An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery.

INTRODUCTION: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy. METHODS: We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results. RESULTS: Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective. CONCLUSION: Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.

Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set.

OBJECTIVE: Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF. METHODS: This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score-matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars). RESULTS: A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score-matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges. CONCLUSIONS: The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).

IONM and minimally invasive videoassisted thyroidectomy.

BACKGROUND: We know that benefits of MIVAT are related to a better cosmetic result and lower post-operative pain in comparison to CT. The incidence of nerve cold palsy is related to a correct identification of the recurrent laringeal nerve (RLN) as standard procedure in thyroid surgery. From September 2014 we have introduced the use of intraoperative neural monitoring(I-IONM) in all thyroidectomies in the Unit of General Surgery of University Hospital of Parma, including in MIVAT. PATIENTS AND METHODS: We have considered all patients treated from September 2014 to September 2017 for thyroid diseases using MIVAT and IONM. Intermittent neuromonitoring with NIM-3.0 equipment (Medtronic, Jacksonville, FL, USA) was used during all operations. We have recorded all data about age, sex, diagnosis, surgical time, i-IONM signal, postoperative pain, postoperative hypocalcemia after 24 hours, haematoma and vocal cord palsy. The mean hospital stay was collected from surgical procedure to hospital discharge. We have considered vocal dysfunctions that persist six months after surgery as permanent. RESULTS: From September 2014 to September 2017 we treated consecutively with both MIVAT and i-IONM 100 patients. Considering the extent of surgery, 26 pts underwent to hemithyroidectomy and 74 pts to total thyroidectomy. The mean surgical time was 61.8 minutes. In 7 cases the patients were affected by preoperative clinical dysphonia. Using I-IONM during thyroidectomy, we recorded in 5 cases (5%) a loss of signal; in two cases (2%) we experienced a temporary postoperative vocal cord palsy. DISCUSSION: In our experience the use of IONM has improved the safety during thyroidectomy because precision that can be achieved by endoscopic procedures is further improved by complementary use of IONM. The costs associated to a potential reduction of medical litigation have not been investigated.

Neurophysiological monitoring during cervical spine surgeries: Longitudinal costs and outcomes.

OBJECTIVES: Well-designed longitudinal studies assessing effectiveness of intraoperative neurophysiologic monitoring (IONM) are lacking. We investigate IONM effects on cost and administrative markers for health outcomes in the year after cervical spine surgery. METHODS: We identified single-level cervical spine surgeries in commercial claims. We constructed linear regression models estimating the effect of IONM (controlling for patient demographics, pre-operative health, services during index admission) on total spending, neurological complications, readmissions, and outpatient opiate usage in the year following index surgery. RESULTS: IONM was associated with increased spending during index admission of $1229 (p = 0.001), but decreased spending post-discharge of $1615 (p = 0.010), for a net - $386 (p = 0.608) for the year after surgery. Shorter length of stay (0.116 days, p = 0.004) and fewer readmissions (20.5 per thousand, p = 0.036) accounted for some post-discharge savings. IONM was associated with decreased rates of nervous system complications (4/1000, p = 0.048) and post-discharge opiate use (17 prescriptions/1000, p = 0.050) in the year after index admission. CONCLUSIONS: IONM was associated with administrative markers suggesting improved health outcomes after cervical spine surgery without greater costs for the year. SIGNIFICANCE: This study suggests IONM may have lasting health and cost benefits.

An initial cost-effectiveness analysis of intraoperative magnetic resonance imaging (iMRI) in pediatric epilepsy surgery.

PURPOSE: Previous studies have illustrated the clinical utility of the addition of intraoperative magnetic resonance imaging (iMRI) to conventional microsurgical resection. While iMRI requires initial capital cost investment, long-term reduction in costly follow-up management and reoperation costs may prove economically efficacious. The objective of this study is to investigate the cost-effectiveness of the addition of iMRI utilization versus conventional microsurgical techniques in focal cortical dysplasia (FCD) resection in pediatric patients with medically refractory epilepsy. METHODS: We retrospectively reviewed the medical records of pediatric subjects who underwent surgical resection of FCD at the Children's National Health System between March 2005 and April 2015. Patients were assigned to one of three cohorts: iMRI-assisted resection, conventional resection with iMRI-assisted reoperation, or conventional resection. Direct costs included preoperative, operative, postoperative, long-term follow-up, and antiepileptic drug (AED) costs. The cost-effectiveness was calculated as the sum total of all direct medical costs over the quality-adjusted life years (QALYs). We also performed sensitivity analysis on numerous variables to assess the validity of our results. RESULTS: Fifty-six consecutive pediatric patients underwent resective surgery for medically intractable FCD. Ten patients underwent iMRI-assisted resection; 7 underwent conventional resection followed by iMRI-assisted reoperation; 39 patients underwent conventional microsurgical resection. Taken over the lifetime of the patient, the cumulative discounted QALY of patients in the iMRI-assisted resection cohort was about 2.91 years, versus 2.61 years in the conventional resection with iMRI-assisted reoperation cohort, and 1.76 years for the conventional resection cohort. Adjusting for inflation, iMRI-assisted surgeries have a cost-effectiveness ratio of $16,179 per QALY, versus $28,514 per QALY for the conventional resection with iMRI-assisted reoperation cohort, and $49,960 per QALY for the conventional resection cohort. Sensitivity analysis demonstrated that no one single variable significantly altered cost-effectiveness across all three cohorts compared to the baseline results. CONCLUSION: The addition of iMRI to conventional microsurgical techniques for resection of FCD in pediatric patients with intractable epilepsy resulted in increased seizure freedom and reduction in long-term direct medical costs compared to conventional surgeries. Our data suggests that iMRI may be a cost-effective addition to the surgical armamentarium for epilepsy surgery.

Cost-effectiveness of intraoperative nerve monitoring in avoidance of bilateral recurrent laryngeal nerve injury in patients undergoing total thyroidectomy.

BACKGROUND: Intraoperative nerve monitoring (IONM) provides dynamic neural information and is recommended for high-risk thyroid surgery. In this analysis, the cost-effectiveness of IONM in preventing bilateral recurrent laryngeal nerve (RLN) injury was investigated. METHODS: A Markov chain model was constructed based on IONM use. The base-case patient was defined as a 40-year-old woman presenting with a 4·1-cm left-sided papillary thyroid cancer who developed RLN injury with loss of monitoring signal during planned bilateral thyroidectomy. It was hypothesized that, if the surgeon had used IONM, the RLN injury would have been detected and the operation would have been concluded as a thyroid lobectomy to avoid the risk of contralateral RLN injury. Cost in US dollars was converted to euros; probabilities and utility scores were identified from the literature and government resources. Length of follow-up was set as 20 years, and willingness-to-pay (WTP) as €38 000 (US $50 000) per quality-adjusted life-year (QALY). RESULTS: At the end of year 20, the not using IONM strategy accrued €163 995·40 (US $215 783·43) and an effectiveness of 14·15 QALYs, whereas use of the IONM strategy accrued €170 283·68 (US $224 057·48) and an effectiveness of 14·33 QALYs. The incremental cost-effectiveness ratio, comparing use versus no use of IONM, was €35 285·26 (US $46 427·97) per QALY, which is below the proposed WTP, indicating that IONM is the preferred and cost-effective management plan. A Monte Carlo simulation test that considered variability of the main study factors in a hypothetical sample of 10 000 patients showed IONM to be the preferred strategy in 85·8 per cent of the population. CONCLUSION: Use of IONM is cost-effective in patients undergoing bilateral thyroid surgery.

Cost-Effectiveness of Two Decision Strategies for Shunt Use During Carotid Endarterectomy.

BACKGROUND: Arterial shunting during carotid endarterectomy (CEA) is essential in some patients because of insufficient cerebral perfusion during cross-clamping. However, the optimal diagnostic modality identifying these patients is still debated. None of the currently used modalities has been proved superior to another. The aim of this study was to assess the cost-effectiveness of two modalities, stump pressure measurement (SPM) versus electroencephalography (EEG) combined with transcranial Doppler (TCD) during CEA. METHODS: Two retrospective cohorts of consecutive patients undergoing CEA with different intraoperative neuromonitoring strategies (SPM vs. EEG/TCD) were analyzed. Clinical data were collected from patient hospital records. Primary clinical outcome was in-hospital stroke or death. Total admission costs were calculated based on volumes of healthcare resources. Analyses of effects and costs were adjusted for clinical differences between patients by means of a propensity score, and cost-effectiveness was estimated. RESULTS: A total of 503 (239 SPM; 264 EEG/TCD) patients were included, of whom 19 sustained a stroke or died during admission (3.3 vs. 4.2%, respectively, adjusted risk difference 1.3% (95% CI -2.3-4.8%)). Median total costs were €4946 (IQR 4424-6173) in the SPM group versus €7447 (IQR 6890-8675) in the EEG/TCD group. Costs for neurophysiologic assessments were the main determinant for the difference. CONCLUSIONS: Given the evidence provided by this small retrospective study, SPM would be the favored strategy for intraoperative neuromonitoring if cost-effectiveness was taken into account when deciding which strategy to adopt.

Continuous intraoperative neuromonitoring (CIONM) of the recurrent laryngeal nerve is sufficient as the only neuromonitoring technique in thyroidectomy performed because of benign goitre.

INTRODUCTION: Recently, intraoperative neurophysiological neuromonitoring (IONM) of recurrent laryngeal nerves (RLN) has been evolving quickly. This evolution touched many aspects of the technique, leading to continuous stimulation of the RLN with real time analysis of the electrical signal. OBJECTIVE: The aim of the study was to estimate the value of continuous intraoperative neuromonitoring (CIONM) as the only technique for intraoperative neuromonitoring in thyroidectomy performed because of benign goitre. MATERIAL AND METHODS: The study comprised 80 women qualified for thyroidectomy due to nodular goitre. The patients were divided into 4 groups depending on the technique used for RLN integrity verification: group 1 - thyroidectomy with CIONM; group 2 - thyroidectomy with direct, intermittent stimulation of RLN and vagus nerve (NX); group 3 - both CIONM and intermittent stimulation of RLN and NX; group 4 - thyroidectomy without any IONM. RESULTS: Mean operation time did not differ significantly among the groups with IONM, but was significantly longer in comparison to group 4, as well as the operation's cost. In the analysed groups there was no significant difference in complication ratio. CONCLUSION: CIONM with RLN visualization in thyroidectomy performed because of benign goitre is as safe as other methods of IONM and gives a continuous confirmation of the electrical integrity of the loop NX-RLN-vocal folds during almost the entire procedure. There is a clinical need for the development of external stimulation of NX (transdermal or trancranial), particularly for minimally invasive techniques in which access to NX is limited (i.e. transoral thyroidectomy).

Economic analysis of routine neuromonitoring of recurrent laryngeal nerve in total thyroidectomy / Análisis económico de la monitorización neurológica rutinaria del nervio laríngeo recurrente en la tiroidectomía total

Introduction: Thyroidectomy is a common surgery. Routine searching of the recurrent laryngeal nerve is the most important strategy to avoid palsy. Neuromonitoring has been recommended to decrease recurrent laryngeal nerve palsy. Objective: To assess if neuromonitoring of recurrent laryngeal nerve during thyroidectomy is cost-effective in a developing country. Materials and methods: We designed a decision analysis to assess the cost-effectiveness of recurrent laryngeal nerve neuromonitoring. For probabilities, we used data from a meta-analysis. Utility was measured using preference values. We considered direct costs. We conducted a deterministic and a probabilistic analysis. Results: We did not find differences in utility between arms. The frequency of recurrent laryngeal nerve injury was 1% in the neuromonitor group and 1.6% for the standard group. Thyroidectomy without monitoring was the less expensive alternative. The incremental cost-effectiveness ratio was COP$ 9,112,065. Conclusion: Routine neuromonitoring in total thyroidectomy with low risk of recurrent laryngeal nerve injury is neither cost-useful nor cost-effective in the Colombian health system.

Introducción. La tiroidectomía es una cirugía común. La búsqueda rutinaria del nervio laríngeo inferior es la estrategia más importante para evitar la parálisis. Objetivo. Evaluar el costo-efectividad en un país en desarrollo de la monitorización neurológica del nervio laríngeo inferior durante la tiroidectomía. Materiales y métodos. Se diseñó un análisis de decisiones para evaluar el costo-efectividad de la monitorización neurológica del nervio laríngeo inferior. Para las probabilidades se usaron datos de un meta-análisis. La utilidad se determinó con medidas de preferencia. Se incluyeron los costos directos. Se hizo un análisis determinístico y probabilístico. Resultados. No se encontraron diferencias en la utilidad entre las estrategias. La frecuencia de la lesión de este nervio fue de 1 % en el grupo bajo monitorización neurológica y de 1,6 % en el grupo de control. La tiroidectomía sin monitorización fue la alternativa menos costosa. La razón de costo-efectividad incremental fue de COP$ 9.112.065 Conclusión. La monitorización neurológica rutinaria en la tiroidectomía total con bajo riesgo de lesión del nervio laríngeo inferior, no es útil con relación a su costo ni costo-efectiva en el sistema de salud colombiano.

Economic analysis of routine neuromonitoring of recurrent laryngeal nerve in total thyroidectomy.

INTRODUCTION: Thyroidectomy is a common surgery. Routine searching of the recurrent laryngeal nerve is the most important strategy to avoid palsy. Neuromonitoring has been recommended to decrease recurrent laryngeal nerve palsy. OBJECTIVE: To assess if neuromonitoring of recurrent laryngeal nerve during thyroidectomy is cost-effective in a developing country. MATERIALS AND METHODS: We designed a decision analysis to assess the cost-effectiveness of recurrent laryngeal nerve neuromonitoring. For probabilities, we used data from a meta-analysis. Utility was measured using preference values. We considered direct costs. We conducted a deterministic and a probabilistic analysis. RESULTS: We did not find differences in utility between arms. The frequency of recurrent laryngeal nerve injury was 1% in the neuromonitor group and 1.6% for the standard group. Thyroidectomy without monitoring was the less expensive alternative. The incremental cost-effectiveness ratio was COP$ 9,112,065. CONCLUSION: Routine neuromonitoring in total thyroidectomy with low risk of recurrent laryngeal nerve injury is neither cost-useful nor cost-effective in the Colombian health system.

A socioeconomic analysis of intraoperative neurophysiological monitoring during spine surgery: national use, regional variation, and patient outcomes.

OBJECT: In the United States in recent years, a dramatic increase in the use of intraoperative neurophysiological monitoring (IONM) during spine surgeries has been suspected. Myriad reasons have been proposed, but no clear evidence confirming this trend has been available. In this study, the authors investigated the use of IONM during spine surgery, identified patterns of geographic variation, and analyzed the value of IONM for spine surgery cases. METHODS: In this retrospective analysis, the Nationwide Inpatient Sample was queried for all spine surgeries performed during 2007-2011. Use of IONM (International Classification of Diseases, Ninth Revision, code 00.94) was compared over time and between geographic regions, and its effect on patient independence at discharge and iatrogenic nerve injury was assessed. RESULTS: A total of 443,194 spine procedures were identified, of which 85% were elective and 15% were not elective. Use of IONM was recorded for 31,680 cases and increased each calendar year from 1% of all cases in 2007 to 12% of all cases in 2011. Regional use of IONM ranged widely, from 8% of cases in the Northeast to 21% of cases in the West in 2011. Iatrogenic nerve and spinal cord injury were rare; they occurred in less than 1% of patients and did not significantly decrease when IONM was used. CONCLUSIONS: As costs of spine surgeries continue to rise, it becomes necessary to examine and justify use of different medical technologies, including IONM, during spine surgery.

Comparative effectiveness analyses of intraoperative neurophysiological monitoring in spinal surgery.

Intraoperative neurophysiological monitoring for surgeries of the spine has been performed in clinical practice for several decades, but recent alterations in reimbursement schemes by third party payers have raised issues of the value of these procedures. Decision modeling using comparative effectiveness techniques holds the promise of evidence-based assessment of both cost and meaningful outcomes. In this article, we review the elements of comparative effectiveness analyses followed by a critical appraisal of the small but growing body of cost-effectiveness literature for intraoperative neurophysiological monitoring in spine.

Changes to CMS reimbursement rules for intraoperative neurophysiological monitoring: implications for telemedicine.

Intraoperative neurophysiological monitoring (IONM) is used as an adjunct for surgeries that pose risk to nervous system structures. IONM is performed by a technologist in the operating room and is overseen by a highly trained fellowship-trained physician clinical neurophysiologist. Telemedicine has allowed the professional oversight component to be done remotely, with reimbursement for multiple simultaneous cases. Recent changes to Current Procedure Terminology coding and Medicare reimbursement policies provide options only for exclusive 1:1 technologist:oversight physician billing. This policy change may create profound repercussions in the practice of telemedicine by actively discouraging the leveraging of highly specialized and scarce expertise through on-site physician extenders.

Cost-benefit analysis: intraoperative neurophysiological monitoring in spinal surgeries.

PURPOSE: To construct a cost-benefit model for intraoperative neurophysiological monitoring (IOM) in spinal surgeries. METHODS: Decision model was based on sensitivity, specificity, IOM cost, prevention rate given an IOM alert, and spinal procedure neurologic complication rates in pooled estimates from the published literature with outcome of lifetime costs after neuromonitored versus unmonitored spinal surgeries. Lifetime cost of neurologic injury was the sum of direct health care costs and lost wages and benefits. Results from Monte Carlo simulation with 10,000 replications were analyzed for cost outcomes and relationship of input variables to outcomes. RESULTS: IOM saved $23,189 (P < 0.001) for the reference case of 50-year-olds with neurologic complication rate of 5%, 2009 Medicare reimbursement of IOM at $1,535 per operation, 52.4% prevention rate given an IOM alert at 94.3% sensitivity and 95.6% specificity, assuming incomplete (nonplegic) motor injury. The baseline risk of surgery, lifetime costs after neurologic deficit, and ability to prevent neurologic deficits after an IOM alert were most correlated with cost outcomes. In linear prediction models, IOM remained cost-saving when neurologic complication rate from surgery exceeded 0.3% (P < 0.001) and prevention rate after IOM alert was greater than 14.2%(P = 0.02). CONCLUSIONS: Intraoperative monitoring is cost-saving for spinal surgeries in a theoretical model based on the current published literature.