title: Operative volume and outcomes of cerebrovascular neurosurgery in children.
abstract: OBJECTIVE The impact of procedural volume on the outcomes of cerebrovascular surgery in children has not been determined. In this study, the authors investigated the association of operative volume on the outcomes of cerebrovascular neurosurgery in pediatric patients. METHODS The authors performed a cohort study of all pediatric patients who underwent a cerebrovascular procedure between 2003 and 2012 and were registered in the Kids' Inpatient Database (KID). To control for confounding, the authors used multivariable regression models, propensity-score conditioning, and mixed-effects analysis to account for clustering at the hospital level. RESULTS During the study period, 1875 pediatric patients in the KID underwent cerebrovascular neurosurgery and met the inclusion criteria for the study; 204 patients (10.9%) underwent aneurysm clipping, 446 (23.8%) underwent coil insertion for an aneurysm, 827 (44.1%) underwent craniotomy for arteriovenous malformation resection, and 398 (21.2%) underwent bypass surgery for moyamoya disease. Mixed-effects multivariable regression analysis revealed that higher procedural volume was associated with fewer inpatient deaths (OR 0.58; 95% CI 0.40-0.85), a lower rate of discharges to a facility (OR 0.87; 95% CI 0.82-0.92), and shorter length of stay (adjusted difference -0.22; 95% CI -0.32 to -0.12). The results in propensity-adjusted multivariable models were robust. CONCLUSIONS In a national all-payer cohort of pediatric patients who underwent a cerebrovascular procedure, the authors found that higher procedural volume was associated with fewer deaths, a lower rate of discharges to a facility, and decreased lengths of stay. Regionalization initiatives should include directing children with such rare pathologies to a center of excellence.
authors: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center.|Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.
authors: Kimon
authors: K
authors: Bekelis
authors: Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Palo Alto; and.|Department of Neurosurgery, University of California, San Francisco, California.
authors: Ian D
authors: ID
authors: Connolly
authors: Departments of Radiology and Neurosurgery, Stanford University School of Medicine, Palo Alto; and.
authors: Huy M
authors: HM
authors: Do
authors: Department of Neurosurgery, University of California, San Francisco, California.
authors: Omar
authors: O
authors: Choudhri
mesh_terms: D000293:Adolescent; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D002648:Child; D015331:Cohort Studies; D016208:Databases, Factual / Q000639:trends; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008297:Male; D019635:Neurosurgical Procedures / Q000639:trends*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: AVM = arteriovenous malformation; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; KID = Kids' Inpatient Database; Kids' Inpatient Database; LOS = length(s) of stay; cerebrovascular neurosurgery; pediatrics; procedural volume; vascular disorders