Regionalization

Regionalization is the tendency to form decentralized regions.

There is a growing body of evidence suggesting that regionalization of subspecialty procedures to high-volume centres may limit patient morbidity and mortality, such as in patients undergoing clipping or endovascular coiling for ruptured and unruptured intracranial aneurysms, evacuation of intracerebral hemorrhage, carotid endarterectomy (CEA), resection of supratentorial brain tumours, resection of vestibular schwannomas, microvascular decompression for neurovascular compression syndromes, and decompression for lumbar stenosis 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12).

To test the hypothesis that RT would be associated with earlier time to surgery and decreased length of stay (LOS).

Traumatic spine injury (TSI) patients >14 yr were identified using International Classification of Diseases Ninth Revision Clinical Modification diagnostic codes. Data from 2008 through 2012 were analyzed before and after RT in 2010.

RESULTS: A total of 4072 patients were identified; 1904 (47%) pre-RT and 2168 (53%) post-RT. Injury severity scores, Spine Abbreviated Injury Scale scores, and the percentage of TSIs with spinal cord injury (tSCI) were similar between time periods. Post-RT TSIs demonstrated a lower median intensive care unit (ICU) LOS (0 vs 1 d; P < 0.0001), underwent spine surgery more frequently (13% vs 11%; P = 0.01), and had a higher rate of spine surgery performed within 24 h of admission (65% vs 55%; P = 0.02). In patients with tSCI post-RT, ICU LOS was decreased (1 vs 2 d; P < 0.0001) and ventilator days were reduced (average days: 2 vs 3; P = 0.006). The post-RT time period was an independent predictor for spine surgery performed in less than 24 h for all TSIs (odds ratio [OR] 1.52, 95% confidence interval [CI]: 1.04-2.22, C-stat = 0.65). Multivariate linear regression analysis demonstrated an independent effect on reduced ICU LOS post-RT for TSIs (OR -1.68; 95% CI: -2.98 to 0.39; R2 = 0.74) and tSCIs (OR -2.42, 95% CI: -3.99-0.85; R2 = 0.72).

CONCLUSION: RT is associated with increased surgical rates, earlier time to surgery, and decreased ICU LOS for patients with TSI 13).

RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI 14).

1)
Nuno M, Patil CG, Lyden P, et al. The effect of transfer and hospital volume in subarachnoid hemorrhage patients. Neurocrit Care. 2012;17:312-23.
2)
Pandey AS, Gemmete JJ, Wilson TJ, et al. High subarachnoid hemorrhage patient volume associated with lower mortality and better outcomes. Neurosurgery. 2015;77:462-70.
3)
Vespa P, Diringer MN. The Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. High-volume centers. Neurocrit Care. 2011;15:369-72.
4)
Barker FG, Amin-Hanjani S, Butler WE, et al. In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996-2000: the effect of hospital and surgeon volume. Neurosurgery. 2003;52: 995-1009.
5)
Cowan JA, Dimick JB, Thompson BG, et al. Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg. 2002;195:814-21.
6)
Patil CG, Alexander AL, Gephart MG, et al. A population-based study of inpatient outcomes after operative management of nontraumatic intracerebral hemorrhage in the United States. World Neurosurg. 2011;78:640-5.
7)
Hastan D, Vandenbroucke JP, van der Mey AG. A meta-analysis of surgical treatment for vestibular schwannoma: is hospital volume related to preservation of facial function? Otol Neurotol. 2009;30:975-80.
8)
Trinh VT, Davies JM, Berger MS. Surgery for primary supratentorial brain tumors in the United States, 2000-2009: effect of provider and hospital caseload on complication rates. J Neurosurg. 2015;122:280-96.
9)
Englot DJ, Ouyang D, Wang DD, et al. Relationship between hospital surgical volume, lobectomy rates, and adverse perioperative events in US epilepsy centers. J Neurosurg. 2013;118:169-74.
10)
Kalkanis SN, Eskander EN, Carter BS, et al. Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery. 2003;52:1251-62.
11)
Wang DD, Ouyang D, Englot DJ, et al. Trends in surgical treatment for trigeminal neuralgia in the United States of America from 1988-2008. J Clin Neurosci. 2013;20:1538-45.
12)
Dasenbrock HH, Clarke MJ, Witham TF, et al. The impact of provide volume on the outcomes after surgery for lumbar spinal stenosis. Neurosurgery. 2012;70:1346-54.
13)
Kelly ML, He J, Roach MJ, Moore TA, Steinmetz MP, Claridge JA. Regionalization of Spine Trauma Care in an Urban Trauma System in the United States: Decreased Time to Surgery and Hospital Length of Stay. Neurosurgery. 2018 Oct 16. doi: 10.1093/neuros/nyy452. [Epub ahead of print] PubMed PMID: 30329091.
14)
Kelly ML, Roach MJ, Banerjee A, Steinmetz MP, Claridge JA. Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system. J Trauma Acute Care Surg. 2015 Sep;79(3):372-377. PubMed PMID: 26307868.