Evaluating the Effects of Enhanced Recovery Pathways in Craniosynostosis

Abstract

Background Enhanced Recovery After Surgery (ERAS) pathways are multimodal approaches aimed at minimizing postoperative surgical stress, reducing hospitalization time, and lowering hospitalization charges. Enhanced Recovery After Surgery is broadly and increasingly implemented in hospitals across the country. Early reports have shown ERAS to reduce length of stay (LOS) after commonly performed pediatric surgeries. However, LOS and hospital charges after craniosynostosis have not been studied. We hypothesized that extended hospital LOS is correlated with increased hospitalization charges associated with open cranial vault surgery (CVS) and that over a multiyear timeframe, LOS and cost would decrease because of the increased adoption of ERAS in pediatric surgery. Methods The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2007 to December 2014. All patients who were diagnosed with craniosynostosis who underwent CVS were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear regression models were used to examine associations between selected variables and the hospitalization charges. Results There were 54,583 patients diagnosed with craniosynostosis between 2007 and 2014. Of these patients, 22,916 (41.9%) received CVS. The median total hospital charge was $66,605.77 (interquartile range, $44,095.60–$101,071.17). The median LOS was 3 days (interquartile range, 2–4 days), and there was no significant change in LOS by year (P = 0.979). However, despite a stable LOS, mean hospitalization charge increased significantly by year (P < 0.01). Regression analysis demonstrated the proportion of eligible patients who underwent CVS substantially increased over the selected timeframe (P < 0.01). Most procedures were performed in urban teaching hospitals and high-volume hospitals. There was no significant association between hospital volume and hospitalization charge (P = 0.331). Conclusions Increasing hospital charges despite constant LOS for craniosynostosis CVS procedures was observed between 2007 and 2014. Although ERAS has reduced LOS for common pediatric surgical procedures, no decrease in LOS for CVS has been observed. The charges significantly increased over the same period including high-volume centers. Further study to safely lower LOS and hospitalization charges for this procedure may reduce the overall health care burden.

Associated Risk Factors for Extended Length of Stay Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database

“…While ERAS pathways implemented in other neurosurgical and craniofacial procedures have been shown to reduce hospital LOS, 27,28 national trends suggest that the implementation of ERAS protocols following cranial vault surgery has not replicated the same success. In a retrospective review of 22,916 patients undergoing cranial vault surgery for craniosynostosis between 2007 and 2014 queried from the Healthcare Cost and Utilization Project's National Inpatient Sample, Wu et al 17 failed to observe a decrease in LOS despite an increase in the adoption of ERAS protocols during the same period. Other studies have advocated for admitting postoperative patients to the wards rather than the ICU.…”

“…6,7,[11][12][13][14] Therefore, a better understanding of patient risk factors portending to inferior outcomes after CVR are necessary to improve patient care and reduce health care resource utilization. [15][16][17] In recent studies, length of stay (LOS) has arisen as a proxy for health care expenditure and quality of care. 18,19 In a retrospective review of 3246 patients identified through the Kids' Inpatient Database (KID) undergoing surgical reconstruction for craniosynostosis, Nguyen et al 20 found that prolonged LOS was associated with a significant increase in health care costs.…”

“…However, CVR does not go without risk and has been associated with increased blood loss requiring blood transfusion, postoperative complications, unplanned readmission, and reoperation 6,7,11–14 . Therefore, a better understanding of patient risk factors portending to inferior outcomes after CVR are necessary to improve patient care and reduce health care resource utilization 15–17 …”

Associated Risk Factors for Extended Operative Time Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database

“…In neurosurgery specifically, extended LOS and unplanned readmissions have been associated with greater rates of complications, mortality, and health care costs 7–9 . Analogous findings apply to cases of cranial vault remodeling (CVR) for craniosynostosis, the premature closure of at least one cranial suture 10–12 . Craniosynostosis impacts ∼1:715 to 1:2500 live births and accrues an estimated $66,606 for each CVR procedure, motivating the identification of risk factors that may engender inferior surgical outcomes after CVR 13 …”

“…[7][8][9] Analogous findings apply to cases of cranial vault remodeling (CVR) for craniosynostosis, the premature closure of at least one cranial suture. [10][11][12] Craniosynostosis impacts ∼1:715 to 1:2500 live births and accrues an estimated $66,606 for each CVR procedure, motivating the identification of risk factors that may engender inferior surgical outcomes after CVR. 13 One modifiable risk factor, extended operative time (EOT), has been linked to postoperative complications, extended LOS, and unplanned readmissions.…”