonstrated a greater likelihood for nonroutine discharges (p < 0.001), higher mean total charges ($109,614.33 [95% CI $92,756.09–$126,472.50] vs $56,370.35 [95% CI $55,595.72–$57,144.98], p < 0.001), and longer hospitalizations (9.27 days [95% CI 7.79–10.75] vs 4.46 days [95% CI 4.39–4.53], p < 0.001).CONCLUSIONSFrailty in patients undergoing transsphenoidal pituitary surgery is associated with worse postoperative outcomes and higher costs, indicating that state’s potential role in routine preoperative risk stratification.

Endoscopic pituitary surgery: a systematic review and meta-analysis

2009 ◽  
Vol 111 (3) ◽  
pp. 545-554 ◽  
Author(s):  
Abtin Tabaee ◽  
Vijay K. Anand ◽  
Yolanda Barrón ◽  
David H. Hiltzik ◽  
Seth M. Brown ◽  
...  
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Pituitary Surgery ◽  
Small Sample ◽  
Csf Leak ◽  
Tumor Control ◽  
Published Data ◽  
Complication Rates ◽  
Short Term ◽  
The Impact

Object Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes. Methods The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes. Results Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67–89%). Hormone resolution was achieved in 81% (95% CI 71–91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76–92%) of growth hormone secreting tumors, and 82% (95% CI 70–94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0–4%) for CSF leak and 1% (95% CI 0–2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%. Conclusions The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery

2018 ◽  
Vol 128 (12) ◽  
pp. 2707-2713 ◽  
Author(s):  
Anni Wong ◽  
Andrey Filimonov ◽  
Yung-Jae Lee ◽  
Wayne D. Hsueh ◽  
Soly Baredes ◽  
...  
Keyword(s):  
Pituitary Surgery ◽  
Transsphenoidal Pituitary Surgery ◽  
The Impact

Effectiveness of Adjuvant Chemotherapy for Locally Advanced Bladder Cancer

2016 ◽  
Vol 34 (8) ◽  
pp. 825-832 ◽  
Author(s):  
Matthew D. Galsky ◽  
Kristian D. Stensland ◽  
Erin Moshier ◽  
John P. Sfakianos ◽  
Russell B. McBride ◽  
...  
Keyword(s):  
Overall Survival ◽  
Bladder Cancer ◽  
Adjuvant Chemotherapy ◽  
Propensity Score ◽  
Observational Study ◽  
Performance Status ◽  
Locally Advanced ◽  
Median Income ◽  
Advanced Bladder Cancer ◽  
The Impact

Purpose Given that randomized trials exploring adjuvant chemotherapy for bladder cancer have been underpowered and/or terminated prematurely, yielding inconsistent results and creating an evidence gap, we sought to compare the effectiveness of cystectomy versus cystectomy plus adjuvant chemotherapy in real-world patients. Patients and Methods We conducted an observational study to compare the effectiveness of adjuvant chemotherapy versus observation postcystectomy in patients with pathologic T3-4 and/or pathologic node-positive bladder cancer using the National Cancer Data Base. We compared overall survival using propensity score (–adjusted, –stratified, –weighted, and –matched) analyses based on patient-, facility-, and tumor-level characteristics. A sensitivity analysis was performed to examine the impact of performance status. Results A total of 5,653 patients met study inclusion criteria; 23% received adjuvant chemotherapy postcystectomy. Chemotherapy-treated patients were younger and more likely to have private insurance, live in areas with a higher median income and higher percentage of high school–educated residents, and have lymph node involvement and positive surgical margins (P < .05 for all comparisons). Stratified analyses adjusted for propensity score demonstrated an improvement in overall survival with adjuvant chemotherapy (hazard ratio, 0.70; 95% CI, 0.64 to 0.76), and similar results were achieved with propensity score matching and weighting. The association between adjuvant chemotherapy and improved survival was consistent in subset analyses and was robust to the effects of poor performance status. Conclusion In this observational study, adjuvant chemotherapy was associated with improved survival in patients with locally advanced bladder cancer. Although neoadjuvant chemotherapy remains the preferred approach based on level I evidence, these data lend further support for the use of adjuvant chemotherapy in patients with locally advanced bladder cancer postcystectomy who did not receive chemotherapy preoperatively.

scholarly journals MON-274 Analysis of Perioperative Prophylactic Steroid for Pituitary Surgery Using a National Inpatient Database in Japan

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Yujiro Hattori ◽  
Shigeyuki Tahara ◽  
Shotaro Aso ◽  
Hiroki Matsui ◽  
Kiyohide Fushimi ◽  
...  
Keyword(s):  
Big Data ◽  
Propensity Score ◽  
Diabetes Insipidus ◽  
Pituitary Surgery ◽  
Adrenocortical Function ◽  
Steroid Administration ◽  
Inverse Probability ◽  
Randomized Controlled Studies ◽  
Transsphenoidal Pituitary Surgery ◽  
Inpatient Database

Abstract BACKGROUND: There is not enough evidence regarding the need for perioperative prophylactic steroid at the time of transsphenoidal pituitary surgery [1], and it is currently administered empirically. In patients with normal preoperative adrenal function, the meta-analysis of nonrandomized studies [2] and only two randomized controlled studies [3,4] suggested no necessity to routine steroid administration, but the number of the studies subjects was small. Analysis using big data has not been performed. Therefore, this study examined the relationship between perioperative steroid administration and complications using a nationwide Diagnosis Procedure Combination database in Japan. Method: We performed a retrospective study on patients who had undergone pituitary surgery (excluding meningiomas, Cushing’s disease, and preoperative steroid administration) between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used, and the patients were divided into a prophylactic steroid-administered group and a nonadministered group. Patients’ complications, including hypopituitarism, diabetes insipidus, meningitis, hyponatremia, and hypokalemia, and discharge status were examined by inverse probability of treatment weighting using propensity score. Result: A total of 7,725 inpatients received prophylactic steroids, whereas 864 did not. The inverse probability of treatment weighting using propensity score revealed that the incidence of hypopituitarism and diabetes insipidus was significantly higher in the prophylactic steroid group than in the nonsteroid group (3.5% vs. 0.5%, P 0.001 and 9.6% vs. 6.0%, P = 0.001, respectively). There were no significant differences in the incidences of meningitis, electrolyte abnormalities, and length of hospital stay. This study using big data suggests that prophylactic steroid administration may not be necessary in patients with an intact adrenocortical function undergoing transsphenoidal pituitary surgery. 1. Fleseriu M, et al. J Clin Endocrinol Metab. 101:3888–3921 (2016) 2. Tohti M, et al. PLoS One 10: e0119621 (2015) 3. Sterl K, et al. Neurosurgery 85: E226-e232 (2019)4. Lee HC, et al. Neurosurg (2020, in press)

scholarly journals SUN-296 Acromegaly Significantly Impacts Employees’ Health Benefit Costs and Increases Work Absenteeism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Kevin C j Yuen ◽  
Kathryn A Munoz ◽  
Richard Alan Brook ◽  
John D Whalen ◽  
Ian A Beren ◽  
...  
Keyword(s):  
Consumer Price Index ◽  
Work Productivity ◽  
Health Benefit ◽  
Indirect Costs ◽  
Pituitary Surgery ◽  
Short Term ◽  
Work Absenteeism ◽  
Productivity Data ◽  
The Difference ◽  
The Impact

Abstract Background: Acromegaly (ACRO) is a rare, chronic disorder of growth hormone hypersecretion associated with increased morbidity that can affect work productivity. Data on ACRO employees’ health costs and work absenteeism are limited. Aims: To assess the impact of ACRO on employees’ health benefit costs and absenteeism. Methods: A US employee database of prescription (Rx) drug, medical claims, and absenteeism (payment and time) from Jan 2010 to Apr 2019 was analyzed. Employees with the diagnosis (Dx) of ACRO were identified based on claims with ICD-9/-10 codes 253.0x/E22.0. A 12 month study period followed each employee’s first ACRO Dx in the database (the index date). ACRO patients in the study had ≥ 2 ACRO Dxs &gt; 30 days apart, or 1 ACRO Dx plus either a pituitary adenoma Dx or a pituitary surgery or radiosurgery claim during the study period. Controls were matched to each ACRO employee on demographic, job-related variables, region, and Charlson comorbidity index (CCI) score. Costs were adjusted using the general Consumer Price Index (CPI), medical CPI, and Rx cost CPI. Outcomes included direct costs (medical and Rx), indirect costs (absence payments by benefit type), and lost time (absences by benefit type). Outcomes were analyzed using two-part regression models (logistic followed by generalized linear) for each outcome, controlling for demographic and job-related variables, region, and CCI scores. Data are shown as likelihood or mean ± standard error. Findings are significant at P &lt; 0.05. Results: Participants were 18–65 yr old with continuous eligibility for medical and Rx benefits for the study period. Forty seven ACRO patients and 940 controls were identified. ACRO employees were similar to the controls in most demographic (age, gender, race) and job-related variables (tenure, full-/part-time status, exempt status, salary), but had a higher CCI (0.60 ± 0.15 vs 0.30 ± 0.03; P = 0.029) and a higher incidence of chronic lung disease (31.9 vs 17.4%; P = 0.012), hyperlipidemia (27.7 vs 16.0%, P = 0.035), arthritis (19.1 vs 3.7%), diabetes (31.9 vs 8.3%), hypertension (40.4 vs 13.6%), and thyroid disease (31.9 vs 8.9%) (P &lt; 0.0001). Patients with ACRO were 64.3% more likely to have undergone an MRI (P &lt; 0.0001).Total indirect costs (including sick leave and disability) were higher for ACRO patients ($10,530 vs $1,157; P &lt; 0.05) with both short-term and long-term disability comprising 96% of the difference. Compared with employees without ACRO, employees with ACRO used more short-term disability (10.9 vs 0.9 days; P = 0.0076) and had more total days absent from work (12.7 vs 3.3 days; P &lt; 0.05). Conclusions: Our findings indicate that ACRO has far-reaching implications on direct and indirect employee health benefit costs and increased work absenteeism. Awareness by employers of ACRO-induced increased absenteeism is important to tailor working conditions and to prevent unrealistic work expectations.

scholarly journals Short-term and long-term unintended impacts of a pilot reform on Beijing's zero markup drug policy: a propensity score-matched study

2019 ◽  
Author(s):  
Jianying Zeng ◽  
Xiwen Chen ◽  
Hongqiao Fu ◽  
Ming Lu ◽  
Weiyan Jian
Keyword(s):  
Propensity Score ◽  
Drug Policy ◽  
Intervention Group ◽  
Substitution Effect ◽  
Short Term ◽  
Medical Expenses ◽  
Drug Sales ◽  
Tertiary Hospitals ◽  
The Impact

Abstract Background In September 2012, Beijing, the capital of China, selected five tertiary hospitals as pilots to remove the previously allowed 15% markup for drug sales. However, while most research demonstrated the significant decrease in drug sales, the core issue of high health expenditure was not well solved because of the unintended policy impact. This study aimed to empirically evaluate the short-term and long-term unintended impacts on controlling medical expenses of Beijing’s zero markup drug policy from 2012 to 2015.Methods This study extracted 2012-2015 individual-level data from the Beijing Urban Employee Basic Medical Insurance (UEBMI) database and performed a propensity score-matched analysis to evaluate the short-term and long-term impacts on controlling medical expenses. All inpatients in the 5 pilot reform hospitals were selected as the intervention group, while inpatients in other tertiary hospitals were selected as the control group.Results A total of 520,996 inpatients were extracted in this study. For patients in the pilot hospitals, the total expenditures per admission decreased from 17,140.3 yuan in 2012 to 15,430.1 yuan in 2013 and then increased to 16,789.8 yuan in 2015. Expenditure on drugs reduced from 5,811.7 yuan in 2012 to 3,903.4 yuan in 2015. However, a significant substitution effect of medical consumables was first observed in the third quarter of 2014, which undermined the impact of the policy. In the long-term, the intervention group and control group demonstrated the same trend.Conclusion After the zero markup drug policy, expenditure on drugs revealed a continuous decline. However, the decline in total expenditure was weakened by the substitution effect of medical consumables in the long term.

Impact of Endoscopic Surgical Techniques on Efficiency in Pituitary Surgery

2011 ◽  
Vol 145 (5) ◽  
pp. 732-736 ◽  
Author(s):  
Brett T. Comer ◽  
A. Byron Young ◽  
Thomas J. Gal
Keyword(s):  
Operating Room ◽  
Univariate Analysis ◽  
Surgical Techniques ◽  
Case Series ◽  
Pituitary Surgery ◽  
Setup Time ◽  
Tertiary Referral Center ◽  
Endoscopic Techniques ◽  
Transsphenoidal Pituitary Surgery ◽  
The Impact

Objective. To assess the impact of the introduction of endoscopic surgical techniques into a neurosurgical practice for pituitary surgery on operative efficiency. Study Design. Case series with chart review. Setting. Tertiary referral center. Subjects and Methods. Patients undergoing transsphenoidal pituitary surgery over a 4-year period were identified. The approach over this period evolved from classic transseptal surgery to exclusively endoscopic techniques. Patients were classified as having transseptal surgery, endoscopic approach with microsurgical resection, aborted endoscopic resection with subsequent microsurgery, and exclusive endoscopic techniques. Patient and surgeon demographics, operative times, total operating room times, and room setup time were examined. Univariate analysis and multivariate regression modeling were used to assess outcome measures. Results. One hundred seven patients were identified. The use of the endoscope for either sphenoid exposure alone (n = 41) or for the entire procedure (n = 35) resulted in a significant reduction in operative and room times compared to transseptal approaches (n = 25). Exclusively endoscopic techniques resulted in a significant reduction in operative and room times independent of all other clinical and surgical parameters ( P < .001). Progressive use of endoscopic techniques resulted in statistically significant progressive reduction in setup time ( P = .001), operative time ( P = .04), and total room time ( P = .03) over the study period. Conclusion. The transition from transseptal transsphenoidal pituitary surgery to endoscopic techniques implies a learning process for both neurosurgeon and otolaryngologist. Despite this, a noteworthy reduction in operative times, operating room times, and room setup times is observed. The impact of endoscopic techniques on efficiency in pituitary surgery is discussed.

scholarly journals Short-term and long-term unintended impacts of a pilot reform on Beijing's zero markup drug policy: a propensity score-matched study

2019 ◽  
Author(s):  
Jianying Zeng ◽  
Xiwen Chen ◽  
Hongqiao Fu ◽  
Ming Lu ◽  
Weiyan Jian
Keyword(s):  
Propensity Score ◽  
Drug Policy ◽  
Intervention Group ◽  
Substitution Effect ◽  
Short Term ◽  
Medical Expenses ◽  
Drug Sales ◽  
Tertiary Hospitals ◽  
The Impact

Abstract In September 2012, Beijing, the capital of China, selected five tertiary hospitals as pilots to remove the previously allowed 15% markup for drug sales. However, while most research demonstrated the significant decrease in drug sales, the core issue of high health expenditure was not well solved because of the unintended policy impact. This study aimed to empirically evaluate the short-term and long-term unintended impacts on controlling medical expenses of Beijing’s zero markup drug policy from 2012 to 2015.Methods This study extracted 2012-2015 individual-level data from the Beijing Urban Employee Basic Medical Insurance (UEBMI) database and performed a propensity score-matched analysis to evaluate the short-term and long-term impacts on controlling medical expenses. All inpatients in the 5 pilot reform hospitals were selected as the intervention group, while inpatients in other tertiary hospitals were selected as the control group.Results A total of 520,996 inpatients were extracted in this study. For patients in the pilot hospitals, the total expenditures per admission decreased from 17,140.3 yuan in 2012 to 15,430.1 yuan in 2013 and then increased to 16,789.8 yuan in 2015. Expenditure on drugs reduced from 5,811.7 yuan in 2012 to 3,903.4 yuan in 2015. However, a significant substitution effect of medical consumables was first observed in the third quarter of 2014, which undermined the impact of the policy. In the long-term, the intervention group and control group demonstrated the same trend.Conclusion After the zero markup drug policy, expenditure on drugs revealed a continuous decline. However, the decline in total expenditure was weakened by the substitution effect of medical consumables in the long term.

Quantile treatment effect and double robust estimators

2017 ◽  
Vol 44 (4) ◽  
pp. 585-604 ◽  
Author(s):  
Francesco Caracciolo ◽  
Marilena Furno
Keyword(s):  
Monte Carlo ◽  
Propensity Score ◽  
Treatment Effect ◽  
Average Treatment Effect ◽  
Short Term ◽  
Content Type ◽  
Double Robust ◽  
Monte Carlo Studies ◽  
And Control ◽  
The Impact

Purpose Several approaches have been proposed to evaluate treatment effect, relying on matching methods propensity score, quantile regression, influence function, bootstrap and various combinations of the above. This paper considers two of these approaches to define the quantile double robust (DR) estimator: the inverse propensity score weights, to compare potential output of treated and untreated groups; the Machado and Mata quantile decomposition approach to compute the unconditional quantiles within each group – treated and control. Two Monte Carlo studies and an empirical application for the Italian job labor market conclude the analysis. The paper aims to discuss these issue. Design/methodology/approach The DR estimator is extended to analyze the tails of the distribution comparing treated and untreated groups, thus defining the quantile based DR estimator. It allows us to measure the treatment effect along the entire outcome distribution. Such a detailed analysis uncovers the presence of heterogeneous impacts of the treatment along the outcome distribution. The computation of the treatment effect at the quantiles, points out variations in the impact of treatment along the outcome distributions. Indeed it is often the case that the impact in the tails sizably differs from the average treatment effect. Findings Two Monte Carlo studies show that away from average, the quantile DR estimator can be profitably implemented. In the real data example, the nationwide results are compared with the analysis at a regional level. While at the median and at the upper quartile the nationwide impact is similar to the regional impacts, at the first quartile – the lower incomes – the nationwide effect is close to the North-Center impact but undervalues the impact in the South. Originality/value The computation of the treatment effect at various quantiles allows to point out discrepancies between treatment and control along the entire outcome distributions. The discrepancy in the tails may differ from the divergence between the average values. Treatment can be more effective at the lower/higher quantiles. The simulations show the performance at the quartiles of quantile DR estimator. In a wage equation comparing long and short term contracts, this estimator shows the presence of an heterogeneous impact of short term contracts. Their impact changes depending on the income level, the outcome quantiles, and on the geographical region.

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