Predicting inpatient complications from cerebral aneurysm clipping: the Nationwide Inpatient Sample 2005–2009

Abstract

Object. Precise delineation of individualized risks of morbidity and mortality is crucial in decision making in cerebrovascular neurosurgery. The authors attempted to create a predictive model of complications in patients undergoing cerebral aneurysm clipping (CAC).Methods. The authors performed a retrospective cohort study of patients who had undergone CAC in the period from 2005 to 2009 and were registered in the Nationwide Inpatient Sample (NIS) database. A model for outcome prediction based on preoperative individual patient characteristics was developed.Results. Of the 7651 patients in the NIS who underwent CAC, 3682 (48.1%) had presented with unruptured aneurysms and 3969 (51.9%) with subarachnoid hemorrhage. The respective inpatient postoperative risks for death, unfavorable discharge, stroke, treated hydrocephalus, cardiac complications, deep vein thrombosis, pulmonary embolism, and acute renal failure were 0.7%, 15.3%, 5.3%, 1.5%, 1.3%, 0.6%, 2.0%, and 0.1% for those with unruptured aneurysms and 11.5%, 52.8%, 5.5%, 39.2%, 1.7%, 2.8%, 2.7%, and 0.8% for those with ruptured aneurysms. Multivariate analysis identified risk factors independently associated with the above outcomes. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated using the area under the receiver operating characteristic curve, and it was found to have good discrimination.Conclusions. The featured model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and can potentially be used as an adjunct in decision making in cerebrovascular neurosurgery. 591Abbreviations used in this paper: ARF = acute renal failure; AVM = arteriovenous malformation; CAC = cerebral aneurysm clipping; CAD = coronary artery disease; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; CRF = chronic renal failure; DVT = deep vein thrombosis; NIS = Nationwide Inpatient Sample; PE = pulmonary embolism; PVD = peripheral vascular disease; SAH = subarachnoid hemorrhage; SE = standard error.* Drs. Bekelis and Missios contributed equally to this work.This article contains some figures that are displayed in color on line but in black-and-white in the print edition. Cohort DefinitionTo establish the study cohort, we used ICD-9-CM codes to identify patients in the registry who had undergone clipping (ICD-9-CM code 39. Independent and Outcome VariablesThe primary outcome variables (Table 1) were the inpatient postoperative risks of stroke, cardiac complications, death, treated hydrocephalus, DVT, PE, ARF, length of hospital stay more than 4 days for patients with unruptured aneurysms, length of hospital stay more than 14 days for patients with ruptured aneurysms, and unfavorable discharge (transfer to short-term hospital, skilled nursing facility, intermediate care, or rehabilitation center). The effect of pertinent exposure variables on outcomes was examined in a multivariate analysis. Age was the on...

A predictive model of hospitalization cost after cerebral aneurysm clipping

“…Although LOS is a major target for cost containment, the focus should be only on excessively lengthy hospitalizations not justified by patient comorbidities. The comorbidities associated with increased LOS, in the setting of CAC, have been identified in prior studies, 19 and should be taken into account to avoid penalizing the care of sicker patients. Other important contributors to increased LOS, and subsequently higher hospitalization costs are patient safety indicators, and hospital acquired conditions.…”

Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

“…3,34 Despite initial criticism about the study’s design and limited focus, further national investigations 4,5,8,9,13,17,22 and a North American trial 29 confirmed its findings. These results have fueled an explosive growth of coiling in this population.…”

Comaneci neck bridging device for the treatment of cerebral aneurysms

“…Patients harboring wide necked aneurysms traditionally pose a higher risk of treatment with endovascular therapy due to the requirement for an adjuvant device. This can be particularly challenging in patients with ruptured cerebral aneurysms in whom microsurgical clipping may be a technical challenge either due to the location of the aneurysm or neurological status of the patient 2. Although stents have been implanted in ruptured aneurysms, there appears to be a high incidence of hemorrhagic complications due to the need for dual antiplatelet agents 3.…”