title: Length of hospital stay after craniotomy for tumor: a National Surgical Quality Improvement Program analysis.
abstract: OBJECT Although the length of hospital stay is often used as a measure of quality of care, data evaluating the predictors of extended hospital stay after craniotomy for tumor are limited. The goals of this study were to use multivariate regression to examine which preoperative characteristics and postoperative complications predict a prolonged hospital stay and to assess the impact of length of stay on unplanned hospital readmission. METHODS Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2013. Patients who underwent craniotomy for resection of a brain tumor were included. Stratification was based on length of hospital stay, which was dichotomized by the upper quartile of the interquartile range (IQR) for the entire population. Covariates included patient age, sex, race, tumor histology, comorbidities, American Society of Anesthesiologists (ASA) class, functional status, preoperative laboratory values, preoperative neurological deficits, operative time, and postoperative complications. Multivariate logistic regression with forward prediction was used to evaluate independent predictors of extended hospitalization. Thereafter, hierarchical multivariate logistic regression assessed the impact of length of stay on unplanned readmission. RESULTS The study included 11,510 patients. The median hospital stay was 4 days (IQR 3-8 days), and 27.7% (n = 3185) had a hospital stay of at least 8 days. Independent predictors of extended hospital stay included age greater than 70 years (OR 1.53, 95% CI 1.28%-1.83%, p < 0.001); African American (OR 1.75, 95% CI 1.44%-2.14%, p < 0.001) and Hispanic (OR 1.68, 95% CI 1.36%-2.08%) race or ethnicity; ASA class 3 (OR 1.52, 95% CI 1.34%-1.73%) or 4-5 (OR 2.18, 95% CI 1.82%-2.62%) designation; partially (OR 1.94, 95% CI 1.61%-2.35%) or totally dependent (OR 3.30, 95% CI 1.95%-5.55%) functional status; insulin-dependent diabetes mellitus (OR 1.46, 95% CI 1.16%-1.84%); hematological comorbidities (OR 1.68, 95% CI 1.25%-2.24%); and preoperative hypoalbuminemia (OR 1.78, 95% CI 1.51%-2.09%, all p ≤ 0.009). Several postoperative complications were additional independent predictors of prolonged hospitalization including pulmonary emboli (OR 13.75, 95% CI 4.73%-39.99%), pneumonia (OR 5.40, 95% CI 2.89%-10.07%), and urinary tract infections (OR 11.87, 95% CI 7.09%-19.87%, all p < 0.001). The C-statistic of the model based on preoperative characteristics was 0.79, which increased to 0.83 after the addition of postoperative complications. A length of stay after craniotomy for tumor score was created based on preoperative factors significant in regression models, with a moderate correlation with length of stay (p = 0.43, p < 0.001). Extended hospital stay was not associated with differential odds of an unplanned hospital readmission (OR 0.97, 95% CI 0.89%-1.06%, p = 0.55). CONCLUSIONS In this NSQIP analysis that evaluated patients who underwent craniotomy for tumor, much of the variance in hospital stay was attributable to baseline patient characteristics, suggesting length of stay may be an imperfect proxy for quality. Additionally, longer hospitalizations were not found to be associated with differential rates of unplanned readmission.
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Hormuzdiyar H
authors.initials: HH
authors.lastname: Dasenbrock
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Kevin X
authors.initials: KX
authors.lastname: Liu
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Devine
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Vamsidhar
authors.initials: V
authors.lastname: Chavakula
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Smith
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: William B
authors.initials: WB
authors.lastname: Gormley
authors.affiliation: Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ian F
authors.initials: IF
authors.lastname: Dunn
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001932:Brain Neoplasms / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000209:etiology*; D011237:Predictive Value of Tests; D058996:Quality Improvement; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
keywords: ACS = American College of Surgeons; ASA = American Society of Anesthesiologists; INR = international normalized ratio; IQR = interquartile range; NSQIP; NSQIP = National Surgical Quality Improvement Program; PTT = partial thromboplastin time; UTI = urinary tract infection; brain tumor; craniotomy; length of hospital stay; outcomes; readmission