Comparative preoperative characteristics and postoperative outcomes at a private versus a safety-net hospital following endoscopic endonasal transsphenoidal resection of pituitary adenomas

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Sociodemographic disparities in health outcomes are well documented, but the effects of such disparities on preoperative presentation of pituitary adenomas (PA) and surgical outcomes following resection are not completely understood. In this study the authors sought to compare the preoperative clinical characteristics and postoperative outcomes in patients undergoing PA resection at a private hospital (PH) versus a safety-net hospital (SNH).</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors conducted a retrospective review over a 36-month period of patients with PAs who underwent endoscopic endonasal transsphenoidal surgery performed by the same attending neurosurgeon at either a PH or an SNH at a single academic medical institution.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>A total of 92 PH patients and 69 SNH patients were included. SNH patients were more likely to be uninsured or have Medicaid (88.4% vs 10.9%, p &lt; 0.0001). A larger percentage of SNH patients were Hispanic (98.7% vs 32.6% p &lt; 0.0001), while PH patients were more likely to be non-Hispanic white (39.1% vs 4.3%, p &lt; 0.0001). SNH patients had a larger mean PA diameter (26.2 vs 22.4 mm, p = 0.0347) and a higher rate of bilateral cavernous sinus invasion (13% vs 4.3%, p = 0.0451). SNH patients were more likely to present with headache (68.1% vs 45.7%, p = 0.0048), vision loss (63.8% vs 35.9%, p &lt; 0.0005), panhypopituitarism (18.8% vs 4.3%, p = 0.0031), and pituitary apoplexy (18.8% vs 7.6%, p = 0.0334). Compared to PH patients, SNH patients were as likely to undergo gross-total resection (73.9% vs 76.1%, p = 0.7499) and had similar rates of postoperative improvement in headache (80% vs 89%, p = 0.14) and vision (82% vs 84%, p = 0.74), but had higher rates of postoperative panhypopituitarism (23% vs 10%, p = 0.04) driven by preoperative endocrinopathies. Although there were no differences in tumor recurrence or progression, loss to follow-up was seen in 7.6% of PH versus 18.6% (p = 0.04) of SNH patients.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Patients presenting to the SNH were more often uninsured or on Medicaid and presented with larger, more advanced pituitary tumors. SNH patients were more likely to present with headaches, vision loss, and apoplexy, likely translating to greater improvements in headache and vision observed after surgery. These findings highlight the association between medically underserved populations and more advanced disease states at presentation, and underscore the likely role of academic tertiary multidisciplinary care teams and endoscopic PA resection in somewhat mitigating sociodemographic factors known to portend poorer outcomes, though longer-term follow-up is needed to confirm these findings.</jats:p></jats:sec>

The impact of hospital safety-net status on inpatient outcomes for brain tumor craniotomy: a 10-year nationwide analysis

“…Prior studies have reported larger or more severe lesions at presentation for glioblastoma and pituitary adenoma patients at SNHs. 11 , 12 Higher brain tumor severity of illness at presentation may be the byproduct of barriers that limit access to care. 30 Because certain outcome differences did not persist following multivariate adjustment for severity metrics, such as increased mortality for glioma, greater presentation severity may partially account for observed outcome differences.…”

“… 11 These resource constraints may also help explain the lower rates of tumor resection for glioma patients at SNHs (93.3%), compared to non-SNH patients (94.2%). Discrepancies in operative management may also be due to SNH patients being more likely to be ruled out as surgical candidates because of higher severity on presentation, 11 , 12 , 31 or lower trust in the healthcare system among marginalized patients due to past negative interactions and historical patterns of discrimination. 32 , 33 Alternatively, patients with brain tumors may have been transferred from a SNH to non-SNH for their surgery, reducing resection rates at SNHs; surgeons in non-SNHs may also have varying incentives, such as different compensation arrangements, that lead to higher rates of resection.…”

Do neurosurgeons receive more patient complaints than other physicians? Describing who is most at risk and how we can improve

“…Patients treated at safety-net versus private hospitals have been more likely to be symptomatic from brain metastases, 25 to have delays to endovascular aneurysm embolization, 26 and to have increased rates of endocrinopathies after pituitary tumor surgery. 27 We were unable to account for the presence of safety-net hospitals, which appears to affect the quality of care delivered, and may have downstream effects on patient-physician communication. Along these lines, the current sample's breakdown of specialties differs from that of neurosurgeons throughout the country in the following numbers (our study vs national): functional (10% vs 2%), general practice (25% vs 51%), and spine (25% vs 12%), whereas similar proportions were seen in pediatrics (10% vs 8%) and tumor (16% vs 14%).…”

Effect of pituitary adenoma consistency on surgical outcomes in patients undergoing endonasal endoscopic transsphenoidal surgery

“…There were 186 recorded operative times. Fibrous adenomas involved longer times (Table 3), which was maintained difference despite getting past the learning curve, with an increasing surgical time of 41 In the univariate analysis, brous adenomas showed a higher incidence of intraoperative CSF leak (OR 5.84, 95% CI 2.86-11.92, p = 0.001). After adjusting for tumor size, an OR of 5.24 (95% CI 2.49-11.02, p = 0.001) was obtained (Table 4).…”