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Thirty-day outcomes of cerebrospinal fluid shunt surgery: data from the National Surgical Quality Improvement
1Division of Neurosurgery, Nemours Neuroscience Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware; and Department of Neurological Surgery and Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
Insights
This study analyzed 30-day outcomes for cerebrospinal fluid (CSF) shunt surgeries, identifying risk factors for infection and failure. While specific factors were found, reliable risk stratification models were not developed.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Healthcare Quality Improvement
Background:
- Cerebrospinal fluid (CSF) shunts are primary treatments for hydrocephalus.
- Previous outcome analyses relied on long-term follow-up (≥1 year).
- Short-term (30-day) outcomes and associated risk factors require further characterization.
Purpose of the Study:
- To characterize 30-day outcomes of CSF shunt surgery.
- To identify clinical risk factors for shunt infection and failure.
- To develop statistical models for risk stratification.
Main Methods:
- Utilized 2012 data from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P).
- Included index surgical procedures for CSF shunt insertion or revision.
- Analyzed 30-day returns to OR for shunt infection or failure without infection using univariate and logistic regression.
Main Results:
- Analyzed 1790 procedures; 30-day shunt infection rate was 2.0%, failure without infection was 11.5%.
- Risk factors for infection included male sex, steroid use, and nutritional support.
- Cardiac disease increased failure risk; initial insertion and neuromuscular disease were protective.
Conclusions:
- Identified novel risk factors for shunt infection and failure using precise NSQIP-P data.
- Thirty-day outcomes show potential as quality metrics, even without risk adjustment.
- Further research is needed to determine institutional or surgeon-specific outcome variations.
Object:
Cerebrospinal fluid shunts are the mainstay of the treatment of hydrocephalus. In past studies, outcomes of shunt surgery have been analyzed based on follow-up of 1 year or longer. The goal of the current study is to characterize 30-day shunt outcomes, to identify clinical risk factors for shunt infection and failure, and to develop statistical models that might be used for risk stratification.
Methods:
Data for 2012 were obtained from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) of the American College of Surgeons. Files with index surgical procedures for insertion or revision of a CSF shunt composed the study set. Returns to the operating room within 30 days for shunt infection and for shunt failure without infection were the study end points. Associations with a large number of potential clinical risk factors were analyzed on a univariate basis. Logistic regression was used for multivariate analysis.
Results:
There were 1790 index surgical procedures analyzed. The overall rates of shunt infection and shunt failure without infection were 2.0% and 11.5%, respectively. Male sex, steroid use in the preceding 30 days, and nutritional support at the time of surgery were risk factors for shunt infection. Cardiac disease was a risk factor for shunt failure without infection, and initial shunt insertion, admission during the second quarter, and neuromuscular disease appeared to be protective. There was a weak association of increasing age with shunt failure without infection. Models based on these factors accounted for no more than 6% of observed variance. Construction of stable statistical models with internal validity for risk adjustment proved impossible.
Conclusions:
The precision of the NSQIP-P dataset has allowed identification of risk factors for shunt infection and for shunt failure without infection that have not been documented previously. Thirty-day shunt outcomes may be useful quality metrics, possibly even without risk adjustment. Whether important variation in 30-day outcomes exists among institutions or among neurosurgeons is yet unknown.