Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning.

METHODS

IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020)

BACKGROUND CONTEXT

Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making.

PURPOSE

This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication.

STUDY DESIGN/SETTING

Cross-sectional retrospective analysis of retrospective and nationally-representative data.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020.

OUTCOME MEASURES

CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication.

METHODS

Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis.

RESULTS

There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919).

CONCLUSION

Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Reported Variation in Hospital Billing Quality

This study examines how US hospitals perform on billing quality measures, including legal actions taken by a hospital to collect medical debt, the timeliness of sending patients an itemized billing statement, and patient access to a qualified billing representative.

Evaluating Patient and Surgeon Characteristics Associated with Care Cost and Outcomes for Knee and Hip Replacement Procedures: A National Medicare Cohort Study

Background

The role of physician credentialing has been widely considered in quality and outcome improvement studies. However, the association between surgeon characteristics and health-care costs remains unclear.

Methods

Our objective was to determine the association of orthopaedic surgeon characteristics with health outcomes and costs, utilizing Medicare data. We used 100% Fee-for-Service Medicare data from 2015 to 2019 to identify all patients ≥65 years of age who underwent 2 common orthopaedic surgical procedures, total hip and knee replacement. After determining whether the patients had been readmitted after discharge from their initial admission for surgery, we computed 3 metrics of total medical expenditure: the costs of the initial surgery admission and 30-day and 180-day episode-based bundles of care. Hierarchical linear regression and logistic regression models were used to evaluate patient and surgeon characteristics associated with care costs and the likelihood of readmission.

Results

We identified 2,269 surgeons who performed total knee replacements on 298,934 patients and 1,426 surgeons who performed total hip replacements on 204,721 patients. Patient characteristics associated with higher initial surgery costs included increasing age, female sex, racial minority status, and a higher Charlson Comorbidity Index. Surgeon characteristics associated with lower readmission rates included practice in the Northeast region and a higher patient volume; having malpractice claims was associated with higher readmission rates.

Conclusions

A higher volume of patients treated by the orthopaedic surgeon was associated with lower overall costs and readmission rates. Information on surgeons' malpractice claims and annual volume should be made publicly available to assist patients, payer networks, and hospitals in surgeon selection and oversight. These results could also inform the guidelines of physician credentialing organizations.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hypothyroidism Impacts Clinical and Healthcare Utilization Outcomes After Primary Total Hip Arthroplasty

BACKGROUND

Our objective was to assess the association of hypothyroidism with outcomes of primary total hip arthroplasty (THA) overall and stratified by underlying diagnosis.

METHODS

We identified patients undergoing primary THA in a national database from 2016 to 2020. We stratified them based on primary diagnoses into hip osteoarthritis (OA; N = 1,761,960), osteonecrosis (ON; N = 78,275), traumatic fracture (N = 532,910), inflammatory arthritis (IA; N = 3,520), and "other" (N = 90,550). We identified hypothyroidism and complications using secondary diagnoses. Among 2,467,215 patients undergoing primary THA, mean age was 68 years (range, 18 to 90), and 58.3% were women. Complications codes only included initial encounters. We performed time-trends analyses and multivariable-adjusted regression analyses adjusted for demographics, expected primary payer, a comorbidity score, elective versus non-elective admission, and hospital characteristic information, with clinical and healthcare utilization outcome as endpoints.

RESULTS

Overall, hypothyroidism was significantly associated with increased LOS, total charges, non-routine discharges, blood transfusions, and prosthetic fractures. In the OA cohort, hypothyroidism was associated with increased LOS, total charges, and non-routine discharges (P < .001 for each), and blood transfusions (P = .02). Hypothyroidism was associated with increased total charges (P = .001) in the ON cohort and with increased LOS, non-routine discharge, and blood transfusion (P < .05 each) in the traumatic fracture cohort.

CONCLUSIONS

Hypothyroidism was associated with blood transfusions, prosthetic fractures, and utilization outcomes in THA patients. Tailored intervention strategies for hypothyroidism should be tested for their efficacy to improve THA peri-operative outcomes.

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards

This Viewpoint discusses new standards proposed by the Centers for Medicare &amp;amp; Medicaid Services for ensuring that Medicare managed care networks meet enrollees’ needs.

RAI-measured frailty predicts non-home discharge following metastatic brain tumor resection: national inpatient sample analysis of 20,185 patients

PURPOSE

Preoperative risk stratification for patients undergoing metastatic brain tumor resection (MBTR) is based on established tumor-, patient-, and disease-specific risk factors for outcome prognostication. Frailty, or decreased baseline physiologic reserve, is a demonstrated independent risk factor for adverse outcomes following MBTR. The present study sought to assess the impact of frailty, measured by the Risk Analysis Index (RAI), on MBTR outcomes.

METHODS

All MBTR were queried from the National Inpatient Sample (NIS) from 2019 to 2020 using diagnosis and procedural codes. The relationship between preoperative RAI frailty score and our primary outcome - non-home discharge (NHD) - and secondary outcomes - complication rates, extended length of stay (eLOS), and mortality - were analyzed via univariate and multivariable analyses. Discriminatory accuracy was tested by computation of concordance statistics in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

There were 20,185 MBTR patients from the NIS database from 2019 to 2020. Each patient's frailty status was stratified by RAI score: 0-20 (robust): 34%, 21-30 (normal): 35.1%, 31-40 (very frail): 13.9%, 41+ (severely frail): 16.8%. Compared to robust patients, severely frail patients demonstrated increased complication rates (12.2% vs. 6.8%, p < 0.001), eLOS (37.6% vs. 13.2%, p < 0.001), NHD (52.0% vs. 20.6%, p < 0.001), and mortality (9.9% vs. 4.1%, p < 0.001). AUROC curve analysis demonstrated good discriminatory accuracy of RAI-measured frailty in predicting NHD after MBTR (C-statistic = 0.67).

CONCLUSION

Increasing RAI-measured frailty status is significantly associated with increased complication rates, eLOS, NHD, and mortality following MBTR. Preoperative frailty assessment using the RAI may aid in preoperative surgical planning and risk stratification for patient selection.