Background
Surgical mortality indicators should be risk-adjusted when evaluating the performance of organisations. This study evaluated the performance of risk-adjustment models that used English ...hospital administrative data for 30-day mortality after neurosurgery.
Methods
This retrospective cohort study used Hospital Episode Statistics (HES) data from 1 April 2013 to 31 March 2018. Organisational-level 30-day mortality was calculated for selected subspecialties (neuro-oncology, neurovascular and trauma neurosurgery) and the overall cohort. Risk adjustment models were developed using multivariable logistic regression and incorporated various patient variables: age, sex, admission method, social deprivation, comorbidity and frailty indices. Performance was assessed in terms of discrimination and calibration.
Results
The cohort included 49,044 patients. Overall, 30-day mortality rate was 4.9%, with unadjusted organisational rates ranging from 3.2 to 9.3%. The variables in the best performing models varied for the subspecialties; for trauma neurosurgery, a model that included deprivation and frailty had the best calibration, while for neuro-oncology a model with these variables plus comorbidity performed best. For neurovascular surgery, a simple model of age, sex and admission method performed best. Levels of discrimination varied for the subspecialties (range: 0.583 for trauma and 0.740 for neurovascular). The models were generally well calibrated. Application of the models to the organisation figures produced an average (median) absolute change in mortality of 0.33% (interquartile range (IQR) 0.15–0.72) for the overall cohort model. Median changes for the subspecialty models were 0.29% (neuro-oncology, IQR 0.15–0.42), 0.40% (neurovascular, IQR 0.24–0.78) and 0.49% (trauma neurosurgery, IQR 0.23–1.68).
Conclusions
Reasonable risk-adjustment models for 30-day mortality after neurosurgery procedures were possible using variables from HES, although the models for trauma neurosurgery performed less well. Including a measure of frailty often improved model performance.
This article has been withdrawn by the authors. A publication of the manuscript with the correct figures and tables has been approved and the authors state the conclusions of the manuscript remain ...unaffected. Specifically, errors are in Figure 6A, Supplementary Figure 10B, Supplementary Figure 10C, and Supplementary Table 5. The details of the errors are as follows: the HLA types for one sample were incorrectly assigned because of a tumor/normal mislabeling from the biobank vendor. Due to the differing HLA types between the tumor and normal sample, the sequence analysis established that the HLA alleles for this patient had been deleted (HLA LOH). The authors conclude that this was an artifact caused by the normal sample mislabeling. The corrected version can be accessed (Pyke, R.M., Mellacheruvu, D., Dea, S., Abbott, C.W., Zhang, S.V., Philips, N.A., Harris, J., Bartha, G., Desai, S., McClory, R., West, J., Snyder, M,P., Chen, R., Boyle, S.M. (2022) Precision Neoantigen Discovery Using Large-Scale Immunopeptidomics and Composite Modeling of MHC Peptide Presentation. Mol. Cell. Proteomics 22, 100506
Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the ...safety of a single-agent, single-dose protocol.
A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies.
Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery.
Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33).
For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.
Neurosurgical practice has seen major changes over several decades. There are no recent evaluations of national neurosurgical practice. The aim of this observational study was to describe ...neurosurgical practice in England and to use outcomes to assess and benchmark the quality of care in neurosurgery.
This national retrospective cohort study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 for all adult admissions with a specialty code for neurosurgery. The epidemiology of patients and RCS Charlson comorbidities were derived and procedure incidence rates per 100,000 person-years calculated. Post-operative outcomes for elective and non-elective patients included: median length of stay, the proportion of patients requiring additional inpatient neurosurgical procedures, the proportion of patients discharged to their usual address, and in-hospital mortality rates.
During the 5-year study period, there were 371,418 admissions to neurosurgery. The proportion of admissions involving a neurosurgical procedure was 77.3% (n = 287,077). Of these, 45% were for cranial surgery and 37% for spinal. Overall, 68.3% were elective procedures. The incidence rates of most procedures were low (<20 per 100,000 person-years). Following elective neurosurgical procedures, in-hospital mortality rates for cranial and spinal surgery were 0.5% (95% CI, 0.5–0.6) and 0.1% (95% CI, 0.04–0.1), respectively. After non-elective neurosurgery, mortality rates were 7.4% (95% CI, 7.2–7.6) and 1.3% (95% CI, 1.2–1.5) for cranial and spinal surgery, respectively. Approximately 1 in 4 patients had additional procedures following non-elective cranial surgery (24%; 95% CI, 23.6–24.3). Outcomes were highly variable across different subspecialty areas.
The incidence rates of neurosurgical procedures are low within England, and neurosurgical units have a high volume of non-surgical admissions. In-hospital mortality rates after elective neurosurgery are low but there may be opportunities for quality improvement programmes to improve outcomes for non-elective surgery as well as ensuring equitable access to treatment.
•This study used Hospital Episode Statistics to describe neurosurgical practice in England.•Neurosurgical procedure incidence rates are low within England.•In-hospital elective mortality rates are low.•Outcomes following non-elective neurosurgery are worse than elective neurosurgery.•The findings provide baseline outcomes for benchmarking of quality of care.
Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the ...UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England.
Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure.
Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied.
A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.
Introduction: Endoscopic anterior skull base surgery is now established practice. For skull base teams to manage complex pathology a variety of good dural repair techniques are required. However ...repairing certain skull base defects can be challenging. We look to see if a learning curve is associated with different types of CSF leaks in the anterior skull base
Methods: Analysis of a prospectively collected database, contain 383 cases, on all endoscopic anterior skull base operations at one UK institution looking at CSF repair. Chi squared statistical analysis was undertaken comparing results from 2009 to 2013 with the 2014 to 2017 results. CSF leaks were categorised as either low flow with defects less than 2cm in diameter or high flow with defects greater than 2cm in diameter associated with a CSF void.
Results:137 cases requiring repair were identified. Overall 96% of cases underwent successful primary repair with low flow CSF defects. The primary repair rate was similar in the early and later years.
Successful repair of large anterior skull base defects was statistically more likely in the 2014-2017 group 96% compare to the 2009-2013 group 65%.
Conclusions: A learning curve for small defects was not seen.
However a learning curve does exist in relation to large defects with high flow over the first 20 cases.
Patterns of surgical care, outcomes, and quality of care can be assessed using hospital administrative databases but this requires accurate and complete data. The aim of this study was to explore ...whether the quality of hospital administrative data was sufficient to assess pituitary surgery practice in England.
The study analysed Hospital Episode Statistics (HES) data from April 2013 to March 2018 on all adult patients undergoing pituitary surgery in England. A series of data quality indicators examined the attribution of cases to consultants, the coding of sellar and parasellar lesions, associated endocrine and visual disorders, and surgical procedures. Differences in data quality over time and between neurosurgical units were examined.
A total of 5613 records describing pituitary procedures were identified. Overall, 97.3% had a diagnostic code for the tumour or lesion treated, with 29.7% (n = 1669) and 17.8% (n = 1000) describing endocrine and visual disorders, respectively. There was a significant reduction from the first to the fifth year in records that only contained a pituitary tumour code (63.7%-47.0%, p < .001). The use of procedure codes that attracted the highest tariff increased over time (66.4%-82.4%, p < .001). Patterns of coding varied widely between the 24 neurosurgical units.
The quality of HES data on pituitary surgery has improved over time but there is wide variation in the quality of data between neurosurgical units. Research studies and quality improvement programmes using these data need to check it is of sufficient quality to not invalidate their results.
A chronic subdural haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high ...income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance.
We convened a cross-disciplinary working group (the 'Improving Care in Elderly Neurosurgery Initiative') in October 2020. This comprised experts in neurosurgical care and a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement.
The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care and presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognizant of the complex, system-wide nature of the problem, and may require a combination of targeted trials at points of clinical equipoise (such as anesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation.
The care of cSDH is a growing clinical problem. Lessons may be learned from the standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.
Background
Trigeminal neuralgia (TN) is a serious health problem, causing brief, recurrent episodes of stabbing or burning facial pain, which patients describe as feeling like an electric shock. The ...consequences of living with the condition are severe. There is currently no cure for TN and management of the condition can be complex, often delayed by misdiagnosis. Patients’ qualitative experiential accounts of TN have not been reported in the literature. Capturing subjective experiences can be used to inform the impact of the condition on quality of life and may contribute to a better understanding of current clinical practice with the aim of improving patient care.
Methods
Participants with TN (
n
= 16; 11 female), including those who have and have not undergone surgical intervention(s), took part in one of four focus groups. We conducted a thematic analysis within an essentialist framework using transcripts.
Results
The impact of TN and treatment on the lives of participants emerged as four predominant themes: (1) diagnosis and support with TN, (2) living in fear of TN pain, (3) isolation and social withdrawal, and (4) medication burden and looking for a cure. Each theme is discussed and illustrated with extracts from the transcripts.
Conclusions
Key issues to address in the management of patients with TN include continued delays in diagnosis, persistent side effects from medication, and a lack of psychological support. Developing strategies to enhance the management of patients with TN, informed by a biopsychosocial approach and multidisciplinary team working, is essential to enhancing the provision of current care.
Abstract
Objective. There are few agreed quantifiable outcome measures in pituitary surgery. The goal of this study is to present the measurement of resection volume after surgery for pituitary ...tumours as a surgeon-specific outcome measure that may have use in illustrating the performance of individual surgeons internally and externally, and contribute to quality improvement in pituitary surgery. Method. The authors used an existing validated method to measure the volume of pituitary tumours. This method was used to retrospectively assess the extent of resection (EOR) in all patients undergoing pituitary surgery for tumour volume reduction over a 3-year period in Leeds, UK. Three surgeons and two techniques (endonasal transsphenoidal surgery and conventional microscopic surgery) were compared. The results are summarised using Funnel plot methodology. Results. The overall mean EOR for the 3 years of study was 54%. There was no difference between endoscopic and microscopic techniques in terms of EOR. Significant differences were found between surgeons' case mix (as estimated by preoperative tumour size) and EOR. One surgeon had smaller tumour cases at operation than the other two surgeons (p = 0.004). One surgeon achieved larger resections than the two other surgeons (p = 0.038 and 0.005). Conclusions. Measuring pituitary volumes manually using segmentation methods and existing software is possible for surgeons and provides valuable information on individual surgeon performance and departmental practice. A simple retrospective review of 3 years of practice has demonstrated that surgeons have different case-mix and their EOR can vary within safe limits. During a period of transition when we changed personnel and technique, the EOR was little affected and this was reassuring from a governance perspective. Performance assessment for low-volume conditions is possible .
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