John P. Sheehy

Disparities in Access to Deep Brain Stimulation Surgery for Parkinson Disease Interaction Between African American Race and Medicaid Use

IMPORTANCE African American individuals experience barriers to accessing many types of health care in the United States, resulting in substantial health care disparities. To improve health care in this patient population, it is important to recognize and study the potential factors limiting access to care. OBJECTIVE To examine deep brain stimulation (DBS) use in Parkinson disease (PD) to determine which factors, among a variety of demographic, clinical, and socioeconomic variables, drive DBS use in the United States. DESIGN, SETTING, AND PARTICIPANTS We queried the Nationwide Inpatient Sample in combination with neurologist and neurological surgeon countywide density data from the Area Resource File. We used International Classification of Diseases, Ninth Revision codes to identify discharges of patients at multicenter, all-payer, nonfederal hospitals in the United States diagnosed with PD (code 332.0) who were admitted for implantation of intracranial neurostimulator lead(s) (code 02.39), DBS. MAIN OUTCOMES AND MEASURES We analyzed factors predicting DBS use in PD using a hierarchical logistic regression analysis including patient and hospital characteristics. Patient characteristics included age, sex, comorbidity score, race, income quartile of zip code, and insurance type. Hospital characteristics included teaching status, size, regional location, urban vs rural setting, experience with DBS discharges, year, and countywide density of neurologists and neurological surgeons. RESULTS Query of the Nationwide Inpatient Sample yielded 2,408,302 PD discharges from 2002 to 2009; 18,312 of these discharges were for DBS. Notably, 4.7% of all PD discharges were African American, while only 0.1% of DBS for PD discharges were African American. A number of factors in the hierarchical multivariate analysis predicted DBS use including younger age, male sex, increasing income quartile of patient zip code, large hospitals, teaching hospitals, urban setting, hospitals with higher number of annual discharges for PD, and increased countywide density of neurologists (P < .05). Predictors of nonuse included African American race (P < .001), Medicaid use (P < .001), and increasing comorbidity score (P < .001). Countywide density of neurological surgeons and Hispanic ethnicity were not significant predictors. CONCLUSIONS AND RELEVANCE: Despite the fact that African American patients are more often discharged from hospitals with characteristics predicting DBS use (ie, urban teaching hospitals in areas with a higher than average density of neurologists), these patients received disproportionately fewer DBS procedures compared with their non-African American counterparts. Increased reliance on Medicaid in the African American population may predispose to the DBS use disparity. Various other factors may be responsible, including disparities in access to care, cultural biases or beliefs, and/or socioeconomic status.

Unchanged safety outcomes in deep brain stimulation surgery for Parkinson disease despite a decentralization of care.

OBJECT Early work on deep brain stimulation (DBS) surgery, when procedures were mostly carried out in a small number of high-volume centers, demonstrated a relationship between surgical volume and procedural safety. However, over the past decade, DBS has become more widely available in the community rather than solely at academic medical centers. The authors examined the Nationwide Inpatient Sample (NIS) to study the safety of DBS surgery for Parkinson disease (PD) in association with this change in practice patterns. METHODS The NIS is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified patients with a primary diagnosis of PD (332.0) and a primary procedure code for implantation/replacement of intracranial neurostimulator leads (02.93) who underwent surgery between 2002 and 2009. They analyzed outcomes using univariate and hierarchical, logistic regression analyses. RESULTS The total number of DBS cases remained stable from 2002 through 2009. Despite older and sicker patients undergoing DBS, procedural safety (rates of non-home discharges, complications) remained stable. Patients at low-volume hospitals were virtually indistinguishable from those at high-volume hospitals, except that patients at low-volume hospitals had slightly higher comorbidity scores (0.90 vs 0.75, p < 0.01). Complications, non-home discharges, length of hospital stay, and mortality rates did not significantly differ between low- and high-volume hospitals when accounting for hospital-related variables (caseload, teaching status, location). CONCLUSIONS Prior investigations have demonstrated a robust volume-outcome relationship for a variety of surgical procedures. However, the present study supports safety of DBS at smaller-volume centers. Prospective studies are required to determine whether low-volume centers and higher-volume centers have similar DBS efficacy, a critical factor in determining whether DBS is comparable between centers.

Inferior short-term safety profile of endoscopic third ventriculostomy compared with ventriculoperitoneal shunt placement for idiopathic normal-pressure hydrocephalus: a population-based study.

BACKGROUND In small series, endoscopic third ventriculostomy (ETV) has been shown to potentially have efficacy similar to that of ventriculoperitoneal shunting (VPS) for idiopathic normal-pressure hydrocephalus (iNPH). Therefore, some clinicians have advocated for ETV to avoid the potential long-term complications associated with VPS. Complication rates for these procedures vary widely based on limited small series data. OBJECTIVE We used a nationwide database that provides a comprehensive investigation of the perioperative safety of ETV for iNPH compared with VPS. METHODS We identified discharges with the primary diagnosis of iNPH (International Classification of Diseases, Ninth Revision code 331.5 [ICD-9]) with ICD-9 primary procedure codes for VPS (02.34) and ETV (02.2) from 2007 to 2010. We analyzed short-term safety outcomes using univariate and hierarchical logistic regression analyses. RESULTS There were a total of 652 discharges for ETV for iNPH and 12,845 discharges for VPS for iNPH over the study period. ETV was associated with a significantly higher mortality (3.2% vs 0.5%) and short-term complication (17.9% vs 11.8%) rates than VPS despite similar mean modified comorbidity scores. On multivariate analysis, ETV alone predicted increased mortality and increased length of stay when adjusted for other patient and hospital factors. CONCLUSION This is the first study that robustly assesses the perioperative complications and safety outcomes of ETV for iNPH. Compared with VPS, ETV is associated with higher perioperative mortality and complication rates. This consideration is important to weigh against the potential benefit of ETV: avoiding long-term shunt dependence. Prospective, randomized studies are needed.

Features and timing of the response of single neurons to novelty in the substantia nigra

Substantia nigra neurons are known to play a key role in normal cognitive processes and disease states. While animal models and neuroimaging studies link dopamine neurons to novelty detection, this has not been demonstrated electrophysiologically in humans. We used single neuron extracellular recordings in awake human subjects undergoing surgery for Parkinson disease to characterize the features and timing of this response in the substantia nigra. We recorded 49 neurons in the substantia nigra. Using an auditory oddball task, we showed that they fired more rapidly following novel sounds than repetitive tones. The response was biphasic with peaks at approximately 250 ms, comparable to that described in primate studies, and a second peak at 500 ms. This response was primarily driven by slower firing neurons as firing rate was inversely correlated to novelty response. Our data provide human validation of the purported role of dopamine neurons in novelty detection and suggest modifications to proposed models of novelty detection circuitry.

Human substantia nigra neurons encode decision outcome and are modulated by categorization uncertainty in an auditory categorization task

The ability to categorize stimuli – predator or prey, friend or foe – is an essential feature of the decision‐making process. Underlying that ability is the development of an internally generated category boundary to generate decision outcomes. While classic temporal difference reinforcement models assume midbrain dopaminergic neurons underlie the prediction error required to learn boundary location, these neurons also demonstrate a robust response to nonreward incentive stimuli. More recent models suggest that this may reflect a motivational aspect to performing a task which should be accounted for when modeling dopaminergic neuronal behavior. To clarify the role of substantia nigra dopamine neurons in uncertain perceptual decision making, we investigated their behavior using single neuron extracellular recordings in patients with Parkinsons disease undergoing deep brain stimulation. Subjects underwent a simple auditory categorical decision‐making task in which they had to classify a tone as either low‐ or high‐pitched relative to an explicit threshold tone and received feedback but no reward. We demonstrate that the activity of human SN dopaminergic neurons is predictive of perceptual categorical decision outcome and is modulated by uncertainty. Neuronal activity was highest during difficult (uncertain) decisions that resulted in correct responses and lowest during easy decisions that resulted in incorrect responses. This pattern of results is more consistent with a “motivational” role with regards to perceptual categorization and suggests that dopamine neurons are most active when critical information – as represented by uncertainty – is available for learning decision boundaries.

Low pressure hydrocephalus acutely following sepsis and cardiovascular collapse

Here we present a case of low pressure hydrocephalus (LPH) ccurring acutely in the wake of sepsis and myocardial infarction n a chronically shunted patient. LPH is a rare treatable condiion consisting of symptomatic hydrocephalus in the presence of elow-normal intracranial pressure (ICP). The first comprehensive escription of LPH in 1994 described this “unique hydrocephalic tate” as occurring in patients admitted with ventriculomegaly and igns typical of increased ICP such as headaches, vomiting, cranial europathies and decreased level of consciousness [1]. On admision, patients present with neurologic deterioration despite the resence of cerebrospinal fluid (CSF) diversion, persistent and proressive ventriculomegaly, normal to low normal ICP, a functioning SF diversion device, and clinical and radiographic improvement ith sub-zero drainage [1]. There have been occasional cases of cute development of LPH [2,3], but usually without clearly defined nciting events. LPH occurring acutely after sepsis and myocardial nfarction, though never before reported, is pathophysiologically onsistent with the poroelastic model of LPH described by Akins t al. [4].

Cost Transparency in Neurosurgery: A Single-Institution Analysis of Patient Out-of-Pocket Spending in 13 673 Consecutive Neurosurgery Cases

BACKGROUND Patient out-of-pocket (OOP) spending is an increasingly discussed topic; however, there is minimal data available on the patient financial burden of surgical procedures. OBJECTIVE To analyze hospital and surgeon expected payment data and patient OOP spending in neurosurgery. METHODS This is a retrospective cohort study of neurosurgical patients at a tertiary-referral center from 2013 to 2016. Expected payments, reflecting negotiated costs-of-care, as well as actual patient OOP payments for hospital care and surgeon professional fees were analyzed. A 4-tiered model of patient OOP cost sharing and a multivariate model of patient expected payments were created. RESULTS A total of 13 673 consecutive neurosurgical cases were analyzed. Patient age, insurance type, case category, severity of illness, length of stay (LOS), and elective case status were significant predictors of increased expected payments (P < .05). Craniotomy (

Multiple meningiomas: a long-term review

53 397 ± 811) and posterior spinal fusion (

Thirty-Day Postoperative Emergency Department Utilization and Hospital Readmission after 559 Sequential Endonasal Operations

48 329 ± 864) were associated with the highest expected payments. In a model of patient OOP cost sharing, nearly all neurosurgical procedures exceeded yearly OOP maximums for Healthcare Marketplace plans. Mean patient payments for hospital care and surgeon professional fees were the highest for anterior/lateral spinal fusion cases for commercially insured patients (

Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review

1662 ± 165). Mean expected payments and mean patient payments for commercially insured patients increased significantly from 2013 to 2016 (P < .05). CONCLUSION Expected payments and patient OOP spending for commercially insured patients significantly increased from 2013 to 2016, representing increased healthcare costs and patient cost sharing in an evolving healthcare environment. Patients and providers can consider this information prior to surgery to better anticipate the individual financial burden for neurosurgical care.