TY - JOUR
T1 - Impact of neurosurgeon specialization on patient outcomes for intracranial and spinal surgery
T2 - A retrospective analysis of the Nationwide Inpatient Sample 1998-2009
AU - McCutcheon, Brandon A.
AU - Hirshman, Brian R.
AU - Gabel, Brandon C.
AU - Heffner, Michael W.
AU - Marcus, Logan P.
AU - Cole, Tyler S.
AU - Chen, Clark C.
AU - Chang, David C.
AU - Carter, Bob S.
N1 - Publisher Copyright:
© AANS, 2018.
PY - 2018/5
Y1 - 2018/5
N2 - OBJECTIVE The subspecialization of neurosurgical practice is an ongoing trend in modern neurosurgery. However, it remains unclear whether the degree of surgeon specialization is associated with improved patient outcomes. The authors hypothesized that a trend toward increased neurosurgeon specialization was associated with improved patient morbidity and mortality rates. METHODS The Nationwide Inpatient Sample (NIS) was used (1998-2009). Patients were included in a spinal analysis cohort for instrumented spine surgery involving the cervical spine (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 81.31-81.33, 81.01-81.03, 84.61-84.62, and 84.66) or lumbar spine (codes 81.04-81.08, 81.34-81.38, 84.64-84.65, and 84.68). A cranial analysis cohort consisted of patients receiving a parenchymal excision or lobectomy operation (codes 01.53 and 01.59). Surgeon specialization was measured using unique surgeon identifiers in the NIS and defined as the proportion of a surgeon's total practice dedicated to cranial or spinal cases. RESULTS A total of 46,029 and 231,875 patients were identified in the cranial and spinal analysis cohorts, respectively. On multivariate analysis in the cranial analysis cohort (after controlling for overall surgeon volume, patient demographic data/comorbidities, hospital characteristics, and admitting source), each percentage-point increase in a surgeon's cranial specialization (that is, the proportion of cranial cases) was associated with a 0.0060 reduction in the log odds of patient mortality (95% CI 0.0034-0.0086) and a 0.0042 reduction in the log odds of morbidity (95% CI 0.0032-0.0052). This resulted in a 15% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of cranial specialization. In the spinal analysis cohort, each percentage-point increase in a surgeon's spinal specialization was associated with a 0.0122 reduction in the log odds of mortality (95% CI 0.0074-0.0170) and a 0.0058 reduction in the log odds of morbidity (95% CI 0.0049-0.0067). This resulted in a 26.8% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of spinal specialization. CONCLUSIONS For both spinal and cranial surgery patient cohorts derived from the NIS database, increased surgeon specialization was significantly and independently associated with improved mortality and morbidity rates, even after controlling for overall case volume.
AB - OBJECTIVE The subspecialization of neurosurgical practice is an ongoing trend in modern neurosurgery. However, it remains unclear whether the degree of surgeon specialization is associated with improved patient outcomes. The authors hypothesized that a trend toward increased neurosurgeon specialization was associated with improved patient morbidity and mortality rates. METHODS The Nationwide Inpatient Sample (NIS) was used (1998-2009). Patients were included in a spinal analysis cohort for instrumented spine surgery involving the cervical spine (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 81.31-81.33, 81.01-81.03, 84.61-84.62, and 84.66) or lumbar spine (codes 81.04-81.08, 81.34-81.38, 84.64-84.65, and 84.68). A cranial analysis cohort consisted of patients receiving a parenchymal excision or lobectomy operation (codes 01.53 and 01.59). Surgeon specialization was measured using unique surgeon identifiers in the NIS and defined as the proportion of a surgeon's total practice dedicated to cranial or spinal cases. RESULTS A total of 46,029 and 231,875 patients were identified in the cranial and spinal analysis cohorts, respectively. On multivariate analysis in the cranial analysis cohort (after controlling for overall surgeon volume, patient demographic data/comorbidities, hospital characteristics, and admitting source), each percentage-point increase in a surgeon's cranial specialization (that is, the proportion of cranial cases) was associated with a 0.0060 reduction in the log odds of patient mortality (95% CI 0.0034-0.0086) and a 0.0042 reduction in the log odds of morbidity (95% CI 0.0032-0.0052). This resulted in a 15% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of cranial specialization. In the spinal analysis cohort, each percentage-point increase in a surgeon's spinal specialization was associated with a 0.0122 reduction in the log odds of mortality (95% CI 0.0074-0.0170) and a 0.0058 reduction in the log odds of morbidity (95% CI 0.0049-0.0067). This resulted in a 26.8% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of spinal specialization. CONCLUSIONS For both spinal and cranial surgery patient cohorts derived from the NIS database, increased surgeon specialization was significantly and independently associated with improved mortality and morbidity rates, even after controlling for overall case volume.
KW - Lobectomy
KW - Multivariate analysis
KW - NIS
KW - Nationwide Inpatient Sample
KW - Parenchymal excision
KW - Specialization
KW - Spinal fusion
KW - Surgical outcomes research
UR - http://www.scopus.com/inward/record.url?scp=85046663848&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85046663848&partnerID=8YFLogxK
U2 - 10.3171/2016.4.JNS152332
DO - 10.3171/2016.4.JNS152332
M3 - Review article
C2 - 28777023
AN - SCOPUS:85046663848
SN - 0022-3085
VL - 128
SP - 1578
EP - 1588
JO - Journal of neurosurgery
JF - Journal of neurosurgery
IS - 5
ER -