The Impact of the 2006 Massachusetts Healthcare Reform on Spine Surgery Patient Payer-Mix and Age

OBJECTIVE Several similarities exist between the Massachusetts health care reform law of 2006 and the Affordable Care Act (ACA). The authors’ prior neurosurgical research showed a decrease in uninsured surgeries without a significant change in surgical volume after the Massachusetts reform. An analysis of the payer-mix status and the age of spine surgery patients, before and after the policy, should provide insight into the future impact of the ACA on spine surgery in the US. METHODS Using the Massachusetts State Inpatient Database and spine ICD-9-CM procedure codes, the authors obtained demographic information on patients undergoing spine surgery between 2001 and 2012. Payer-mix status was assigned as Medicare, Medicaid, private insurance, uninsured, or other, which included government-funded programs and workers’ compensation. A comparison of the payer-mix status and patient age, both before and after the policy, was performed. The New York State data were used as a control. RESULTS The authors analyzed 81,821 spine surgeries performed in Massachusetts and 248,757 in New York. After 2008, there was a decrease in uninsured and private insurance spine surgeries, with a subsequent increase in the Medicare and “other” categories for Massachusetts. Medicaid case numbers did not change. This correlated to an increase in surgeries performed in the age group of patients 65–84 years old, with a decrease in surgeries for those 18–44 years old. New York showed an increase in all insurance categories and all adult age groups. CONCLUSIONS After the Massachusetts reform, spine surgery decreased in private insurance and uninsured categories, with the majority of these surgeries transitioning to Medicare. Moreover, individuals who were younger than 65 years did not show an increase in spine surgeries, despite having greater access to health insurance. In a health care system that requires insurance, the decrease in private insurance is primarily due to an increasing elderly population. The Massachusetts model continues to show that this type of policy is not causing extreme shifts in the payer mix, and suggests that spine surgery will continue to thrive in the current US health care system

Pain as a symptom of peripheral nerve sheath tumors: clinical significance and future therapeutic directions

Tumors arising from the supporting cells of peripheral nerve sheaths are relatively uncommon neoplasms, and as such many clinicians are unfamiliar with the details of their presentation, diagnosis and management. Further, little is known regarding the pathogenesis of these tumors, how they cause symptoms, and how to treat these symptoms. One classic symptom of peripheral nerve tumors is pain, however there has been little formal discussion regarding the significance of pain in this setting. Here we present a brief review of the clinical significance of pain, its relevance in pre-operative planning for the treatment of these tumors, and what is known regarding the molecular mechanisms of pain generation by these tumors

Statistical Analysis for Hospital Length-of-Stay and Readmission Rate Study

Hospital readmission rate has become a major indicator of quality of care, with penalties given to hospitals that have high rates of readmission. At the same time, insurers are applying increasing pressure to improve efficiency and reduce costs, including decreasing hospital lengths of stay. We analyze these trends to determine if reducing lengths of stay (LOS) may actually worsen readmission rates. All records of patients admitted to the neurosurgical service at one hospital from October 2007 through June 2014 were aggregated and analyzed for several variables, including initial length of stay, readmission occurrence, and length of stay, admitting diagnosis, admission priority and discharge disposition. Any trends over time were also noted. 925 out of 9,409 patient encounters are readmissions. Readmission rate and average length of stay were found significantly negative correlated. Besides linear regression which directly connecting average length of stay and readmission rate, survival analysis methods with Cox proportional hazard ratio model were employed to determine which factors were associated with a higher risk of readmission. There was a clear increase in readmissions over the study period, but LOS remained relatively constant, suggesting that increasing medical complexity confounded efforts to decrease LOS and was responsible for increased readmission rates. This study can help providers avoid readmissions by focusing on effective management of comorbidities

Hospital Length of Stay and Readmission Rate for Neurosurgical Patients

BACKGROUND Hospital readmission rate has become a major indicator of quality of care, with penalties given to hospitals with high rates of readmission. At the same time, insurers are increasing pressure for greater efficiency and reduced costs, including decreasing hospital lengths of stay (LOS). OBJECTIVE To analyze the authors’ service to determine if there is a relationship between LOS and readmission rates. METHODS Records of patients admitted to the authors’ institution from October 2007 through June 2014 were analyzed for several data points, including initial LOS, readmission occurrence, admitting and secondary diagnoses, and discharge disposition. RESULTS Out of 9409 patient encounters, there were 925 readmissions. Average LOS was 6 d. Univariate analysis indicated a higher readmission rate with more diagnoses upon admission (P < .001) and an association between insurance type and readmission (P < .001), as well as decreasing average yearly LOS (P = .0045). Multivariate analysis indicated statistically significant associations between longer LOS (P = .03) and government insurance (P < .01). CONCLUSION A decreasing LOS over time has been associated with an increasing readmission rate at the population level. However, at the individual level, a prolonged LOS was associated with a higher risk of readmission. This was attributed to patient comorbidities. However, this increasing readmission rate may represent many factors including patients’ overall health status. Thus, the rate of readmission may represent a burden of illness rather than a valid metric for quality of care

Speech Preservation during Language-dominant, Left Temporal Lobe Seizures: Report of a Rare, Potentially Misleading Finding

Purpose: To evaluate the prevalence and mechanism of ictal speech in patients with language-dominant, left temporal lobe seizures. Methods: We retrospectively reviewed the video-EEG telemetry records for the presence of ictal speech in 96 patients with surgically proven left temporal lobe epilepsy and studied the seizure-propagation patterns in three patients who required intracranial EEG recordings for seizure localization. Results: Ictal speech preservation was observed in five patients. One patient's seizures demonstrated rapid propagation of the ictal discharges to the contralateral temporal area where the seizure evolved, resembling a nondominant temporal lobe seizure. The other two patients had ictal discharges that remained confined to the inferomesial temporal areas, sparing language cortex. Conclusions: Preservation of speech in complex partial seizures of language-dominant, left temporal lobe origin is rare. Based on intracranial EEG recordings, the likely mechanism underlying this potentially misleading clinical finding is the preservation of language areas due to limited seizure-propagation patterns.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65559/1/j.1528-1167.2006.00606.x.pd

External cortical landmarks for localization of the hippocampus: Application for temporal lobectomy and amygdalohippocampectomy

Background: Accessing the hippocampus for amygdalohippocampectomy and minimally invasive procedures, such as depth electrode placement, require an accurate knowledge regarding the location of the hippocampus. Methods: The authors removed 10 human cadaveric brains from the cranium and observed the relationships between the lateral temporal neocortex and the underlying hippocampus. They then measured the distance between the hippocampus and superficial landmarks. The authors also validated their study using magnetic resonance imaging (MRI) scans of 10 patients suffering from medial temporal lobe sclerosis where the distance from the hippocampal head to the anterior temporal tip was measured. Results: In general, the length of the hippocampus was along the inferior temporal sulcus and inferior aspect of the middle temporal gyrus. Although the hippocampus tended to be more superiorly located in female specimens and on the left side, this did not reach statistical significance. The length of the hippocampus tended to be shorter in females, but this too failed to reach statistical significance. The mean distance from the anterior temporal tip to the hippocampal head was identical in the cadavers and MRIs of patients with medial temporal lobe sclerosis. Conclusions: Additional landmarks for localizing the underlying hippocampus may be helpful in temporal lobe surgery. Based on this study, there are relatively constant anatomical landmarks between the hippocampus and overlying temporal cortex. Such landmarks may be used in localizing the hippocampus during amygdalohippocampectomy and depth electrode implantation in verifying the accuracy of image-guided methods and as adjuvant methodologies when these latter technologies are not used or are unavailable

Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia

OBJECTIVE Common surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control. METHODS The authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up. RESULTS Of 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th–75th quartiles: 57–131 months) for MVD and 53 months (25th–75th quartiles: 37–69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001–1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213–0.723; p = 0.003) were associated with favorable outcome for SRS. CONCLUSIONS In this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection

Aberrant seizure-induced neurogenesis in experimental temporal lobe epilepsy

Neurogenesis in the hippocampal dentate gyrus persists throughout life and is increased by seizures. The dentate granule cell (DGC) layer is often abnormal in human and experimental temporal lobe epilepsy, with dispersion of the layer and the appearance of ectopic granule neurons in the hilus. We tested the hypothesis that these abnormalities result from aberrant DGC neurogenesis after seizure-induced injury. Bromodeoxyuridine labeling, in situ hybridization, and immunohistochemistry were used to identify proliferating progenitors and mature DGCs in the adult rat pilocarpine temporal lobe epilepsy model. We also examined dentate gyri from epileptic human hippocampal surgical specimens. Prox-1 immunohistochemistry and pulse-chase bromodeoxyuridine labeling showed that progenitors migrate aberrantly to the hilus and molecular layer after prolonged seizures and differentiate into ectopic DGCs in rat. Neuroblast marker expression indicated the delayed appearance of chainlike progenitor cell formations extending into the hilus and molecular layer, suggesting that seizures alter migratory behavior of DGC precursors. Ectopic putative DGCs also were found in the hilus and molecular layer of epileptic human dentate gyrus. These findings indicate that seizure-induced abnormalities of neuroblast migration lead to abnormal integration of newborn DGCs in the epileptic adult hippocampus, and implicate aberrant neurogenesis in the development or progression of recurrent seizures. Ann Neurol 2005Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/49280/1/20699_ftp.pd

Categorical speech representation in human superior temporal gyrus.

nature neurOSCIenCe advance online publication a r t I C l e S A fundamental property of speech perception is that listeners map continuously variable acoustic speech signals onto discrete phonetic sound categories A number of studies support the notion that the posterior superior temporal gyrus (pSTG) in Wernicke&apos;s area is important for higher order auditory processing of speech sounds To answer these questions, we recorded cortical local field poten tials from the pSTG in four human subjects undergoing awake crani otomy with speech mapping as part of their epilepsy 14 or brain tumor surgery RESULTS We employed a classic procedure first described in 1957 (ref. 6) to investigate the perceptual and neural organization of stop conso nant phonemes. Consonantvowel syllables were synthesized with 14 equal and parametric changes in the starting frequency of the F2 transition (second vocal tract resonance) that ranged perceptually across three initial consonants /ba/ to /da/ to /ga