If We Can See the Outcome, We Can Change the Outcome

Tom Lee: This is Tom Lee, and I’m pleased to be chatting with Roy Rosin, a very interesting and effective Chief Innovation Officer at Penn Medicine. A bunch of organizations have chief innovation officers these days. I think Penn’s program is among the most robust in the country, and they’ve got one of the most interesting leaders. Roy, you came from outside health care to be a chief leader of innovation at Penn. What were you doing before, and why did you make this move?

Roy Rosin: It’s great to talk to you, Tom. It was fun to have an opportunity to do something like it in health care when I did. I had spent many years at Intuit, which a lot of people know as the maker of TurboTax or Quicken or QuickBooks, and it’s just a fantastic company out in Silicon Valley. I had been there quite a long time, had built some of the software businesses like Quicken, but back in 2003 — my wife is from Philadelphia and wanted to move home to be near family, so I made that transition with her. I sometimes say I never really left Intuit, I just wanted to stay married, and I needed to go back and rethink what I wanted to do.

Intuit was fabulous. They gave me an opportunity to stay with the company. In fact, I stayed for another 9 years working remotely, and in those 9 years what I was able to do was think about enterprise, scale, innovation. How do you get new things going and turn ideas into actions and outcomes, and how do you get a lot of new things off the ground that actually have some impact? So we did that. We built these programs over the course of 9 years. I could do it remotely because we had new businesses starting all over the place, and we learned a tremendous amount.

Intuit was a learning organization, and after 9 years it was a lot of travel. I had kids, going back and forth, and I had started talking with Kevin Volpp who I know you know well. He’s an old friend of mine from college, and Kevin had started an innovation center at Penn that also was doing just fascinating work in behavior changes applied to health care.

Some of what we had done at Intuit was . . . thinking about, how do you get people to make different and better decisions? A lot of what we did was for profit at Intuit, but some of it worked so well that you start to wonder, well, gee, how can I do this for purely a social mission to provide some meaningful difference in the world? So talking to Kevin got me fascinated. And then seeing about what was happening in health care, [in terms of] moving toward value-based plans and into value-based care, all of a sudden I realized this was a fascinating time to be going after social missions that I could be part of as a nonclinical person. That’s what led to my leaning into it and coming over and starting to work with Penn.

Lee: I’ve been following along and in just a few years, if memory serves me, you guys have launched like 90 or so projects. That’s a lot. It’s an overwhelming number. How is it going? Is 90 too many? Is 90 not enough? How are you thinking about the overall scale of what you’re doing?

Rosin: Yeah. It is a lot of projects. Now, to be fair, some of them are very light-touch. Sometimes we’re just advising or just consulting on a project and we meet with somebody a couple of times a month and it doesn’t take up a tremendous amount of time. [But] some of the projects we’re leading in a much deeper dive, so it’s a little bit hard to get a picture. But we’ve done 90 over about 5 years. And it’s going really well.

One of the things that I absolutely love to see are outcomes, measurable outcomes, where we’re defining, what is the needle we want to move. We want to move 30-day readmissions or an infection rate or something that is important and that we’re able to do so. And we find that we can. Those projects were across a lot of different areas. They cross new care models, models about how do you get people with uncontrolled hypertension to be normotensive, new models around how do you treat women who have had a miscarriage so they don’t end up in the ER or the OR, even models like IMPaCT, just a wonderful program that has to do with how do you treat vulnerable populations where the normal care design isn’t working well and they end up being what’s often called superutilizers in the wrong setting of care and the wrong cost and not being treated well. And from those new models to technology interventions to — Kevin and David [Asch] spent a lot of time developing connected health interventions, so seeing and knowing things we never saw or knew before, things that are going on in the home or in different settings that could determine the health outcomes, and as we start see those, we can change the outcome — to all kinds of technology interventions. It’s a broad, broad range of work that we’ve been able to do, and overall I’m happy with the way it’s been going.

Lee: When I’ve spoken with you, you told me that everywhere you look you see low-hanging fruit and I’m sure it’s true, but with so much opportunity to improve, how do you prioritize, how do you choose what to do and what not to do?

Rosin: It’s a blend. We try to stay aware of what the system’s priorities are. David Asch — he’s my co-conspirator — and I, we’ll often go on listening tours and spend time with the CEOs of the entities and the chief medical officers and chief nursing officers. We will try to plug into some of the operating mechanisms where the senior leadership is talking about system priorities. Of course, we’re aware of big changes in our environment like when an area becomes bundles and all of a sudden you’re responsible in a different way than you have been before. [For example,] we just signed a fairly public big deal with Independence Blue Cross where we’re now responsible for all 30-day readmissions and not being paid for 30-day readmissions, so those certainly set some of our priorities, but I think what’s an important insight is that the way innovation works is that you have to find passion. You have to find people who really want to make a change. Innovation doesn’t work well as an assignment where you go and say hey, I want you to work on this and please go do it.

What you’re looking for are clinical champions and care teams who are engaged, who want to work on the problem, and I always say they’re pulling instead of us pushing, so we are a blended tops-down and bottoms-up model. We also will do bottoms-up work that may involve a fascinating idea, or a new idea from a clinical or administrative leader or somebody on the front lines, that doesn’t necessarily seem fully aligned with some of the system priorities just because there’s a lot of energy and passion, and it might be off our radar, and those are exciting, too. We do have a blend, and it’s a portfolio of projects that we pay attention to. We stay mostly aligned with the top priorities in the health system.

Lee: Is the goal making money for Penn, or making money for innovators, or is the top priority changing Penn’s health care?

Rosin: We have a fairly lucky position, I’d say, in that we do get to spend time [doing] what I call “de-risking” more future models. We see the world moving toward more risk-bearing contracts. We see an increasing focus on value-based care. And we have a tremendous number of colleagues across Penn who are innovating, frankly, who are changing the way we work and doing good work. We’re certainly not the only people who are innovating care, and in many cases what we try to do is enable and create infrastructure where every team can go faster and do better work.

But our work has often stayed focused on where things become a little bit more risk-bearing and the future where we expect to be pretty soon. Now, we will certainly do operations projects so we’re looking for economic wins, we’re looking for places that our work can have a measurable economic impact on what Penn is doing, but we’re also in some areas that don’t.

A good example might be [that] when we started off we did work on some benefit redesign. We have 30,000 employees and they’re self-insured, so the cost of health care just makes bottom line. Doing work there that made our own employees better off and healthier saved a tremendous amount of money and it bought us the right to work on things like hypertension, where David had a strong desire to look at our folks who had uncontrolled hypertension to try to get it normal blood pressure.

If you’re perfect there, you don’t save or make any money in the near term, but it’s, as you know, a critically important area of health. We try to keep our eye out to a balance of both long and short term as well as things that are system priorities, tops-down and bottoms-up.

Lee: It sounds like you’re amassing political capital and using it as well as financial capital. But now, have you had disappointments that bug you? Things that you think should’ve worked and they fell short, they couldn’t move any needle, at least so far for reasons that you hadn’t anticipated or you haven’t figured out how to surmount yet?

Rosin: The ones I put in that bucket haven’t not worked, they’re maybe what I call stalled. When we do our work, we often will do small pilots with a small sample size because we are trying to get things ready before we scale them. That’s one of the big changes in an innovation approach — that you don’t scale until you figure out what works and you can validate a lot of the hypotheses that you may have about a new intervention or a new care model. We had a long list of successes at the pilot stage, but to the extent that I feel frustrated is how quickly some of those moved into a scaled model. Real wins and real success for us are scale of impact, things that help lots and lots of people, millions or an entire population.

And what we love is when we do work that gets taken even beyond Penn’s walls and applied in other locations. So the pace of getting from a successful pilot to a scaled win is probably the thing that’s been frustrating. It’s a solvable problem.

We have a new CEO at the Hospital of the University of Pennsylvania, a woman named Regina Cunningham who came up as a nurse and a chief nursing officer, and we had a great meeting with Regina the other day where we had a couple of important successful pilots. One was around people who are discharged on IV antibiotics — a  high-risk, high–readmission rate population — and another was the liver population, cirrhosis and liver transplant.

In both cases the teams had done extraordinarily good work cutting that readmission rate, and in the case of liver, dramatically reducing the cost of the intervention from $1,000 a person down to $50 a person, so cutting 95% of the cost out. And even with those kind of results sometimes the pilot would stay sort of in this middle ground of no man’s land.

We were always smart enough not to throw it over the wall. We know that us doing pilots and then going to find a champion doesn’t work. We have certainly done a pretty good job of engaging operations and moving them upstream and trying to stay in tight contact with the operational leaders of the system and have good partnerships, but I love what Regina did. In this meeting she said, “Look, here’s what we have to do. You guys have to do a better job of thinking of the budget cycles and getting in front of my leadership team. Here’s the setting I’m providing to you, here is the timing [for how] we’re going to do it. Here’s the story that you need to sell and the analysis that we need to have.”

And so, making sure we’re absolutely clear on who will operationalize and how good is good enough, what is that economic argument that we need, and making sure we have the audience set up early before it’s time to do a handoff. We’re getting better at that, and that’s what is getting me around some of the things that I might otherwise call disappointments. With hindsight, I think about an intervention very early [on] that turned into a success but wasn’t for a long time. It was the early days of connected health, and you already saw this at Partners with Joe Kvedar, and Kevin and David were already doing a wonderful job talking about automated hovering and talking about we need to stay connected once people leave the hospital. We have done a version of that in the CHF population, and working with one of our physicians we ended up with zero preventable readmissions, which was probably better than anyone expected. Again, a fairly small sample size.

Everyone saw this, and the analysis was done that it was successful and financially important. We decided to scale it. And a whole year went by, I mean a full year passed without forward motion, and what we realized is that organizationally, there wasn’t anybody who owned at that time — this was many years ago now — who owned the job of preventing readmissions, of keeping someone healthy and out of the hospital. The executive team created a structure called, basically our service line, so now you were not just focused on inpatient and separately on outpatient, but more focused on patient populations, and it was remarkable what happened after the organizational change.

All of a sudden, now somebody had this job and was accountable for keeping people healthy and out of the hospital, and then they were looking for a tool that essentially did what we had figured out how to do — all of a sudden it was adopted. The problem wasn’t a technology problem or a, say, can you come up with some kind of service model that works — it was actually, gosh, I need an organizational approach that embraces and wants it. That was interesting to see that when the org[anization] changed the innovation became successful, became adopted, and became scaled.

Lee: Let me close by asking a question that may be impossible because we can’t ask someone which child you love the most, but is there any particular innovation that you bring up as one that as among those that you love the most?

Rosin: It is hard to say your favorite child. I certainly love Shreya Kangovi’s IMPaCT program because of how completely she rethought the use of community health workers and how they’re hired and identified, trained, deployed, and get out the extraordinarily difficult problems of social determinants. [That] would be one. And she’s seeing a few dollar return for every dollar invested, which I think is phenomenal.

If I could tell a single story right now, it might be a program we call Heart Safe Motherhood. Heart Safe Motherhood is a neat program. It grows out of that same connected health approach of seeing and knowing about things we never used to see and know about.

In this case it was postpartum preeclampsia and that was the number one driver of both 7-day readmissions and morbidity in the maternal population. And the team had done a whole bunch of work, good work, and yet it wasn’t moving the needle. There were free walk-in clinics. We called people and tried to follow up. They weren’t answering the phone or returning our calls and [were] not showing up to the free walk-in clinic.

And what the team did was led by two doctors . . . and at first they realized that the preferred modality was texting, because in many cases this population . . . they didn’t want to talk to us maybe ever, certainly not at any particular point in time, and we would send the women home with a blood pressure cuff. One of the interesting insights early on was that it wasn’t high-tech. It wasn’t one of these wireless cuffs that would automatically broadcast. It was actually a low-tech off-the-shelf at a Walmart or CVS because they could just text us the number and that addressed connectivity and wireless issues. They started to iterate and play with the texting, can I get these blood pressure values.

Around the same time, ACOG, the American College of OB-GYN, created a standard that said, look, to keep this population safe you need two blood pressure values, that first week after discharge, one around 3 days, one around 7 days. And in all of the top systems, including Penn, we had that for nobody. We were at 0%, and by sending women home with these blood pressure cuffs and beginning the texting protocol, that team ended up going from 0% to 82% of coverage, where we have the information, the blood pressure information we needed to keep the women safe.

But why I like the program so much is [that] it wasn’t just about this automated hovering, it wasn’t just about having that information. The real outcome you’re trying to change is could you avoid the morbidity and the readmissions and the bad outcomes, bad outcomes both for the patient and for the health system. And they were able to do that. The numbers are growing, and they moved a couple hundred patients through the system now and it has zero readmissions.

It went from the highest, 7 day readmissions, to so far no readmissions, which [is] the real impact that we’re looking for, and then you get scale, because this program is now being adopted not only in other settings across Penn, but even in other cities and in other places. When we can get that kind of endorsement and support from, for example, the National Preeclampsia Foundation and others, and see the stuff start to scale and go to other places to have a population effect, I get really happy. That’s probably it.

Lee: That is a great story, Roy. It’s a lovely one and it also shows that innovation really has to occur at that disease level. It can’t happen across the board for all readmissions. But you have a lot to be proud of and I know a lot more great work’s going to come out. The approaches you’re using I think will be instructive for all the other folks out there listening. I want to thank you for taking the time to share your insights with the NEJM Catalyst audience today.

New Project Aims to Set Effectiveness Guidelines for Hemophilia Gene Therapy Trials

New Project Aims to Set Effectiveness Guidelines for Hemophilia Gene Therapy Trials

An international team has joined efforts to establish guidelines for effectiveness and outcome measurements regarding gene therapies in hemophilia.

The CoreHEM project will be led by researchers from McMaster University in Ontario, Canada, in collaboration with the National Hemophilia Foundation (NHF) in the U.S. and the Green Park Collaborative — a major initiative of the Center for Medical Technology Policy (CMTP), based in Baltimore, Maryland.

“With a growing pipeline of gene therapy products for hemophilia, it is an ideal time for this work,” Sean Tunis, president and CEO of CMTP, said in a news release. “This effort will potentially serve as a model for achieving consensus around outcomes to demonstrate effectiveness and value for promising emerging therapies in many other clinical areas, as well as for other rare conditions.”

Hemophilia is caused by a genetic defect that leads to low levels or the total absence of clotting factors — factor VIII in hemophilia A and factor IX in hemophilia B — which are necessary for effective bleeding control. Hemophilia patients need to receive routine injections of the missing clotting factors to control symptoms of the disease. This demanding therapy schedule can have an extreme impact on patients’ quality of life.

Scientific advances have led to the development of new treatments that may have the potential to cure hemophilia A and B by replacing the damaged gene. Clinical trials on these new gene therapies should provide enough evidence demonstrating their effectiveness, but also substantial improvements in reducing or eliminating burdens of the disease.

The CoreHEM project aims to define a core outcome, set through a consensus process, which should be considered when evaluating the effectiveness of gene therapies in patients with hemophilia.

Taking into consideration input from patients, clinicians, researchers, product manufacturers, public and private payers, and U.S. and international government agencies, the team will create a list of potential outcome domains and measurement approaches that will be reviewed by a steering committee.

This list will go through an online Delphi voting process and an in-person consensus meeting to prioritize and condense the list into the final core outcome set.

“These breakthroughs have the potential to be life-changing,” said Val Bias, CEO of the National Hemophilia Foundation. “This collaborative effort will bring a much needed voice from our patients, and the important role they play in identifying outcomes that are vital to their health.”

The final results of the CoreHEM project, expected early in 2018, will be published in a peer-reviewed article providing recommendations for important patient outcomes in clinical studies focused on gene therapies for hemophilia. In addition, an “effectiveness guidance document” will also be published.

Implementing these outcome-defined measures will not only help patients and clinicians to make better treatment-related decisions, but will also potentially improve the way clinical trials are conducted and assessed.

“The enthusiasm from so many stakeholders to becoming part of the project speaks volumes to the potential of this initiative,” said Alfonso Iorio, co-principal investigator and associate professor of health research methods, evidence, and impact at McMaster University.

Creating a consensus for implementation early in the development of breakthrough technology is a key to success, he added.

Volumetric analysis of subarachnoid hemorrhage: assessment of the reliability of two computerized methods and their comparison with other radiographic scales.


There were two main purposes to this study: first, to assess the feasibility and reliability of 2 quantitative methods to assess bleeding volume in patients who suffered spontaneous subarachnoid hemorrhage (SAH), and second, to compare these methods to other qualitative and semiquantitative scales in terms of reliability and accuracy in predicting delayed cerebral ischemia (DCI) and outcome.


A prospective series of 150 patients consecutively admitted to the Hospital 12 de Octubre over a 4-year period were included in the study. All of these patients had a diagnosis of SAH, and diagnostic CT was able to be performed in the first 24 hours after the onset of the symptoms. All CT scans were evaluated by 2 independent observers in a blinded fashion, using 2 different quantitative methods to estimate the aneurysmal bleeding volume: region of interest (ROI) volume and the Cavalieri method. The images were also graded using the Fisher scale, modified Fisher scale, Claasen scale, and the semiquantitative Hijdra scale. Weighted κ coefficients were calculated for assessing the interobserver reliability of qualitative scales and the Hijdra scores. For assessing the intermethod and interrater reliability of volumetric measurements, intraclass correlation coefficients (ICCs) were used as well as the methodology proposed by Bland and Altman. Finally, weighted κ coefficients were calculated for the different quartiles of the volumetric measurements to make comparison with qualitative scales easier. Patients surviving more than 48 hours were included in the analysis of DCI predisposing factors and analyzed using the chi-square or the Mann-Whitney U-tests. Logistic regression analysis was used for predicting DCI and outcome in the different quartiles of bleeding volume to obtain adjusted ORs. The diagnostic accuracy of each scale was obtained by calculating the area under the receiver operating characteristic curve (AUC).


Qualitative scores showed a moderate interobserver reproducibility (weighted κ indexes were always < 0.65), whereas the semiquantitative and quantitative scores had a very strong interobserver reproducibility. Reliability was very high for all quantitative measures as expressed by the ICCs for intermethod and interobserver agreement. Poor outcome and DCI occurred in 49% and 31% of patients, respectively. Larger bleeding volumes were related to a poorer outcome and a higher risk of developing DCI, and the proportion of patients suffering DCI or a poor outcome increased with each quartile, maintaining this relationship after adjusting for the main clinical factors related to outcome. Quantitative analysis of total bleeding volume achieved the highest AUC, and had a greater discriminative ability than the qualitative scales for predicting the development of DCI and outcome.


The use of quantitative measures may reduce interobserver variability in comparison with categorical scales. These measures are feasible using dedicated software and show a better prognostic capability in relation to outcome and DCI than conventional categorical scales.

Source: Journal of neurosurgery.



Measuring surgical outcomes in neurosurgery: implementation, analysis, and auditing a prospective series of more than 5000 procedures.

Health care reform debate includes discussions regarding outcomes of surgical interventions. Yet quality of medical care, when judged as a health outcome, is difficult to define because of impediments affecting accuracy in data collection, analysis, and reporting. In this prospective study, the authors report the outcomes for neurosurgical treatment based on point-of-care interactions recorded in the electronic medical record (EMR).


The authors’ neurosurgery practice collected outcome data for 19 physicians and ancillary personnel using the EMR. Data were analyzed for 5361 consecutive surgical cases, either elective or emergency procedures, performed during 2009 at multiple hospitals, offices, and an ambulatory spine surgery center. Main outcomes included complications, length of stay (LOS), and discharge disposition for all patients and for certain frequently performed procedures. Physicians, nurses, and other medical staff used validated scales to record the hospital LOS, complications, disposition at discharge, and return to work.


Of the 5361 surgical procedures performed, two-thirds were spinal procedures and one-third were cranial procedures. Organization-wide compliance with reporting rates of major complications improved throughout the year, from 80.7% in the first quarter to 90.3% in the fourth quarter. Auditing showed that rates of unreported complications decreased from 11% in the first quarter to 4% in the fourth quarter. Complication data were available for 4593 procedures (85.7%); of these, no complications were reported in 4367 (95.1%). Discharge dispositions reported were home in 86.2%, rehabilitation center in 8.9%, and nursing home in 2.5%. Major complications included culture-proven infection in 0.61%, CSF leak in 0.89%, reoperation within the same hospitalization in 0.38%, and new neurological deficits in 0.77%. For the commonly performed procedures, the median hospital LOS was 3 days for craniotomy for aneurysm or intraaxial tumor and less than 1 day for angiogram, anterior cervical discectomy with fusion, or lumbar discectomy.


With prospectively collected outcome data for more than 5000 surgeries, the authors achieved their primary end point of institution-wide compliance and data accuracy. Components of this process included staged implementation with physician pilot studies and oversight, nurse participation, point-of-service data capture, EMR form modification, data auditing, and confidential surgeon reports.

Source: Journal of Neurosurgery.





The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI.

Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries.


The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patient’s injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline.


Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R2 = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score.


Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.

Source: Journal of Neurosurgery.


A randomized study of urgent computed tomography–based hematoma puncture and aspiration in the emergency department and subsequent evacuation using craniectomy versus craniectomy only.

When treating patients with a spontaneous supratentorial massive (≥ 70 ml) intracerebral hemorrhage (ICH), the results of surgery are gloomy. A worsening pupil response has been observed in patients preoperatively, despite blood pressure control and diuretic administration. Because open surgery needs time for decompression to occur, the authors conducted a prospective randomized study to determine whether patients who have suffered a massive ICH can benefit from a more urgently performed decompressive procedure.


Overall, 36 eligible patients admitted 6 or fewer hours post-ictus were enrolled in the study. In Group A, 12 patients underwent CT-based hematoma puncture and partial aspiration in the emergency department (ED) and subsequent evacuation via a craniectomy; in Group B, 24 patients underwent hematoma evacuation via a craniectomy only. Pupil responses were categorized into 5 grades (Grade 0, bilaterally fixed; Grade 1, unilaterally fixed with the fixed pupil > 7 mm; Grade 2, unilaterally fixed with the fixed pupil ≤ 7 mm; Grade 3, a unilaterally sluggish response; and Grade 4, a bilaterally brisk response). Grades were obtained on admission, at surgical decompression (defined as the point at which liquid hematoma began to flow out in Group A and at dural opening in Group B), and at completion of craniectomy. The Barthel Scale was used to assess survivors’ functional outcome at 12 months. Comparisons were made between Groups A and B. Logistic regression analysis was used to evaluate the positive likelihood ratio of all variables for survival and function (Barthel Scale score of ≥ 35 at 12 months).


Decompressive surgery was undertaken approximately 60 minutes earlier in Group A than B. A worsening pupil reflex before decompression was observed in no Group A patient and in 9 Group B patients. At the time of decompression pupil response was better in Group A than B (p < 0.05). Although only approximately one-third of the hematoma volume documented on initial CT scanning had been drained before the craniectomy in Group A, when partial aspiration was followed by craniectomy, better pupil-response results were obtained in Group A at the completion of craniectomy, and survival rate and 12-month Barthel Scale score were better as well (p < 0.05). Logistic regression analysis revealed that one variable, a minimum pupil grade of 3 at the time of decompression, had the highest predictive value for survival at 12 months (8.0, 95% CI 2.0–32.0), and a pupil grade of 4 at the same time was the most valuable predictor of a Barthel Scale score of 35 or greater at 12 months (15.0, 95% CI 1.9–120.9).


Patients with massive spontaneous supratentorial ICHs may benefit from more urgent surgical decompression. The results of logistic regression analysis implied that, to improve long-term functional outcome, decompression should be performed in patients before herniation occurs. Due to the fact that most of these patients have signs of herniation when presenting to the ED and because conventional surgical decompression requires time to take effect, this combination of surgical treatment provides a feasible and effective surgical option.

Source: Journal of Neurosurgery.



Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage.

Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (SAH). The primary objective of this study was to identify at which time point clinical assessment using the World Federation of Neurosurgical Societies (WFNS) grading scale and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome.


This study is a retrospective cohort study on the association between poor outcome and clinical grading determined at presentation, nadir, and postresuscitation. Poor functional outcome was defined as a Glasgow Outcome Scale score of 1–3 at 6 months after SAH.


The authors identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. The patients’ mean age (± SD) was 56.9 ± 13.7 years, and 63% were women. Twenty-four percent had poor functional outcome (the mortality rate was 17%). On univariable logistic regression analyses, GCS score determined at presentation (OR 0.80, p < 0.0001), nadir (OR 0.73, p < 0.0001), and postresuscitation (OR 0.53, p < 0.0001); modified Fisher scale (OR 2.21, p = 0.0013); WFNS grade assessed at presentation (OR 1.92, p < 0.0001), nadir (OR 3.51, < 0.0001), and postresuscitation (OR 3.91, p < 0.0001); intracerebral hematoma on initial CT (OR 4.55, p < 0.0002); acute hydrocephalus (OR 2.29, p = 0.0375); and cerebral infarction (OR 4.84, p < 0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR 5.80, p = 0.0013) and WFNS grade postresuscitation (OR 3.43, p < 0.0001) were associated with poor outcome. Receiver operating characteristic/area under the curve (AUC) analysis demonstrated that WFNS grade determined postresuscitation had a stronger association with poor outcome (AUC 0.90) than WFNS grade assessed upon admission or at nadir.


Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

Source: Journal of neurosurgery.