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Kalagara R, Asfaw ZK, Carr M, Quinones A, Downes MH, Vasan V, Li T, McCarthy L, Hrabarchuk EI, Genadry L, Schupper AJ, DeMaria S, Gal JS, Choudhri TF. Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review. World Neurosurg 2024; 183:94-105. [PMID: 38123131 DOI: 10.1016/j.wneu.2023.12.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery. METHODS We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery. RESULTS We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%). CONCLUSIONS This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.
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Affiliation(s)
- Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Zerubabbel K Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Carr
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Troy Li
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lisa Genadry
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Sanghvi J, Qian D, Olumuyide E, Mokuolu DC, Keswani A, Morewood GH, Burnett G, Park CH, Gal JS. Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America. Anesth Analg 2024:00000539-990000000-00734. [PMID: 38324349 DOI: 10.1213/ane.0000000000006763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.
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Affiliation(s)
| | | | | | - Deborah C Mokuolu
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aakash Keswani
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gordon H Morewood
- Department of Anesthesiology, Temple University Health System, Philadelphia, Pennsylvania
| | - Garrett Burnett
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Feng R, Valliani AA, Martini ML, Gal JS, Neifert SN, Kim NC, Geng EA, Kim JS, Cho SK, Oermann EK, Caridi JM. Reliable Prediction of Discharge Disposition Following Cervical Spine Surgery With Ensemble Machine Learning and Validation on a National Cohort. Clin Spine Surg 2024; 37:E30-E36. [PMID: 38285429 DOI: 10.1097/bsd.0000000000001520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 07/19/2023] [Indexed: 01/30/2024]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The purpose of this study is to develop a machine learning algorithm to predict nonhome discharge after cervical spine surgery that is validated and usable on a national scale to ensure generalizability and elucidate candidate drivers for prediction. SUMMARY OF BACKGROUND DATA Excessive length of hospital stay can be attributed to delays in postoperative referrals to intermediate care rehabilitation centers or skilled nursing facilities. Accurate preoperative prediction of patients who may require access to these resources can facilitate a more efficient referral and discharge process, thereby reducing hospital and patient costs in addition to minimizing the risk of hospital-acquired complications. METHODS Electronic medical records were retrospectively reviewed from a single-center data warehouse (SCDW) to identify patients undergoing cervical spine surgeries between 2008 and 2019 for machine learning algorithm development and internal validation. The National Inpatient Sample (NIS) database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for external validation of algorithm performance. Gradient-boosted trees were constructed to predict nonhome discharge across patient cohorts. The area under the receiver operating characteristic curve (AUROC) was used to measure model performance. SHAP values were used to identify nonlinear risk factors for nonhome discharge and to interpret algorithm predictions. RESULTS A total of 3523 cases of cervical spine fusion surgeries were included from the SCDW data set, and 311,582 cases were isolated from NIS. The model demonstrated robust prediction of nonhome discharge across all cohorts, achieving an area under the receiver operating characteristic curve of 0.87 (SD=0.01) on both the SCDW and nationwide NIS test sets. Anterior approach only, age, elective admission status, Medicare insurance status, and total Elixhauser Comorbidity Index score were the most important predictors of discharge destination. CONCLUSIONS Machine learning algorithms reliably predict nonhome discharge across single-center and national cohorts and identify preoperative features of importance following cervical spine fusion surgery.
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Affiliation(s)
| | | | | | - Jonathan S Gal
- Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai
| | - Sean N Neifert
- Department of Neurosurgery, New York University Langone Medical Center
| | - Nora C Kim
- Department of Neurosurgery, New York University Langone Medical Center
| | - Eric A Geng
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai
| | - Jun S Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai
| | - Samuel K Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai
| | - Eric K Oermann
- Department of Neurosurgery, New York University Langone Medical Center
- Department of Radiology, New York University Langone Medical Center
- Center for Data Science, New York University Langone Medical Center, New York, NY
| | - John M Caridi
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX
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Tang J, Gal JS, Geng E, Duey A, Ferriter P, Sicard R, Zaidat B, Girdler S, Rhee H, Zapolsky I, Al-Attar P, Markowitz J, Kim J, Cho S. An 11-Year-Long Analysis of the Risks Associated With Age in Patients Undergoing Anterior Cervical Discectomy and Fusion in a Large, Urban Academic Hospital. Global Spine J 2023:21925682231202579. [PMID: 37703497 DOI: 10.1177/21925682231202579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
STUDY DESIGN A retrospective database study of patients at an urban academic medical center undergoing an Anterior Cervical Discectomy and Fusion (ACDF) surgery between 2008 and 2019. OBJECTIVE ACDF is one of the most common spinal procedures. Old age has been found to be a common risk factor for postoperative complications across a plethora of spine procedures. Little is known about how this risk changes among elderly cohorts such as the difference between elderly (60+) and octogenarian (80+) patients. This study seeks to analyze the disparate rates of complications following elective ACDF between patients aged 60-69 or 70-79 and 80+ at an urban academic medical center. METHODS We identified patients who had undergone ACDF procedures using CPT codes 22,551, 22,552, and 22,554. Emergent procedures were excluded, and patients were subdivided on the basis of age. Then each cohort was propensity matched for univariate and univariate logistic regression analysis. RESULTS The propensity matching resulted in 25 pairs in both the 70-79 and 80+ y.o. cohort comparison and 60-69 and 80+ y.o. cohort comparison. None of the cohorts differed significantly in demographic variables. Differences between elderly cohorts were less pronounced: the 80+ y.o. cohort experienced only significantly higher total direct cost (P = .03) compared to the 70-79 y.o. cohort and significantly longer operative time (P = .04) compared to the 60-69 y.o. cohort. CONCLUSIONS Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.
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Affiliation(s)
- Justin Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric Geng
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Akiro Duey
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pierce Ferriter
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Sicard
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven Girdler
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hannah Rhee
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ivan Zapolsky
- Department of Orthopedic Surgery, Penn Medicine at the University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Paul Al-Attar
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Markowitz
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Li CJ, Vaile JR, Gal JS, Park CH, Burnett GW. Analgesic options for anterior approach to scoliosis repair: a scoping review. Spine Deform 2023; 11:1031-1040. [PMID: 37233950 DOI: 10.1007/s43390-023-00699-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE The ideal analgesic regimen for the anterior approach to scoliosis repair is not clearly defined. The purpose of the study was to summarize and identify gaps in the current literature specific to the anterior approach to scoliosis repair. METHODS A scoping review was conducted in July 2022 utilizing PubMed, Cochrane, and Scopus databases guided by the PRISMA-ScR framework. RESULTS The database search generated 641 possible articles, 13 of which met all inclusion criteria. All articles focused on the effectiveness and safety of regional anesthetic techniques, while a minority also provided both opioid and non-opioid medication frameworks. CONCLUSION Continuous Epidural Analgesia (CEA) is the most well-studied intervention for pain control in anterior scoliosis repair, but other, more novel regional anesthetic techniques offer safe and effective potential alternatives. More research is indicated to compare the effectiveness of different regional techniques and perioperative medication regimens specific to anterior scoliosis repair.
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Affiliation(s)
- Chris J Li
- Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA, 19107, USA.
| | - John R Vaile
- Sidney Kimmel Medical College, Thomas Jefferson University, 833 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Chang H Park
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Garrett W Burnett
- Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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Geng EA, Gal JS, Kim JS, Martini ML, Markowitz J, Neifert SN, Tang JE, Shah KC, White CA, Dominy CL, Valliani AA, Duey AH, Li G, Zaidat B, Bueno B, Caridi JM, Cho SK. Robust prediction of nonhome discharge following elective anterior cervical discectomy and fusion using explainable machine learning. Eur Spine J 2023:10.1007/s00586-023-07621-8. [PMID: 36854862 DOI: 10.1007/s00586-023-07621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/25/2023] [Accepted: 02/19/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. METHODS 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model's decision making. RESULTS The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. CONCLUSION We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model's "thinking" aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.
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Affiliation(s)
- Eric A Geng
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan S Gal
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.,Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jun S Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America.
| | - Michael L Martini
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Sean N Neifert
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, United States of America
| | - Justin E Tang
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Kush C Shah
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Christopher A White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Calista L Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Aly A Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Akiro H Duey
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Gavin Li
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Bashar Zaidat
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - Brian Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
| | - John M Caridi
- Department of Neurosurgery, McGovern Medical School at University of Texas Health, Houston, United States of America
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, United States of America
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Henson P, Shuman WH, Li AY, Ali M, Kalagara R, Hrabarchuk E, Schupper AJ, Steinberger J, Gal JS, Choudhri TF. Seasonal Effects on Postoperative Complications After Spinal Surgery: A National Database Analysis. World Neurosurg 2023; 170:e455-e466. [PMID: 36375802 DOI: 10.1016/j.wneu.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the role of seasonality on postoperative complications after spinal surgery. METHODS Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2018. Current Procedural Terminology codes were used to identify the following procedures: posterior cervical decompression and fusion, cervical laminoplasty, posterior lumbar fusion, lumbar laminectomy, and spinal deformity surgery. The database was queried for deep vein thrombosis (DVT), pulmonary embolism, pneumonia, sepsis, septic shock, Clostridium difficile infection, stroke, cardiac arrest, myocardial infarction, urinary tract infection (UTI), and early unplanned hospital readmission (readmission). Warm season was defined as April-September, whereas cold season was defined as October-March. Statistical analysis included computing overall complication rates and comparison between seasons using univariate analysis and multivariable logistic regression. RESULTS A total of 208,291 individuals underwent spinal surgery from 2011 to 2018. There was a statistically significant increase in UTI (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.07-1.26; P = 0.0002) and readmission (OR, 1.06; 95% CI, 1.02-1.11, P = 0.007) in the warm season compared with the cold season. An investigation into the July effect showed increases in DVT (OR, 1.24; 95% CI, 1.03-1.48; P = 0.020) and thromboembolic events (OR 1.17; 95% CI, 1.01-1.35; P = 0.032) in July-September compared with the preceding 3 months. CONCLUSIONS The results showed a higher incidence of UTI and readmission among spine surgery patients in the warm season and a higher incidence of DVT and thromboembolic events from July to September. In both cases, the effect of seasonality is statistically significant, but the absolute difference is small and may not suggest policy changes.
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Affiliation(s)
- Philip Henson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA.
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Adam Y Li
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Eugene Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Alex J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Jeremy Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Jonathan S Gal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
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Kahn RA, Gal JS, Hofer IS, Wax DB, Villar JI, Levin MA. Visual Analytics to Leverage Anesthesia Electronic Health Record. Anesth Analg 2022; 135:1057-1063. [PMID: 36066480 DOI: 10.1213/ane.0000000000006175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Visual analytics is the science of analytical reasoning supported by interactive visual interfaces called dashboards. In this report, we describe our experience addressing the challenges in visual analytics of anesthesia electronic health record (EHR) data using a commercially available business intelligence (BI) platform. As a primary outcome, we discuss some performance metrics of the dashboards, and as a secondary outcome, we outline some operational enhancements and financial savings associated with deploying the dashboards. METHODS Data were transferred from the EHR to our departmental servers using several parallel processes. A custom structured query language (SQL) query was written to extract the relevant data fields and to clean the data. Tableau was used to design multiple dashboards for clinical operation, performance improvement, and business management. RESULTS Before deployment of the dashboards, detailed case counts and attributions were available for the operating rooms (ORs) from perioperative services; however, the same level of detail was not available for non-OR locations. Deployment of the yearly case count dashboards provided near-real-time case count information from both central and non-OR locations among multiple campuses, which was not previously available. The visual presentation of monthly data for each year allowed us to recognize seasonality in case volumes and adjust our supply chain to prevent shortages. The dashboards highlighted the systemwide volume of cases in our endoscopy suites, which allowed us to target these supplies for pricing negotiations, with an estimated annual cost savings of $250,000. Our central venous pressure (CVP) dashboard enabled us to provide individual practitioner feedback, thus increasing our monthly CVP checklist compliance from approximately 92% to 99%. CONCLUSIONS The customization and visualization of EHR data are both possible and worthwhile for the leveraging of information into easily comprehensible and actionable data for the improvement of health care provision and practice management. Limitations inherent to EHR data presentation make this customization necessary, and continued open access to the underlying data set is essential.
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Affiliation(s)
- Ronald A Kahn
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
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Nistal DA, Martini ML, Neifert SN, Price G, Carrasquilla A, Gal JS, Caridi JM. The Impact of Obstructive Sleep Apnea on Clinical, Perioperative, and Cost Outcomes in Patients Who Underwent Posterior Cervical Decompression and Fusion: A Single-Center Retrospective Analysis From 2008 to 2016. Int J Spine Surg 2022; 16:1075-1083. [PMID: 36153042 PMCID: PMC9807052 DOI: 10.14444/8324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a pervasive problem that can result in diminished neurocognitive performance, increased risk of all-cause mortality, and significant cardiovascular disease. While previous studies have examined risk factors that influence outcomes following cervical fusion procedures, to our knowledge, no study has examined the cost or outcome profiles for posterior cervical decompression and fusion (PCDF) procedures in patients with OSA. METHODS All cases at a single institution between 2008 and 2016 involving a PCDF were included. The primary outcome was prolonged extubation, defined as an extubation that took place outside of the operating room. Secondary outcomes included admission to the intensive care unit (ICU), complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 days, emergency room visit within 30 and 90 days, and higher total costs. RESULTS We reviewed 1191 PCDF cases, of which 93 patients (7.81%) had a history of OSA. At the univariate level, patients with OSA had higher rates of ICU admissions (33.3% vs 16.8%, P < 0.0001), total complications (29.0% vs 19.0%, P = 0.0202), and respiratory complications (12.9% vs 6.6%, P = 0.0217). Multivariate regression analyses revealed no difference in the odds of a prolonged extubation (P = 0.4773) and showed that history of OSA was not predictive of higher costs. However, a significant difference was observed in the odds of having an ICU admission (P = 0.0046). CONCLUSION While patients with sleep apnea may be more likely to be admitted to the ICU postoperatively, OSA status a lone is not a risk factor for poor primary and secondary clinical outcomes following posterior cervical fusion procedures. CLINICAL RELEVANCE Various deformities of the cervical spine can exert extraluminal forces that partially collapse or obstruct the airway, thereby predisposing patients to OSA; however, no study has examined the cost or outcome profiles for PCDF procedures in patients with OSA. Therefore, this investigation highlights the ways in which OSA influences the risks, outcomes, and costs following PCDF using medical data from an institutional registry. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Dominic A. Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael L. Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jonathan S. Gal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M. Caridi
- Department of Neurosurgery, UTHealth Neurosciences Spine Center, Houston, TX, USA, John M. Caridi, Department of Neurosurgery, UTHealth Neurosciences Spine Center, 6400 Fannin St, Suite 2150, Houston, TX, 77030, USA;
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10
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Neifert SN, Cho LD, Gal JS, Martini ML, Shuman WH, Chapman EK, Monterey M, Oermann EK, Caridi JM. Neurosurgical Performance in the First 2 Years of Merit-Based Incentive Payment System: A Descriptive Analysis and Predictors of Receiving Bonus Payments. Neurosurgery 2022; 91:87-92. [PMID: 35343468 DOI: 10.1227/neu.0000000000001927] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The merit-based incentive payment system (MIPS) program was implemented to tie Medicare reimbursements to value-based care measures. Neurosurgical performance in MIPS has not yet been described. OBJECTIVE To characterize neurosurgical performance in the first 2 years of MIPS. METHODS Publicly available data regarding MIPS performance for neurosurgeons in 2017 and 2018 were queried. Descriptive statistics about physician characteristics, MIPS performance, and ensuing payment adjustments were performed, and predictors of bonus payments were identified. RESULTS There were 2811 physicians included in 2017 and 3147 in 2018. Median total MIPS scores (99.1 vs 90.4, P < .001) and quality scores (97.9 vs 88.5, P < .001) were higher in 2018 than in 2017. More neurosurgeons (2758, 87.6%) received bonus payments in 2018 than in 2017 (2013, 71.6%). Of the 2232 neurosurgeons with scores in both years, 1347 (60.4%) improved their score. Reporting through an alternative payment model (odds ratio [OR]: 32.3, 95% CI: 16.0-65.4; P < .001) and any practice size larger than 10 (ORs ranging from 2.37 to 10.2, all P < .001) were associated with receiving bonus payments. Increasing years in practice (OR: 0.99; 95% CI: 0.982-0.998, P = .011) and having 25% to 49% (OR: 0.72; 95% CI: 0.53-0.97; P = .029) or ≥50% (OR: 0.48; 95% CI: 0.28-0.82; P = .007) of a physician's patients eligible for Medicaid were associated with lower rates of bonus payments. CONCLUSION Neurosurgeons performed well in MIPS in 2017 and 2018, although the program may be biased against surgeons who practice in small groups or take care of socially disadvantaged patients.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Logan D Cho
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Health System, New York, New York, USA
| | - Michael L Martini
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William H Shuman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily K Chapman
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael Monterey
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Eric K Oermann
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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11
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Valliani AA, Feng R, Martini ML, Neifert SN, Kim NC, Gal JS, Oermann EK, Caridi JM. Pragmatic Prediction of Excessive Length of Stay After Cervical Spine Surgery With Machine Learning and Validation on a National Scale. Neurosurgery 2022; 91:322-330. [DOI: 10.1227/neu.0000000000001999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/10/2022] [Indexed: 11/19/2022] Open
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12
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Shuman WH, Neifert SN, Gal JS, Snyder DJ, Deutsch BC, Zimering JH, Rothrock RJ, Caridi JM. The Impact of Diabetes on Outcomes and Health Care Costs Following Anterior Cervical Discectomy and Fusion. Global Spine J 2022; 12:780-786. [PMID: 33034217 PMCID: PMC9344522 DOI: 10.1177/2192568220964053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Anterior cervical discectomy and fusion (ACDF) is commonly used to treat an array of cervical spine pathology and is associated with good outcomes and low complication rates. Diabetes mellitus (DM) is a common comorbidity for patients undergoing ACDF, but the literature is equivocal about the impact it has on outcomes. Because DM is a highly prevalent comorbidity, it is crucial to determine if it is an associated risk factor for outcomes after ACDF procedures. METHODS Patients at a single institution from 2008 to 2016 undergoing ACDF were compared on the basis of having a prior diagnosis of DM versus no DM. The 2 cohorts were compared utilizing univariate tests and multivariate logistic and linear regressions. RESULTS Data for 2470 patients was analyzed. Diabetic patients had significantly higher Elixhauser scores (P < .0001). Univariate testing showed diabetic patients were more likely to suffer from sepsis (0.82% vs 0.10%, P = .03) and bleeding complications (3.0% vs 1.5%, P = .04). In multivariate analyses, diabetic patients had higher rates of non-home discharge (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.07-1.75, P = .013) and prolonged length of stay (OR = 1.95, 95% CI = 1.25-3.05, P = .003), but similar complication (OR = 1.46, 95% CI = 0.85-2.52, P = .17), reoperation (OR = 0.77, 95% CI = 0.33-1.81, P = .55), and 90-day readmission (OR = 1.53, 95% CI = 0.97-2.43) rates compared to nondiabetic patients. Direct cost was also shown to be similar between the cohorts after adjusting for patient, surgical, and hospital-related factors (estimate = -$30.25, 95% CI = -$515.69 to $455.18, P = .90). CONCLUSIONS Diabetic patients undergoing ACDF had similar complication, reoperation, and readmission rates, as well as similar cost of care compared to nondiabetic patients.
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Affiliation(s)
- William H. Shuman
- Icahn School of Medicine at Mount
Sinai, New York, NY, USA,Will Shuman, Department of Neurosurgery,
Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY
10029, USA.
| | | | | | | | | | | | | | - John M. Caridi
- Icahn School of Medicine at Mount
Sinai, New York, NY, USA
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13
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Arrighi-Allisan AE, Neifert SN, Gal JS, Zeldin L, Zimering JH, Gilligan JT, Deutsch BC, Snyder DJ, Nistal DA, Caridi JM. Diabetes Is Predictive of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion. Global Spine J 2022; 12:229-236. [PMID: 35253463 PMCID: PMC8907640 DOI: 10.1177/2192568220948480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The present study analyzes complication rates and episode-based costs for patients with and without diabetes mellitus (DM) following posterior lumbar fusion (PLF). METHODS PLF cases at a single institution from 2008 to 2016 were queried (n = 3226), and demographic and perioperative data were analyzed. Patients with and without the diagnosis of DM were compared using chi-square, Student's t test, and multivariable regression modeling. RESULTS Patients with diabetes were older (63.10 vs 56.48 years, P < .001) and possessed a greater number of preoperative comorbidities (47.84% of patients had Elixhauser Comorbidity Index >0 vs 42.24%, P < .001) than did patients without diabetes. When controlling for preexisting differences, diabetes remained a significant risk factor for prolonged length of stay (OR = 1.59, 95% CI 1.26-2.01, P < .001), intensive care unit stay (OR = 1.52, 95% CI 1.07-2.17, P = .021), nonhome discharge (OR = 1.86, 95% CI 1.46-2.37, P < .001), 30-day readmission (OR = 2.15, 95% CI 1.28-3.60, P = .004), 90-day readmission (OR = 1.65, 95% CI 1.05-2.59, P = .031), 30-day emergency room visit (OR = 2.15, 95% CI 1.27-3.63, P = .004), and 90-day emergency room visit (OR = 2.27, 95% CI 1.41-3.65, P < .001). Cost modeling controlling for overall comorbidity burden demonstrated that diabetes was associated with a $1709 increase in PLF costs (CI $344-$3074, P = .014). CONCLUSIONS The present findings indicate a correlation between diabetes and a multitude of postoperative adverse outcomes and increased costs, thus illustrating the substantial medical and financial burdens of diabetes for PLF patients. Future studies should explore preventive measures that may mitigate these downstream effects.
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Affiliation(s)
- Annie E. Arrighi-Allisan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Annie Arrighi-Allisan, Icahn School of
Medicine at Mount Sinai, 1468 Madison Avenue, New York, NY 10029, USA.
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14
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Weiner AR, Durbin JR, Lunardi SR, Li AY, Hannah TC, Schupper AJ, Gal JS, Jumreornvong O, Spiera Z, Ali M, Marayati NF, Gometz A, Lovell MR, Choudhri TF. Incidence and Severity of Concussions Among Young Soccer Players Based on Age, Sex, and Player Position. Orthop J Sports Med 2022; 10:23259671211059216. [PMID: 35083358 PMCID: PMC8785311 DOI: 10.1177/23259671211059216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Previously studied risk factors for sports-related concussion in soccer players include sex, age, and player position. However, prior studies were limited in number, they reported conflicting results, and most did not assess initial concussion severity. Purpose/Hypothesis: The purpose of this study was to conduct an in-depth analysis of soccer players across key demographic groups (sex, age, position) for both concussion incidence and severity. It was hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers. Study Design: Cohort study; Level of evidence, 3. Methods: The authors analyzed baseline and postinjury ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) scores for athletes aged 12 to 22 years between July 2009 and June 2019. Players were assigned to an age group based on when they had their most recent baseline test. Concussion incidence and concussion severity index were compared using t tests and multivariate logistic regression. Results: For 1189 individuals who reported soccer as their primary sport, 1032 contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. Of these players, 254 (24.6%) had both a baseline and a postinjury test and were analyzed for concussion severity. Linear regression showed that forwards had a lower incidence of ImPACT-proxied concussions than goalkeepers had (P = .008). Female players had a significantly higher incidence of ImPACT concussions compared with male players (mean, 0.07 [female] vs 0.04 [male] concussions per person-year; P = .05). Players in the ≥17-year age group had a higher incidence of ImPACT concussions than players in the 15- to 16-year age group (P = .04), although the 15- to 16-year age group had more severe concussions than the ≥17-year age group (mean severity index, 2.91 [age 15-16 years] vs 1.73 [age ≥17 years]; P = .001). Conclusion: Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity.
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Affiliation(s)
- Alden R. Weiner
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John R. Durbin
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Adam Y. Li
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Theodore C. Hannah
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J. Schupper
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S. Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Oranicha Jumreornvong
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zachary Spiera
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoum Fares Marayati
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex Gometz
- Concussion Management of New York, New York, New York, USA
| | - Mark R. Lovell
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tanvir F. Choudhri
- Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Shuman WH, Baron RB, Gal JS, Li AY, Neifert SN, Hannah TC, Dreher N, Schupper AJ, Steinberger JM, Caridi JM, Choudhri TF. Seasonal Effects on Surgical Site Infections Following Spine Surgery. World Neurosurg 2022; 161:e174-e182. [DOI: 10.1016/j.wneu.2022.01.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 11/28/2022]
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Chapman EK, Valliani AA, Shuman WH, Martini ML, Neifert SN, Gilligan JT, Yuk FJ, Schupper AJ, Gal JS, Caridi JM. Clinical Trials in Spinal Tumors: A Two-Decade Review. World Neurosurg 2021; 161:e39-e53. [PMID: 34861445 DOI: 10.1016/j.wneu.2021.11.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Clinical trials are essential for assessing advancements in spine tumor therapeutics. The purpose of this study is to characterize trends in clinical trials for primary and metastatic tumor treatments over the past two decades. METHODS ClinicalTrials.gov was queried using the search term "spine" for all interventional studies spanning 1999 to 2020 with categories of "Cancer", "Neoplasm", "Tumor", or "Metastasis". Tumor type, phase data, enrollment numbers and home institution country were recorded. The sponsor was categorized as academic institution, industry, government or other and intervention type as procedure, drug, device, radiation or other. Frequency of each category and cumulative frequency over twenty years were calculated. RESULTS 106 registered trials for spine tumors were listed. All except two that began before 2008 have been completed, enrollment of 51-100 subjects (29.8%) was the most common, and the majority were phase II (54.4%). Most examined metastatic tumors (58.5%) and new trials per year increased 3.4-fold between 2009 and 2020. The majority were conducted in the United States (56.4%). The most common intervention strategy was radiation (32.1%), although between 2010-2020 procedural studies became the most frequent (2.4 per year). The majority were sponsored by academic institutions (63.2%), and over twenty years have sponsored 3.2-fold more studies than industry partners. CONCLUSIONS The number of clinical trials for spine tumor therapies has rapidly increased over the past 15 years, driven by studies at United States academic medical institutions investigating radiosurgery for treatment of metastases. Targeted therapies for tumor subtypes and sequelae have updated international best practices.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Aly A Valliani
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey T Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Chapman EK, Scherschinski L, Gal JS, Shuman WH, Doctor T, Neifert SN, Martini ML, McNeill IT, Yuk FJ, Schupper AJ, Caridi JM. The Impact of ASA Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion. World Neurosurg 2021; 161:e54-e60. [PMID: 34856400 DOI: 10.1016/j.wneu.2021.11.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Increasing numbers of posterior cervical decompression and fusion (PCDF) over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of healthcare costs, length of stay, and other postoperative outcomes in PCDF patients. OBJECTIVE To evaluate correlations between ASA and postoperative outcomes, length of stay (LOS), and healthcare costs in patients undergoing PCDF. METHODS 971 patients that underwent PCDF between 2008 and 2016 at a single institution were evaluated by low (I and II) versus high (III and IV) ASA. Demographics were compared using univariate analysis. Cost of care, LOS and postoperative complications were compared using multivariable logistic and linear regression, controlling for gender, age, length of surgery and number of segments fused. RESULTS The high ASA cohort had greater mean age (62 vs. 55, p<0.0001) and higher Elixhauser comorbidity index (ECI) scores (p<0.0001). ASA was independently associated with longer LOS (+2.1 days, CI: 1.3-2.9; p<0.0001) and higher cost (+$2,936, CI: $1,457-$4,415; p<0.0001). High ASA patients were more likely to have a non-home discharge (3.9, 95% CI 2.8-5.6, p<0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, p=0.006), ICU stay (2.4, 95% CI 1.5-3.7, p=0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, p=0.03) and 30-day (3.2, 95% CI 1.5-6.8, p=0.003) and 90-day (3.2, 95% CI 1.8-5.7, p=0.0001) readmission. CONCLUSIONS High ASA is strongly associated with increased costs, LOS and adverse outcomes following PCDF. Therefore, ASA could be useful for preoperative prediction of these outcomes.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Lea Scherschinski
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M Caridi
- Department of Neurosurgery, UT Health, Houston, TX, USA
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18
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Chapman EK, Doctor T, Gal JS, Shuman WH, Neifert SN, Martini ML, McNeill IT, Rothrock RJ, Schupper AJ, Caridi JM. The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis. Spine (Phila Pa 1976) 2021; 46:1535-1541. [PMID: 34027927 DOI: 10.1097/brs.0000000000004127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. METHODS Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. RESULTS Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). CONCLUSION Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesia, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Gal JS, Morewood GH, Mueller JT, Popovich MT, Caridi JM, Neifert SN. Anesthesia provider performance in the first two years of merit-based incentive payment system: Shifts in reporting and predictors of receiving bonus payments. J Clin Anesth 2021; 76:110582. [PMID: 34775348 DOI: 10.1016/j.jclinane.2021.110582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE The Merit-Based Incentive Payment System (MIPS) program was intended to align CMS quality and incentive programs. To date, no reports have described anesthesia clinician performance in the first two years of the program. DESIGN Observational retrospective cohort study. SETTING Centers for Medicare and Medicaid Services public datasets for their Quality Payment Program. PATIENTS Anesthesia clinicians who participated in MIPS for 2017 and 2018 performance years. INTERVENTIONS Descriptive statistics compared anesthesia clinician characteristics, practice setting, and MIPS performance between the two years to determine associations with MIPS-based payment adjustments. MEASUREMENTS Logistic regression identified independent predictors of bonus payments for exceptional performance. MAIN RESULTS Compared with participants in 2017 (n = 25,604), participants in 2018 (n = 54,381) had a higher proportion of reporting through groups and alternative payment models (APMs) than as individuals (p < 0.001). The proportion of clinicians earning performance bonuses increased from 2017 to 2018 except for those MIPS participants reporting as individuals. Median total MIPS scores were higher in 2018 than 2017 (84.6 vs. 82.4, p < 0.001), although median total scores fell for participants reporting as individuals (40.9 vs 75.5, p < 0.001). Among clinicians with scores in both years (n = 20,490), 10,559 (51.3%) improved their total score between 2017 and 2018, and 347 (1.7%) changed reporting from individual to APM. Reporting as an individual compared with group reporting (OR: 0.75; 95% CI: 0.71 to 0.80; p < 0.001) was associated with lower rates of bonus payments, as was having a greater proportion of patients dual-eligible for Medicaid and Medicare. Reporting through an APM (OR: 149.6; 95% CI: 110 to 203.4; p < 0.001) and increasing practice group size were associated with higher likelihood of bonus payments. CONCLUSIONS Anesthesia clinician MIPS participation and performance were strong during 2017 and 2018 performance years. Providers who reported through groups or APMs have a higher likelihood of receiving bonus payments.
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Affiliation(s)
- Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Gordon H Morewood
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19102, USA.
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Phoenix, AZ 85054, USA.
| | - Matthew T Popovich
- Quality and Regulatory Affairs, American Society of Anesthesiologists, Washington, DC 20006, USA.
| | - John M Caridi
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
| | - Sean N Neifert
- Department of Neurosurgery, NYU Langone Health, New York, NY 10016, USA.
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Crooms RC, Lin HM, Neifert S, Deiner SG, Brallier JW, Goldstein NE, Gal JS, Gelfman LP. Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center. J Palliat Med 2021; 24:1550-1554. [PMID: 34166114 DOI: 10.1089/jpm.2021.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hung-Mo Lin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Neifert
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stacie G Deiner
- Dartmouth Hitchcock and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jess W Brallier
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jonathan S Gal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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Martini ML, Neifert SN, Oermann EK, Gilligan JT, Rothrock RJ, Yuk FJ, Gal JS, Nistal DA, Caridi JM. Application of Cooperative Game Theory Principles to Interpret Machine Learning Models of Nonhome Discharge Following Spine Surgery. Spine (Phila Pa 1976) 2021; 46:803-812. [PMID: 33394980 DOI: 10.1097/brs.0000000000003910] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of prospectively acquired data. OBJECTIVE The aim of this study was to identify interaction effects that modulate nonhome discharge (NHD) risk by applying coalitional game theory principles to interpret machine learning models and understand variable interaction effects underlying NHD risk. SUMMARY OF BACKGROUND DATA NHD may predispose patients to adverse outcomes during their care. Previous studies identified potential factors implicated in NHD; however, it is unclear how interaction effects between these factors contribute to overall NHD risk. METHODS Of the 11,150 reviewed cases involving procedures for degenerative spine conditions, 1764 cases (15.8%) involved NHD. Gradient boosting classifiers were used to construct predictive models for NHD for each patient. Shapley values, which assign a unique distribution of the total NHD risk to each model variable using an optimal cost-sharing rule, quantified feature importance and examined interaction effects between variables. RESULTS Models constructed from features identified by Shapley values were highly predictive of patient-level NHD risk (mean C-statistic = 0.91). Supervised clustering identified distinct patient subgroups with variable NHD risk and their shared characteristics. Focused interaction analysis of surgical invasiveness, age, and comorbidity burden suggested age as a worse risk factor than comorbidity burden due to stronger positive interaction effects. Additionally, negative interaction effects were found between age and low blood loss, indicating that intraoperative hemostasis may be critical for reducing NHD risk in the elderly. CONCLUSION This strategy provides novel insights into feature interactions that contribute to NHD risk after spine surgery. Patients with positively interacting risk factors may require special attention during their hospitalization to control NHD risk.Level of Evidence: 3.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeffrey T Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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Schupper AJ, Neifert SN, Martini ML, Gal JS, Yuk FJ, Caridi JM. Surgeon experience influences patient characteristics and outcomes in spine deformity surgery. Spine Deform 2021; 9:341-348. [PMID: 33105015 DOI: 10.1007/s43390-020-00227-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/10/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE To characterize differences in patient demographics and outcomes by surgeon experience in a cohort of patients undergoing adult spinal deformity surgery. METHODS Patients undergoing degenerative spinal deformity were included. Patients whose surgeons graduated from fellowship ≤ 5 years prior to surgery versus > 5 years were compared. Multivariable linear and logistic regression, controlling for age, sex, comorbidity burden, number of segments fused, blood loss and operative time were used to evaluate differences in outcomes. Characteristics of operative invasiveness were plotted against surgeons' level of experience, and trends in these measures were assessed with univariate linear regression. RESULTS Three-hundred sixty-three patients were included. 147 patients' surgeons had ≤ 5 years of experience. Patient demographics were evenly matched. Patients with junior surgeons had more pre-existing medical complications, and senior surgeons were less likely to take care of patients with Medicare/Medicaid (p < 0.001). Junior surgeons were more likely to operate on non-elective patients (p < 0.001). Patients of junior surgeons received larger fusions (9.6 vs. 7.6 segments fused, p < 0.001). There were no differences in complication rates or death. Patients of junior surgeons had longer overall length of stays (p = 0.037) and higher rates of nonhome discharge (OR 2.0, p < 0.001), 30- and 90-day (p < 0.005) ED visits, and higher costs (+ $8548, 95% CI: $1596 to $15,502; p = 0.016). CONCLUSION Junior surgeons tend to perform more extensive deformity operations on more medically complex patients compared to senior surgeons, associated with higher costs and more resource utilization than senior surgeons.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
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Shuman WH, Chapman EK, Gal JS, Neifert SN, Martini ML, Schupper AJ, Lamb CD, McNeill IT, Gilligan J, Caridi JM. Surgery for spinal deformity: non-elective admission status is associated with higher cost of care and longer length of stay. Spine Deform 2021; 9:373-379. [PMID: 33006745 DOI: 10.1007/s43390-020-00215-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/21/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Surgery is commonly indicated for adult spinal deformity. Annual rates and costs of spinal deformity surgery have both increased over the past two decades. However, the impact of non-elective status on total cost of hospitalization and patient outcomes has not been quantified. OBJECTIVE To evaluate the impact of admission status on patient outcomes and healthcare costs in spinal deformity surgery. METHODS All patients who underwent spinal deformity surgery at a single institution between 2008 and 2016 were grouped by admission status: elective, emergency (ED), or transferred. Demographics were compared by univariate analysis. Cost of care and length of stay (LOS) were compared between admission statuses using multivariable linear regression with elective admissions as reference. Multivariate logistic regression was utilized to assess in-hospital complications, discharge destination, and readmission rates. RESULTS There were 427 spinal deformity surgeries included in this study. Compared to elective patients, ED patients had higher Elixhauser Comorbidity Index scores (p < 0.0001), longer LOS (+ 10.9 days, 97.5% CI 6.1-15.6 days, p < 0.0001), and higher costs (+ $20,076, 97.5% CI $9,073-$31,080, p = 0.0008). Transferred patients had significantly higher Elixhauser scores (p = 0.0002), longer LOS (+ 8.8 days, 97.5% CI 3.0-14.7 days, p < 0.0001), and higher rates of non-home discharge (OR = 15.8, 97.5% CI 2.3-110.0, p = 0.001). CONCLUSION Patients admitted from the ED undergoing spinal deformity surgery had significantly higher cost of care and longer LOS compared to elective patients. Transferred patients had significantly longer LOS and a higher rate of non-home discharge compared to elective patients.
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Affiliation(s)
- William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA.
| | - Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Colin D Lamb
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Jeffrey Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
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Maron SZ, Dan J, Gal JS, Neifert SN, Martini ML, Lamb CD, Genadry L, Rothrock RJ, Steinberger J, Rasouli JJ, Caridi JM. Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes. Clin Spine Surg 2021; 34:E107-E111. [PMID: 33633067 DOI: 10.1097/bsd.0000000000001063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective analysis of clinical data from a single institution. OBJECTIVE The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy. SUMMARY OF BACKGROUND DATA The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy. METHODS Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates. RESULTS Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts. CONCLUSION The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.
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Affiliation(s)
| | | | - Jonathan S Gal
- Anesthesia, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, NY
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Chapman EK, Doctor T, Gal JS, Martini ML, Shuman WH, Neifert SN, Gilligan JT, Yuk FJ, Zimering JH, Schupper AJ, Caridi JM. Comparison of Surgical Outcomes of Microdiskectomy Procedures by Patient Admission Status. World Neurosurg 2021; 150:e38-e44. [PMID: 33610871 DOI: 10.1016/j.wneu.2021.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to compare the cost and in-hospital outcomes following lumbar microdiskectomy procedures by admission type. METHODS Patients undergoing lumbar microdiskectomy at a single institution from 2008 to 2016 following an elective admission (EL) were compared against those who were admitted from the emergency department (ED) or from elsewhere within or outside the hospital system (TR) for their perioperative outcomes and cost. Multivariable modeling controlled for age, sex, self-reported race, Elixhauser comorbidity score, payer type, number of segments, and procedure length. RESULTS Of the 1249 patients included in this study, 1116 (89.4%) were admitted electively while 123 (9.8%) were admitted from the ED and 10 (0.8%) were transferred from other hospitals. EL patients had significantly lower comorbidity burdens (P < 0.0001). Univariate and multivariable analyses revealed that transfer admission patients experienced significantly longer hospitalizations (ED: +1.7 days; P < 0.0001; TR: +5.3 days; P < 0.0001) and higher direct costs (ED: $1889; P < 0.0001; TR: $7001; P < 0.0001) compared with EL patients. Despite these risks, ED and TR patients only had increased odds of nonhome discharge compared with EL patients (ED: 3.4; P = 0.002; TR: 7.9; P = 0.02). CONCLUSIONS Patients admitted as transfers and from the ED had significantly increased hospitalization lengths of stay and direct costs compared with electively admitted patients.
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Affiliation(s)
- Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Tahera Doctor
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesia, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey T Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey H Zimering
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Martini ML, Neifert SN, Gal JS, Oermann EK, Gilligan JT, Caridi JM. Drivers of Prolonged Hospitalization Following Spine Surgery: A Game-Theory-Based Approach to Explaining Machine Learning Models. J Bone Joint Surg Am 2021; 103:64-73. [PMID: 33186002 DOI: 10.2106/jbjs.20.00875] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Understanding the interactions between variables that predict prolonged hospital length of stay (LOS) following spine surgery can help uncover drivers of this risk in patients. This study utilized a novel game-theory-based approach to develop explainable machine learning models to understand such interactions in a large cohort of patients treated with spine surgery. METHODS Of 11,150 patients who underwent surgery for degenerative spine conditions at a single institution, 3,310 (29.7%) were characterized as having prolonged LOS. Machine learning models predicting LOS were built for each patient. Shapley additive explanation (SHAP) values were calculated for each patient model to quantify the importance of features and variable interaction effects. RESULTS Models using features identified by SHAP values were highly predictive of prolonged LOS risk (mean C-statistic = 0.87). Feature importance analysis revealed that prolonged LOS risk is multifactorial. Non-elective admission produced elevated SHAP values, indicating a clear, strong risk of prolonged LOS. In contrast, intraoperative and sociodemographic factors displayed bidirectional influences on risk, suggesting potential protective effects with optimization of factors such as estimated blood loss, surgical duration, and comorbidity burden. CONCLUSIONS Meticulous management of patients with high comorbidity burdens or Medicaid insurance who are admitted non-electively or spend clinically indicated time in the intensive care unit (ICU) during their hospitalization course may be warranted to reduce their risk of unanticipated prolonged LOS following spine surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael L Martini
- Departments of Neurosurgery (M.L.M., S.N.N., E.K.O., J.T.G., and J.M.C.) and Anesthesiology (J.S.G.), Icahn School of Medicine at Mount Sinai, New York, NY
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Schupper AJ, Shuman WH, Baron RB, Neifert SN, Chapman EK, Gilligan J, Gal JS, Caridi JM. Utilization of the American Society of Anesthesiologists (ASA) classification system in evaluating outcomes and costs following deformity spine procedures. Spine Deform 2021; 9:185-190. [PMID: 32780301 DOI: 10.1007/s43390-020-00176-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Adult spinal deformity (ASD) has increased prevalence in aging populations. Due to the high cost of surgery, studies have evaluated risk factors that predict readmissions and poor outcomes. The American Society of Anesthesiologists (ASA) classification system has been applied to patients with ASD to assess preoperative health and assess the correlation between ASA class and postoperative complications. This study evaluates the relationship between ASA and complications, length of stay (LOS), and direct costs following spine deformity surgery. METHODS Patients undergoing spine deformity surgery at a single institution from 2008-2016 were included and stratified based upon ASA status. Primary outcomes included patient demographics, adjusted LOS, and cost of care. Secondary measures compared between cohorts included adverse events, non-home discharge, and readmission rates. RESULTS 442 patients with ASD were included in this study. Higher ASA class was correlated with greater Elixhauser Comorbidity Index (ECI) scores (p < 0.0001) and older age (p < 0.0001). Univariate analysis showed longer LOS (p < 0.0001) and greater direct costs in patients with higher ASA class (p < 0.0001). Patients in ASA Class III or IV had the greatest incidence of ICU stay when compared to patients without systemic disease (p < 0.0001). Upon multivariable regression analysis, high ASA class was associated with higher rates of non-home discharge (OR 5.0, 95% CI 3.1-8.1). Direct costs were greater for higher ASA class (regression estimate = + $9,666, p = 0.002). CONCLUSION This study demonstrates that ASA class is correlated with a more complicated postoperative hospital course, greater rates of non-home discharge, total direct costs in spine deformity patients.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA.
| | - William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Rebecca B Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Jeffrey Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, 10029, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Annenberg 8th Floor, 1 Gustave Levy Place, New York, NY, 10029, USA
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Neifert SN, Chapman EK, Rothrock RJ, Gilligan J, Yuk F, McNeill IT, Rasouli JJ, Gal JS, Caridi JM. Lower Mortality and Morbidity with Low-Molecular-Weight Heparin for Venous Thromboembolism Prophylaxis in Spine Trauma. Spine (Phila Pa 1976) 2020; 45:1613-1618. [PMID: 33156289 DOI: 10.1097/brs.0000000000003664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE The objective of this study was to evaluate outcomes between patients receiving LMWH versus UH in a retrospective cohort of patients with spine trauma. SUMMARY OF BACKGROUND DATA Although multiple clinical trials have been conducted, current guidelines do not have enough evidence to suggest low-molecular-weight heparin (LMWH) or unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in spine trauma. METHODS Patients with spine trauma in the Trauma Quality Improvement Program datasets were identified. Those who died, were transferred within 72 hours, were deemed to have a fatal injury, were discharged within 24 hours, suffered from polytrauma, or were missing data for VTE prophylaxis were excluded. A propensity score was created using age, sex, severity of injury, time to prophylaxis, presence of a cord injury, and altered mental status or hypotension upon arrival, and inverse probability weighted logistic regression modeling was used to evaluate mortality, venous thromboembolic, return to operating room, and total complication rates. E values were used to calculate the likelihood of unmeasured confounders. RESULTS Those receiving UH (n = 7172) were more severely injured (P < 0.0001), with higher rates of spinal cord injury (32.26% vs. 25.32%, P < 0.0001) and surgical stabilization (29.52% vs. 22.94%, P < 0.0001) compared to those receiving LMWH (n = 20,341). Patients receiving LMWH had lower mortality (odds ratio [OR]: 0.47; 95% CI: 0.42-0.53; P < 0.001; E = 3.68), total complication (OR: 0.92; 95% CI: 0.88-0.95; P < 0.001; E = 1.39), and VTE event (OR: 0.80; 95% CI: 0.72-0.88; P < 0.001; E = 1.81) rates than patients receiving UH. There were no differences in rates of unplanned return to the operating room (OR: 1.01; 95% CI: 0.80-1.27; P = 0.93; E = 1.11). CONCLUSION There is an association between lower mortality and receiving LMWH for VTE prophylaxis in patients with spine trauma. A large randomized clinical trial is necessary to confirm these findings. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
| | | | | | - Frank Yuk
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
| | - Ian T McNeill
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
| | | | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Mount Sinai Hospital, New York, NY
| | - John M Caridi
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
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Hannah TC, Neifert SN, Caridi JM, Martini ML, Lamb C, Rothrock RJ, Yuk FJ, Gilligan J, Genadry L, Gal JS. Utility of the Hospital Frailty Risk Score for Predicting Adverse Outcomes in Degenerative Spine Surgery Cohorts. Neurosurgery 2020; 87:1223-1230. [PMID: 32542353 DOI: 10.1093/neuros/nyaa248] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As spine surgery becomes increasingly common in the elderly, frailty has been used to risk stratify these patients. The Hospital Frailty Risk Score (HFRS) is a novel method of assessing frailty using International Classification of Diseases, Tenth Revision (ICD-10) codes. However, HFRS utility has not been evaluated in spinal surgery. OBJECTIVE To assess the accuracy of HFRS in predicting adverse outcomes of surgical spine patients. METHODS Patients undergoing elective spine surgery at a single institution from 2008 to 2016 were reviewed, and those undergoing surgery for tumors, traumas, and infections were excluded. The HFRS was calculated for each patient, and rates of adverse events were calculated for low, medium, and high frailty cohorts. Predictive ability of the HFRS in a model containing other relevant variables for various outcomes was also calculated. RESULTS Intensive care unit (ICU) stays were more prevalent in high HFRS patients (66%) than medium (31%) or low (7%) HFRS patients. Similar results were found for nonhome discharges and 30-d readmission rates. Logistic regressions showed HFRS improved the accuracy of predicting ICU stays (area under the curve [AUC] = 0.87), nonhome discharges (AUC = 0.84), and total complications (AUC = 0.84). HFRS was less effective at improving predictions of 30-d readmission rates (AUC = 0.65) and emergency department visits (AUC = 0.60). CONCLUSION HFRS is a better predictor of length of stay (LOS), ICU stays, and nonhome discharges than readmission and may improve on modified frailty index in predicting LOS. Since ICU stays and nonhome discharges are the main drivers of cost variability in spine surgery, HFRS may be a valuable tool for cost prediction in this specialty.
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Affiliation(s)
- Theodore C Hannah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Colin Lamb
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey Gilligan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lisa Genadry
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Shuman WH, Neifert SN, Gal JS, Martini ML, Schupper AJ, Steinberger JM, Maron SZ, Lamb CD, Rothrock RJ, McNeill IT, Cho SK, Caridi JM. Correction to: Adult spinal deformity surgery: the effect of surgical start time on patient outcomes and cost of care. Spine Deform 2020; 8:1025. [PMID: 32424696 DOI: 10.1007/s43390-020-00135-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The original version of this article unfortunately contained a mistake. The first name of the author "Samuel Z. Maron" was incorrectly provided as "Sam" instead of "Samuel".
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Affiliation(s)
- William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA.
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Jeremy M Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Samuel Z Maron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Colin D Lamb
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Ian T McNeill
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
| | - Samuel K Cho
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 50 East 98th St, Apartment 7D-4, New York, NY, 10029, USA
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Baron RB, Neifert SN, Ranson WA, Schupper AJ, Gal JS, Cho SK, Caridi JM. A Comparison of the Elixhauser and Charlson Comorbidity Indices: Predicting In-Hospital Complications Following Anterior Lumbar Interbody Fusions. World Neurosurg 2020; 144:e353-e360. [PMID: 32841797 DOI: 10.1016/j.wneu.2020.08.138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) are commonly used measures that use administrative data to characterize a patient's comorbidity burden. The purpose of this study was to compare the ability of these measures to predict outcomes following anterior lumbar interbody fusion. METHODS The National Inpatient Sample was queried for all ALIF procedures between 2013 and 2014. The area under the receiver operating curve (AUC) was used to compare the ECI and CCI in their ability to predict postoperative complications when incorporated into a base model containing age, sex, race, and primary payer. Percent superiority was computed using AUC values for ECI, CCI, and base models. RESULTS A total of 43,930 hospitalizations were included in this study. The ECI was superior to the CCI and baseline models in predicting minor (AUC 71 vs. 0.66, P < 0.0001) and major (AUC 0.74 vs. 0.67, P < 0.0001) complications. When evaluating individual complications, the ECI was superior to the CCI in predicting airway complications (65% superior, AUC 0.85 vs. 0.72, P = 0.0001); hemorrhagic anemia (83% superior, AUC 0.71 vs. 0.66, P < 0.0001); myocardial infarction (76% superior, AUC 0.86 vs. 0.67, P < 0.0001); cardiac arrest (75% superior, AUC 0.85 vs. 0.67, P < 0.0001); pulmonary embolism (105% superior, AUC 0.91 vs. 0.71, P < 0.0001); and urinary tract infection (43% superior, AUC 0.76 vs. 0.73, P = 0.046). CONCLUSIONS The ECI was superior to the CCI in predicting 6 of the 15 complications analyzed in this study. Combined with previous results, the ECI may be a better predictive model in spine surgery.
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Affiliation(s)
- Rebecca B Baron
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William A Ranson
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lakha S, Levin MA, Leibowitz AB, Lin HM, Gal JS. Intraoperative Electronic Alerts Improve Compliance With National Quality Program Measure for Perioperative Temperature Management. Anesth Analg 2020; 130:1167-1175. [PMID: 32287124 DOI: 10.1213/ane.0000000000004546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Reimbursement for anesthesia services has been shifting from a fee-for-service model to a value-based model that ties payment to quality metrics. The Centers for Medicare & Medicaid Service's (CMS) value-based payment program includes a quality measure for perioperative temperature management (Measure #424, Perioperative Temperature Management). Compliance may impose new challenges in clinical practice, data collection, and reporting. We investigated the impact of an electronic decision-support tool on adherence to this emerging standard. METHODS In this retrospective observational study, perioperative temperature data were collected from cases eligible for reporting this measure to CMS from a single academic medical center before and after the implementation of an electronic decision-support tool that prompted temperature measurement and maintenance of normothermia. Proportions of measure compliance were assessed using segmented regression analysis. Proportions of intraoperative temperature measurement were also assessed, and multivariable logistic regression was performed to assess the association between patient and surgical factors and measure compliance. RESULTS A total of 24,755 cases eligible for reporting in 2017 were assessed, and 25,274 cases from 2016 were included as an extended baseline. Segmented time-series regression did not show a significant baseline trend in measure compliance. Introduction of the alerts was associated with an increase in overall compliance from 84.4% (95% confidence interval [CI], 83.6%-85.2%) to 92.4% (91.4%-93.4%), and an increase in intraoperative compliance from 26.8% (25.8%-27.8%) to 71.0% (69.6%-72.4%). The association between the alerts and overall compliance was also present on multivariable analysis. CONCLUSIONS Implementation of an intraoperative decision-support tool was associated with statistically significant improvement in the maintenance of normothermia in cases eligible for reporting to CMS. This led to improved compliance with Measure #424 and suggests that electronic alerts can help practices improve their performance and payment bonus eligibility.
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Affiliation(s)
- Sameer Lakha
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Matthew A Levin
- From the Departments of Anesthesiology, Perioperative and Pain Medicine.,Genetics and Genomic Sciences
| | | | - Hung-Mo Lin
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan S Gal
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
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Martini ML, Caridi JM, Zeldin L, Neifert SN, Nistal DA, Kim JD, Khelemsky Y, Gal JS. Perioperative Outcomes of Spinal Cord Stimulator Placement in Patients with Complex Regional Pain Syndrome Compared with Patients without Complex Regional Pain Syndrome. World Neurosurg 2020; 137:e106-e117. [PMID: 31954908 DOI: 10.1016/j.wneu.2020.01.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Complex regional pain syndrome (CRPS) is a multifaceted disorder resulting in an abnormal pain response to tissue injury. Among key CRPS features are neurogenic inflammation, maladaptive plasticity, and vasomotor dysfunction, which can result in severe pain and disability. Spinal cord stimulation (SCS) is an efficacious treatment for several chronic pain conditions and may improve pain and life quality in CRPS patients with CRPS. However, little information exists regarding perioperative outcomes of patients with CRPS undergoing surgical implantation of an SCS device. METHODS Patients were included if they underwent an SCS procedure at our institution between 2008 and 2016 for chronic pain. Cases were excluded if the procedure involved stimulator removal or if it was an outpatient procedure. Multivariate regression assessed the effect of CRPS and other clinical variables on perioperative outcomes. RESULTS Eighty-one inpatient SCS implantation cases for chronic pain were included, with 9 patients (11.1%) having a CRPS diagnosis. The CRPS cohort received higher mean quantities of intraoperative opioids and had a lower proportion of patients reporting meaningful pain reduction (16.7%) in the 24-hour postoperative setting compared with patients without CRPS (35.9%), although this was not statistically significant. Multivariate regression modeling suggested that CRPS was a significant predictor of increased odds of extended time to the postanesthesia care unit discharge (P = 0.0406) and higher direct costs of hospitalization (P = 0.0326). CONCLUSIONS Our data suggest that CRPS may pose several unique risks in the perioperative period after inpatient SCS implantation. These findings support the need for future prospective investigations examining risks and outcomes for SCS procedures in this population.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lawrence Zeldin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dominic A Nistal
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jinseong D Kim
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yury Khelemsky
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Chapman EK, Neifert SN, Rothrock RJ, Yuk F, McNeill IT, Rasouli JJ, Gal JS, Caridi JM. Lower Mortality and Morbidity With Low Molecular Weight Heparin for Venous Thromboembolic Event Prophylaxis in Spine Trauma. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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35
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Zeldin L, Neifert SN, Rothrock RJ, McNeill IT, Gal JS, Caridi JM. Surgery Delay Increases Length of Stay in Thoracolumbar Trauma. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Snyder DJ, Neifert SN, Gal JS, Deutsch BC, Caridi JM. Posterior Cervical Decompression and Fusion: Assessing Risk Factors for Nonhome Discharge and the Impact of Disposition on Postdischarge Outcomes. World Neurosurg 2019; 125:e958-e965. [DOI: 10.1016/j.wneu.2019.01.214] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
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Arrighi-Allisan AE, Neifert SN, Gal JS, Deutsch BC, Caridi JM. Discharge Destination as a Predictor of Postoperative Outcomes and Readmission Following Posterior Lumbar Fusion. World Neurosurg 2019; 122:e139-e146. [DOI: 10.1016/j.wneu.2018.09.147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 01/17/2023]
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Bronheim RS, Steinberger J, Hunter S, Neifert SN, Deutch BC, Gal JS, Caridi JM. 159 ASA Status is Associated With Cost and Length of Stay in Lumbar Laminectomy and Fusion. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Flaherty DC, Lonner B, Gal JS. Successful Management of a Patient With X-Linked Myotubular Myopathy for Scoliosis Surgery and Previous Cardiac Arrest After Prone Positioning: A Case Report. A A Pract 2018; 10:340-342. [PMID: 29634567 DOI: 10.1213/xaa.0000000000000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 15-year-old boy with X-linked myotubular myopathy associated with severe hypotonia and pectus excavatum presented for posterior spinal fusion of T2-sacrum because of rest pain and severe progressive neuromuscular scoliosis. Previously, he experienced 2 separate instances of cardiac arrest after prone positioning under general anesthesia. A preoperative computed topography angiogram in the supine and prone positions revealed inferior vena cava and right ventricular outflow tract obstruction on prone positioning. Successful positioning and posterior spinal fusion occurred by staging the procedure, correction of volume status, early use of vasoactive and inotropic agents, and oblique prone positioning.
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Affiliation(s)
- Devon C Flaherty
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine
| | - Baron Lonner
- Orthopedics, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Jonathan S Gal
- From the Departments of Anesthesiology, Perioperative, and Pain Medicine
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Gal JS, Curatolo CJ, Zerillo J, Hill B, Lonner B, Cuddihy LA, Antonacci MD, Betz RR, DeMaria S, Khelemsky Y. Anesthetic considerations for a novel anterior surgical approach to pediatric scoliosis correction. Paediatr Anaesth 2017; 27:1028-1036. [PMID: 28857329 DOI: 10.1111/pan.13216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Idiopathic scoliosis is a condition that may require surgical correction. Limitations of previous surgical modalities, however, created the need for novel methods of repair. One such technique, a newer form of anterolateral scoliosis correction, has shown considerable promise, which our center has had substantial experience performing. AIM In this article, we present the case details of our first 105 patients for the purposes of describing the evolution and details of the anesthetic management and considerations for this procedure. METHODS A retrospective review of medical records for 105 patients undergoing anterolateral instrumentation procedure for idiopathic scoliosis correction done at a single institution from May 2014 to June 2016 was performed. The details of perioperative management as well as surgical technique were reported for all patients. RESULTS The mean age for patients was 14.8 years (range 10-18); the mean weight was 49.9 kg (range 25-82). Unilateral procedures were performed on 46.7%, with bilateral and hybrid procedures performed on 50.5% and 4.7%, respectively. The median number of levels corrected was 8 (interquartile range [IQR] 7-9) for unilateral, right 7 (IQR 6-7) and left 5 (IQR 4-5) for bilateral, and 4 (IQR 4-4.5) for hybrids. The average estimated blood loss (EBL) was 310 mL±138, with cell salvaged blood transfused in 61% of patients, and allogenic blood transfusion required in only two patients. CONCLUSIONS The described anesthetic and analgesic management provides a framework for delivering perioperative care for this challenging procedure, which is gaining popularity as a modality for scoliosis correction.
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Affiliation(s)
- Jonathan S Gal
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher J Curatolo
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Baron Lonner
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laury A Cuddihy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M D Antonacci
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Randal R Betz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yury Khelemsky
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Gal JS, Morozov YM, Ayoub AE, Chatterjee M, Rakic P, Haydar TF. Molecular and morphological heterogeneity of neural precursors in the mouse neocortical proliferative zones. J Neurosci 2006; 26:1045-56. [PMID: 16421324 PMCID: PMC3249619 DOI: 10.1523/jneurosci.4499-05.2006] [Citation(s) in RCA: 250] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The proliferative ventricular zone (VZ) is the main source of projection neurons for the overlying cerebral neocortex. The number and diversity of neocortical neurons is determined, in part, by factors controlling the proliferation and specification of VZ cells during embryonic development. We used a variety of methods, including in utero electroporation with specific cellular markers, computer-assisted serial EM cell reconstruction, and time-lapse multiphoton imaging to characterize the molecular and morphological characteristics of the VZ constituents and to capture their behavior during cell division. Our analyses reveal at least two types of dividing cells in the VZ: (1) radial glial cells (RGCs) that span the entire neocortical wall and maintain contact both at the ventricular and pial surfaces throughout mitotic division, and (2) short neural precursors (SNPs) that possess a ventricular endfoot and a basal process of variable length that is retracted during mitotic division. These two precursor cell classes are present concomitantly in the VZ, but their relative number changes over the course of cortical neurogenesis. Moreover, the SNPs are morphologically, ultrastructurally and molecularly distinct from dividing RGCs. For example, SNPs are marked by their preferential expression of the tubulin alpha-1 promoter whereas RGCs instead express the glutamate-aspartate transporter and brain lipid binding protein promoters. In contrast to recent studies that suggest that RGCs are the sole type of VZ precursor, the present study indicates that the VZ in murine dorsal telencephalon is similar to that in human and nonhuman primates, because it contains multiple types of neuronal precursors.
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Affiliation(s)
- Jonathan S Gal
- Center for Neuroscience Research, Children's Research Institute, Children's National Medical Center, Washington, DC 20010, USA
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