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J Neurol Surg B Skull Base 2022; 83(S 02): e410-e418
DOI: 10.1055/s-0041-1729980
Original Article

30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients

Michael K. Ghiam
1   Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Darius E. Chyou
2   University of Miami Miller School of Medicine, Miami, Florida, United States
,
Cortney L. Dable
2   University of Miami Miller School of Medicine, Miami, Florida, United States
,
Andrew P. Katz
1   Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Daniel G. Eichberg
3   Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Hang Zhang
4   Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida, United States
,
Alejandro R. Ayala
5   Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Atil Y. Kargi
5   Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Ricardo J. Komotar
3   Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
,
Zoukaa Sargi
6   Department of Otolaryngology, Head and Neck Surgery, Sylvester Comprehensive Cancer Center, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, United States
› Author Affiliations Funding None.
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Abstract

Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions.

Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center.

Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88).

Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS.

Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.

Keywords

readmissions - transsphenoidal surgery - pituitary surgery - risk factors - endocrinology - coordination of care

Note

Interim results of this study were presented as a poster at the 2019 American Rhinologic Society Meeting in September 2019, New Orleans, LA.


Authors' Contributions

M.K.G. supported in study design, data collection, analysis, and presentation. D.E.C. and C.L.D. performed data collection, analysis, and presentation. A.P.K., D.G.E., H.Z., A.R.A., A.Y.K., and R.J.K. carried out study analysis. Z.S. contributed to study design, analysis, and presentation.


Supplementary Material



Publication History

Received: 12 July 2020

Accepted: 26 March 2021

Article published online:
25 May 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program. Accessed January 21, 2020 at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
    PubMedGoogle Scholar
  • 2 Villwock JA, Villwock M, Deshaies E, Goyal P. Significant increases of pituitary tumors and resections from 1993 to 2011. Int Forum Allergy Rhinol 2014; 4 (09) 767-770
    CrossrefPubMedGoogle Scholar
  • 3 Gittleman H, Ostrom QT, Farah PD. et al. Descriptive epidemiology of pituitary tumors in the United States, 2004-2009. J Neurosurg 2014; 121 (03) 527-535
    CrossrefPubMedGoogle Scholar
  • 4 Chibbaro S, Ganau M, Gubian A. et al. The role of endoscopic endonasal approach in the multimodal management of giant pituitary adenoma: case report and literature review. Asian J Neurosurg 2018; 13 (03) 888-892
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Gondim JA, Almeida JP, Albuquerque LA. et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 2011; 14 (02) 174-183
    CrossrefPubMedGoogle Scholar
  • 6 Gondim JA, de Albuquerque LAF, Almeida JP. et al. Endoscopic endonasal surgery for treatment of pituitary apoplexy: 16 years of experience in a specialized pituitary center. World Neurosurg 2017; 108: 137-142
    CrossrefPubMedGoogle Scholar
  • 7 Messerer M, Cossu G, George M, Daniel RT. Endoscopic endonasal trans-sphenoidal approach: minimally invasive surgery for pituitary adenomas. J Vis Exp 2018; 131: 55896
    PubMedGoogle Scholar
  • 8 Taghvaei M, Sadrehosseini SM, Ardakani JB, Nakhjavani M, Zeinalizadeh M. Endoscopic endonasal approach to the growth hormone-secreting pituitary adenomas: endocrinologic outcome in 68 patients. World Neurosurg 2018; 117: e259-e268
    CrossrefPubMedGoogle Scholar
  • 9 Alzhrani G, Sivakumar W, Park MS, Taussky P, Couldwell WT. Delayed complications after transsphenoidal surgery for pituitary adenomas. World Neurosurg 2018; 109: 233-241
    CrossrefPubMedGoogle Scholar
  • 10 Chowdhury T, Prabhakar H, Bithal PK, Schaller B, Dash HH. Immediate postoperative complications in transsphenoidal pituitary surgery: a prospective study. Saudi J Anaesth 2014; 8 (03) 335-341
    CrossrefPubMedGoogle Scholar
  • 11 Fan YP, Lv MH, Feng SY. et al. Full endoscopic transsphenoidal surgery for pituitary adenoma-emphasized on surgical skill of otolaryngologist. Indian J Otolaryngol Head Neck Surg 2014; 66 (Suppl. 01) 334-340
    CrossrefPubMedGoogle Scholar
  • 12 Carminucci AS, Ausiello JC, Page-Wilson G. et al. Outcome of implementation of a multidisciplinary team approach to the care of patients after transsphenoidal surgery. Endocr Pract 2016; 22 (01) 36-44
    CrossrefPubMedGoogle Scholar
  • 13 Bur AM, Brant JA, Newman JG. et al. Incidence and risk factors for prolonged hospitalization and readmission after transsphenoidal pituitary surgery. Otolaryngol Head Neck Surg 2016; 155 (04) 688-694
    CrossrefPubMedGoogle Scholar
  • 14 Hendricks BL, Shikary TA, Zimmer LA. Causes for 30-day readmission following transsphenoidal surgery. Otolaryngol Head Neck Surg 2016; 154 (02) 359-365
    CrossrefPubMedGoogle Scholar
  • 15 Cote DJ, Dasenbrock HH, Muskens IS. et al. Readmission and other adverse events after transsphenoidal surgery: prevalence, timing, and predictive factors. J Am Coll Surg 2017; 224 (05) 971-979
    CrossrefPubMedGoogle Scholar
  • 16 Barber SM, Liebelt BD, Baskin DS. Incidence, etiology and outcomes of hyponatremia after transsphenoidal surgery: experience with 344 consecutive patients at a single tertiary center. J Clin Med 2014; 3 (04) 1199-1219
    CrossrefPubMedGoogle Scholar
  • 17 Graboyes EM, Kallogjeri D, Saeed MJ, Olsen MA, Nussenbaum B. Postoperative care fragmentation and thirty-day unplanned readmissions after head and neck cancer surgery. Laryngoscope 2017; 127 (04) 868-874
    CrossrefPubMedGoogle Scholar
  • 18 Rizvi ZH, Ferrandino R, Luu Q, Suh JD, Wang MB. Nationwide analysis of unplanned 30-day readmissions after transsphenoidal pituitary surgery. Int Forum Allergy Rhinol 2019; 9 (03) 322-329
    CrossrefPubMedGoogle Scholar
  • 19 Shaftel KA, Cole TS, Little AS. National trends in hospital readmission following transsphenoidal surgery for pituitary lesions. Pituitary 2019
    PubMedGoogle Scholar
  • 20 Younus I, Gerges MM, Dobri GA, Ramakrishna R, Schwartz TH. Readmission after endoscopic transsphenoidal pituitary surgery: analysis of 584 consecutive cases. J Neurosurg 2019; 1-6
    PubMedGoogle Scholar
  • 21 Ajlan A, Almufawez KA, Albakr A, Katznelson L, Harsh IV GR. Adrenal axis insufficiency after endoscopic transsphenoidal resection of pituitary adenomas. World Neurosurg 2018; 112: e869-e875
    CrossrefPubMedGoogle Scholar
  • 22 Bohl MA, Ahmad S, Jahnke H. et al. Delayed hyponatremia is the most common cause of 30-day unplanned readmission after transsphenoidal surgery for pituitary Tumors. Neurosurgery 2016; 78 (01) 84-90
    CrossrefPubMedGoogle Scholar
  • 23 Cusick JF, Hagen TC, Findling JW. Inappropriate secretion of antidiuretic hormone after transsphenoidal surgery for pituitary tumors. N Engl J Med 1984; 311 (01) 36-38
    CrossrefPubMedGoogle Scholar
  • 24 Olson BR, Gumowski J, Rubino D, Oldfield EH. Pathophysiology of hyponatremia after transsphenoidal pituitary surgery. J Neurosurg 1997; 87 (04) 499-507
    CrossrefPubMedGoogle Scholar
  • 25 Krogh J, Kistorp CN, Jafar-Mohammadi B, Pal A, Cudlip S, Grossman A. Transsphenoidal surgery for pituitary tumours: frequency and predictors of delayed hyponatraemia and their relationship to early readmission. Eur J Endocrinol 2018; 178 (03) 247-253
    CrossrefPubMedGoogle Scholar
  • 26 Tomita Y, Kurozumi K, Inagaki K. et al. Delayed postoperative hyponatremia after endoscopic transsphenoidal surgery for pituitary adenoma. Acta Neurochir (Wien) 2019; 161 (04) 707-715
    CrossrefPubMedGoogle Scholar
  • 27 Hussain NS, Piper M, Ludlam WG, Ludlam WH, Fuller CJ, Mayberg MR. Delayed postoperative hyponatremia after transsphenoidal surgery: prevalence and associated factors. J Neurosurg 2013; 119 (06) 1453-1460
    CrossrefPubMedGoogle Scholar
  • 28 Yoon HK, Lee HC, Kim YH, Lim YJ, Park HP. Predictive factors for delayed hyponatremia after endoscopic transsphenoidal surgery in patients with nonfunctioning pituitary tumors: a retrospective observational study. World Neurosurg 2019; 122: e1457-e1464
    CrossrefPubMedGoogle Scholar
  • 29 Zada G, Liu CY, Fishback D, Singer PA, Weiss MH. Recognition and management of delayed hyponatremia following transsphenoidal pituitary surgery. J Neurosurg 2007; 106 (01) 66-71
    CrossrefPubMedGoogle Scholar
  • 30 Deaver KE, Catel CP, Lillehei KO, Wierman ME, Kerr JM. Strategies to reduce readmissions for hyponatremia after transsphenoidal surgery for pituitary adenomas. Endocrine 2018; 62 (02) 333-339
    CrossrefPubMedGoogle Scholar
  • 31 Conger A, Zhao F, Wang X. et al. Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 2018; 130 (03) 861-875
    CrossrefPubMedGoogle Scholar
  • 32 Umamaheswaran P, Krishnaswamy V, Krishnamurthy G, Mohanty S. Outcomes of surgical repair of skull base defects following endonasal pituitary surgery: a retrospective observational study. Indian J Otolaryngol Head Neck Surg 2019; 71 (01) 66-70
    CrossrefPubMedGoogle Scholar
  • 33 Hensen J, Henig A, Fahlbusch R, Meyer M, Boehnert M, Buchfelder M. Prevalence, predictors and patterns of postoperative polyuria and hyponatraemia in the immediate course after transsphenoidal surgery for pituitary adenomas. Clin Endocrinol (Oxf) 1999; 50 (04) 431-439
    CrossrefPubMedGoogle Scholar
  • 34 Jahangiri A, Wagner J, Tran MT. et al. Factors predicting postoperative hyponatremia and efficacy of hyponatremia management strategies after more than 1000 pituitary operations. J Neurosurg 2013; 119 (06) 1478-1483
    CrossrefPubMedGoogle Scholar
  • 35 Taylor SL, Tyrrell JB, Wilson CB. Delayed onset of hyponatremia after transsphenoidal surgery for pituitary adenomas. Neurosurgery 1995; 37 (04) 649-653 , discussion 653–654
    CrossrefPubMedGoogle Scholar
  • 36 Woodmansee WW, Carmichael J, Kelly D, Katznelson L. AACE Neuroendocrine and Pituitary Scientific Committee. Pituitary Scientific C. American Association of Clinical Endocrinologists and American College of Endocrinology Disease State Clinical Review: postoperative management following pituitary surgery. Endocr Pract 2015; 21 (07) 832-838
    CrossrefPubMedGoogle Scholar
  • 37 Winograd D, Staggers KA, Sebastian S, Takashima M, Yoshor D, Samson SL. An effective and practical fluid restriction protocol to decrease the risk of hyponatremia and readmissions after transsphenoidal surgery. Neurosurgery 2020; 87 (04) 761-769
    CrossrefPubMedGoogle Scholar
  • 38 Burke WT, Cote DJ, Iuliano SI, Zaidi HA, Laws ER. A practical method for prevention of readmission for symptomatic hyponatremia following transsphenoidal surgery. Pituitary 2018; 21 (01) 25-31
    CrossrefPubMedGoogle Scholar
  • 39 Rosen D, McCall JD, Primack BA. Telehealth protocol to prevent readmission among high-risk patients with congestive heart failure. Am J Med 2017; 130 (11) 1326-1330
    CrossrefPubMedGoogle Scholar