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

Gottlieb

et al. 2016

World Neurosurgery

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Background The impact of early physician follow-up on out-of-hospital outcomes after cerebral aneurysm treatment has not been studied before. We investigated the association of early physician follow-up (within 30 days of discharge) with mortality and readmissions for elderly patients undergoing treatment for unruptured and ruptured cerebral aneurysms. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent treatment for cerebral aneurysms from 2007 to 2012. In order to control for confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the HRR level. Results Of the 8,703 patients presenting with unruptured aneurysms, 5,673 (65.2%) had early physician follow-up, and 3,030 (34.8%) did not. Of the 3,211 patients presenting with subarachnoid hemorrhage, 1,504 (46.8%) had early physician follow-up, and 1,707 (53.2%) did not. Propensity score adjusted analysis demonstrated that patients treated for unruptured aneurysms, who visited a physician within 30 days of discharge had lower 3-month mortality (OR, 0.52; 95% CI, 0.36 to 0.74), but a higher rate of 90-day readmissions (OR, 1.14; 95% CI, 1.03–1.28). Similarly, early follow-up was associated with lower 3-month mortality (OR, 0.33; 95% CI, 0.24 to 0.46), and a higher rate of 90-day readmissions (OR, 1.79; 95% CI, 1.02–3.14) for patients presenting with SAH. Conclusions In a cohort of Medicare patients undergoing treatment for cerebral aneurysms, we identified an association of early physician follow-up with decreased short-term post-discharge mortality, but increased 90-day readmissions. More studies on the impact of strengthening the post-discharge network on the outcomes of this population are warranted.

Section: Discussionmentioning

confidence: 95%

“…14 Short-term mortality and readmissions are commonly such tracked measures. 3 Especially in frail surgical groups, such as the elderly, these outcomes are likely to depend more on the quality of the patients’ post-discharge network, than the care they received in the hospital or the skill of the surgeon.…”

Section: Introductionmentioning

confidence: 99%

Early Physician Follow-Up and Out-of-Hospital Outcomes After Cerebral Aneurysm Treatment in Elderly Patients

Gottlieb

et al. 2016

World Neurosurgery

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“…Fragmentation of care has been identified as a contributing factor to readmissions in several prior studies. Bekelis et al 5 identified an association between assessment in the hospital at which the original procedure was performed and a lower rate of 30-day readmissions for patients undergoing cerebral aneurysm treatment. In a meta-analysis Leppin et al 16 demonstrated that, overall, interventions establishing a solid postdischarge network are effective at reducing readmissions.…”

Section: Discussionmentioning

confidence: 99%

Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State

Missios

Journal of Neurosurgery

2017

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OBJECTIVE Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection. METHODS A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score-adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level. RESULTS Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41-0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40-0.96) and a propensity score-adjusted model (OR 0.64, 95% CI 0.41-0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed. CONCLUSIONS Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

“…Previous studies used these codes to identify patients undergoing cerebrovascular interventions. 1,2,4,10,11,18,26,27 ICD-9-CM codes cannot differentiate AVMs from cavernous malformations or other vascular malformations. Therefore, the ICD-9-CM codes for vascular malformations represent all such lesions and have no specificity.…”

Section: Discussionmentioning

confidence: 99%

Operative volume and outcomes of cerebrovascular neurosurgery in children

Connolly

et al. 2016

PED

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OBJECTIVE The impact of procedural volume on the outcomes of cerebrovascular surgery in children has not been determined. In this study, the authors investigated the association of operative volume on the outcomes of cerebrovascular neurosurgery in pediatric patients. METHODS The authors performed a cohort study of all pediatric patients who underwent a cerebrovascular procedure between 2003 and 2012 and were registered in the Kids' Inpatient Database (KID). To control for confounding, the authors used multivariable regression models, propensity-score conditioning, and mixed-effects analysis to account for clustering at the hospital level. RESULTS During the study period, 1875 pediatric patients in the KID underwent cerebrovascular neurosurgery and met the inclusion criteria for the study; 204 patients (10.9%) underwent aneurysm clipping, 446 (23.8%) underwent coil insertion for an aneurysm, 827 (44.1%) underwent craniotomy for arteriovenous malformation resection, and 398 (21.2%) underwent bypass surgery for moyamoya disease. Mixed-effects multivariable regression analysis revealed that higher procedural volume was associated with fewer inpatient deaths (OR 0.58; 95% CI 0.40–0.85), a lower rate of discharges to a facility (OR 0.87; 95% CI 0.82–0.92), and shorter length of stay (adjusted difference −0.22; 95% CI −0.32 to −0.12). The results in propensity-adjusted multivariable models were robust. CONCLUSIONS In a national all-payer cohort of pediatric patients who underwent a cerebrovascular procedure, the authors found that higher procedural volume was associated with fewer deaths, a lower rate of discharges to a facility, and decreased lengths of stay. Regionalization initiatives should include directing children with such rare pathologies to a center of excellence.