A cost analysis of MR-guided laser interstitial thermal therapy for adult refractory epilepsy.

OBJECTIVE: MR-guided laser interstitial thermal therapy (LITT) is used increasingly for refractory epilepsy. The goal of this investigation is to directly compare cost and short-term adverse outcomes for adult refractory epilepsy treated with temporal lobectomy and LITT, as well as to identify risk factors for increased costs and adverse outcomes. METHODS: The National Inpatient Sample (NIS) was queried for patients who received LITT between 2012 and 2019. Patients with adult refractory epilepsy were identified. Multivariable mixed-effects models were used to analyze predictors of cost, length of stay (LOS), and complications. RESULTS: LITT was associated with reduced LOS and overall cost relative to temporal lobectomy, with a statistical trend toward lower incidence of postoperative complications. High-volume surgical epilepsy centers had lower LOS overall. Longer LOS was a significant driver of increased cost for LITT, and higher comorbidity was associated with non-routine discharge. SIGNIFICANCE: LITT is an affordable alternative to temporal lobectomy for adult refractory epilepsy with an insignificant reduction in inpatient complications. Patients may benefit from expanded access to this treatment modality for both its reduced LOS and lower cost.

Surgical revascularization for Moyamoya disease in the United States: A cost-effectiveness analysis.

OBJECTIVE: Moyamoya disease (MMD) is a vasculopathy of the internal carotid arteries with ischemic and hemorrhagic sequelae. Surgical revascularization confers upfront peri-procedural risk and costs in exchange for long-term protective benefit against hemorrhagic disease. The authors present a cost-effectiveness analysis (CEA) of surgical versus non-surgical management of MMD. METHODS: A Markov Model was used to simulate a 41-year-old suffering a transient ischemic attack (TIA) secondary to MMD and now faced with operative versus nonoperative treatment options. Health utilities, costs, and outcome probabilities were obtained from the CEA registry and the published literature. The primary outcome was incremental cost-effectiveness ratio which compared the quality adjusted life years (QALYs) and costs of surgical and nonsurgical treatments. Base-case, one-way sensitivity, two-way sensitivity, and probabilistic sensitivity analyses were performed with a willingness to pay threshold of $50,000. RESULTS: The base case model yielded 3.81 QALYs with a cost of $99,500 for surgery, and 3.76 QALYs with a cost of $106,500 for nonsurgical management. One-way sensitivity analysis demonstrated the greatest sensitivity in assumptions to cost of surgery and cost of admission for hemorrhagic stroke, and probabilities of stroke with no surgery, stroke after surgery, poor surgical outcome, and death after surgery. Probabilistic sensitivity analyses demonstrated that surgical revascularization was the cost-effective strategy in over 87.4% of simulations. CONCLUSIONS: Considering both direct and indirect costs and the postoperative QALY, surgery is considerably more cost-effective than non-surgical management for adults with MMD.

Comparative Assessment of Extracranial-to-Intracranial and Intracranial-to-Intracranial In Situ Bypass for Complex Intracranial Aneurysm Treatment Based on Rupture Status: A Case Series.

BACKGROUND: Comparative outcomes of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass for complex aneurysm treatment based on rupture status are not well described in the literature. In this study, we compare outcomes of EC-IC and IC-IC bypass for complex intracranial aneurysm treatment based on rupture status. METHODS: A prospective neurosurgical patient database was retrospectively reviewed. Sixty-three consecutive patients with aneurysm managed with revascularization were identified between July 2014 and December 2018. RESULTS: During the study period, 41 patients with aneurysm underwent EC-IC bypass (65%; 24 [58.5%] ruptured, 17 [41.5%] unruptured) and 22 patients with aneurysm underwent IC-IC bypass (34.9%; 13 [59.1%] ruptured, 9 [40.9%] unruptured). Graft spasm occurred in 4 patients (9.8%) in the EC-IC group (all ruptured aneurysms) and all anastomoses were patent on immediate postoperative imaging. Perioperative mortality occurred in 5 patients who underwent EC-IC bypass (12.2%; 3 ruptured, 2 unruptured) EC-IC and 2 patients who underwent IC-IC bypass (9.1%; both ruptured); (P = 0.709). Bypass-related complications occurred only in patients with ruptured aneurysm (2 [8.3%] in the EC-IC group and 0 [0%] in the IC-IC group; P = 0.285). For unruptured aneurysms, the overall complication rate was lower in IC-IC compared with the EC-IC group (P = 0.006). Modified Rankin Scale scores on discharge were significantly lower in IC-IC compared with EC-IC bypass for unruptured aneurysms (P = 0.008). There was a trend for shorter temporary occlusion and hospitalization times and overall better outcomes with IC-IC compared with EC-IC bypass. CONCLUSIONS: Although often considered riskier than EC-IC bypass, IC-IC in situ bypass showd a favorable technical and safety profile for the treatment of complex, unruptured aneurysms.

Quality of care at safety-net hospitals and the impact on pay-for-performance reimbursement.

BACKGROUND: Pay-for-performance reimbursement ties hospital payments to standardized quality-of-care metrics. To the authors' knowledge, the impact of pay-for-performance reimbursement models on hospitals caring primarily for uninsured or underinsured patients remains poorly defined. The objective of the current study was to evaluate how standardized quality-of-care metrics vary by a hospital's propensity to care for uninsured or underinsured patients and demonstrate the potential impact that pay-for-performance reimbursement could have on hospitals caring for the underserved. METHODS: The authors identified 1,703,865 patients with cancer who were diagnosed between 2004 and 2015 and treated at 1344 hospitals. Hospital safety-net burden was defined as the percentage of uninsured or Medicaid patients cared for by that hospital, categorizing hospitals into low-burden, medium-burden, and high-burden hospitals. The authors evaluated the impact of safety-net burden on concordance with 20 standardized quality-of-care measures, adjusting for differences in patient age, sex, stage of disease at diagnosis, and comorbidity. RESULTS: Patients who were treated at high-burden hospitals were more likely to be young, male, Black and/or Hispanic, and to reside in a low-income and low-educated region. High-burden hospitals had lower adherence to 13 of 20 quality measures compared with low-burden hospitals (all P < .05). Among the 350 high-burden hospitals, concordance with quality measures was found to be lowest for those caring for the highest percentage of uninsured or Medicaid patients, minority patients, and less educated patients (all P < .001). CONCLUSIONS: Hospitals caring for uninsured or underinsured individuals have decreased quality-of-care measures. Under pay-for-performance reimbursement models, these lower quality-of-care scores could decrease hospital payments, potentially increasing health disparities for at-risk patients with cancer.

Assessment of ischemic risk following intracranial-to-intracranial and extracranial-to-intracranial bypass for complex aneurysms using intraoperative Indocyanine Green-based flow analysis.

Cerebral bypass is often needed for complex aneurysms requiring vessel sacrifice, yet intraoperative predictors of ischemic risk in bypass-dependent territories are limited. Indocyanine Green (ICG)-based flow analyses (ICG-BFAs; Flow 800, Carl Zeiss, Oberkochen, Germany) semi-quantitatively assess cortical perfusion, and in this work we determine the efficacy of ICG-BFA for assessing post-operative ischemic risk during cerebral bypass surgery for complex aneurysms. Retrospective clinical and pre/post-bypass intra-operative ICG-BFA data (delay and blood flow index [BFI]) on ten patients undergoing cerebral bypass for complex cerebral aneurysms requiring vessel sacrifice were collected from a single-institution prospective database and analyzed via non-parametric testing and logistic regression. Mean age was 55.9 ±â€¯14.8 years. Pre/post-bypass delay (median 35.6 [5.1-51.3] vs. 26.0 [17.1-59.9]; p = 0.2) and BFI (median 56.1 [8.1-120.4] vs. 32.2 [3.0-147.4]; p = 0.2) did not significantly differ. Two patients (20%) developed post-operative ischemia in bypass dependent territories. Delay ratio did not differ between patients with and without post-operative ischemia (median 1.15 [0.67-1.64] vs. 0.83 [0.36-3.56]; p = 0.6), nor predict stroke risk (odds ratio = 1.1, p = 0.9). Conversely, BFI ratio was significantly lower for patients experiencing post-operative ischemia than those without ischemia (median 0.11 [0.06-0.17] vs. 0.99 [0.28-1.42]; p = 0.03). A BFI ratio <0.21 predicted the occurrence of post-operative ischemia (odds ratio = 0.02, p = 0.05). These data suggest that intraoperative ICG-BFA may help assess post-operative ischemic risk during cerebral bypass surgery for complex aneurysms requiring vessel sacrifice.

The Cost to Attending Surgeons of Resident Involvement in Academic Hand Surgery.

PURPOSE: For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. METHODS: Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. RESULTS: A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. CONCLUSIONS: Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.

Cost-effectiveness of Intraoperative MRI for Treatment of High-Grade Gliomas.

Background Intraoperative MRI has been shown to improve gross-total resection of high-grade glioma. However, to the knowledge of the authors, the cost-effectiveness of intraoperative MRI has not been established. Purpose To construct a clinical decision analysis model for assessing intraoperative MRI in the treatment of high-grade glioma. Materials and Methods An integrated five-state microsimulation model was constructed to follow patients with high-grade glioma. One-hundred-thousand patients treated with intraoperative MRI were compared with 100 000 patients who were treated without intraoperative MRI from initial resection and debulking until death (median age at initial resection, 55 years). After the operation and treatment of complications, patients existed in one of three health states: progression-free survival (PFS), progressive disease, or dead. Patients with recurrence were offered up to two repeated resections. PFS, valuation of health states (utility values), probabilities, and costs were obtained from randomized controlled trials whenever possible. Otherwise, national databases, registries, and nonrandomized trials were used. Uncertainty in model inputs was assessed by using deterministic and probabilistic sensitivity analyses. A health care perspective was used for this analysis. A willingness-to-pay threshold of $100 000 per quality-adjusted life year (QALY) gained was used to determine cost efficacy. Results Intraoperative MRI yielded an incremental benefit of 0.18 QALYs (1.34 QALYs with intraoperative MRI vs 1.16 QALYs without) at an incremental cost of $13 447 ($176 460 with intraoperative MRI vs $163 013 without) in microsimulation modeling, resulting in an incremental cost-effectiveness ratio of $76 442 per QALY. Because of parameter distributions, probabilistic sensitivity analysis demonstrated that intraoperative MRI had a 99.5% chance of cost-effectiveness at a willingness-to-pay threshold of $100 000 per QALY. Conclusion Intraoperative MRI is likely to be a cost-effective modality in the treatment of high-grade glioma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Bettmann in this issue.

The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms.

OBJECTIVE: Safety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms. METHODS: The authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals. RESULTS: A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition. CONCLUSIONS: Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

Markov modeling for the neurosurgeon: a review of the literature and an introduction to cost-effectiveness research.

OBJECTIVE Markov modeling is a clinical research technique that allows competing medical strategies to be mathematically assessed in order to identify the optimal allocation of health care resources. The authors present a review of the recently published neurosurgical literature that employs Markov modeling and provide a conceptual framework with which to evaluate, critique, and apply the findings generated from health economics research. METHODS The PubMed online database was searched to identify neurosurgical literature published from January 2010 to December 2017 that had utilized Markov modeling for neurosurgical cost-effectiveness studies. Included articles were then assessed with regard to year of publication, subspecialty of neurosurgery, decision analytical techniques utilized, and source information for model inputs. RESULTS A total of 55 articles utilizing Markov models were identified across a broad range of neurosurgical subspecialties. Sixty-five percent of the papers were published within the past 3 years alone. The majority of models derived health transition probabilities, health utilities, and cost information from previously published studies or publicly available information. Only 62% of the studies incorporated indirect costs. Ninety-three percent of the studies performed a 1-way or 2-way sensitivity analysis, and 67% performed a probabilistic sensitivity analysis. A review of the conceptual framework of Markov modeling and an explanation of the different terminology and methodology are provided. CONCLUSIONS As neurosurgeons continue to innovate and identify novel treatment strategies for patients, Markov modeling will allow for better characterization of the impact of these interventions on a patient and societal level. The aim of this work is to equip the neurosurgical readership with the tools to better understand, critique, and apply findings produced from cost-effectiveness research.

Management of glioblastoma at safety-net hospitals.

BACKGROUND: Safety-net hospitals (SNHs) provide disproportionate care for underserved patients. Prior studies have identified poor outcomes, increased costs, and reduced access to certain complex, elective surgeries at SNHs. However, it is unknown whether similar patterns exist for the management of glioblastoma (GBM). We sought to determine if patients treated at HBHs receive equitable care for GBM, and if safety-net burden status impacts post-treatment survival. METHODS: The National Cancer Database was queried for GBM patients diagnosed between 2010 and 2015. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital, and stratified as low (LBH), medium (MBH), and high-burden (HBH) hospitals. The impact of safety-net burden on the receipt of any treatment, trimodality therapy, gross total resection (GTR), radiation, or chemotherapy was investigated. Secondary outcomes included post-treatment 30-day mortality, 90-day mortality, and overall survival. Univariate and multivariate analyses were utilized. RESULTS: Overall, 40,082 GBM patients at 1202 hospitals (352 LBHs, 553 MBHs, and 297 HBHs) were identified. Patients treated at HBHs were significantly less likely to receive trimodality therapy (OR = 0.75, p < 0.001), GTR (OR = 0.84, p < 0.001), radiation (OR = 0.73, p < 0.001), and chemotherapy (OR = 0.78, p < 0.001) than those treated at LBHs. Patients treated at HBHs had significantly increased 30-day (OR = 1.25, p = 0.031) and 90-day mortality (OR = 1.24, p = 0.001), and reduced overall survival (HR = 1.05, p = 0.039). CONCLUSIONS: GBM patients treated at SNHs are less likely to receive standard-of-care therapies and have increased short- and long-term mortality. Additional research is needed to evaluate barriers to providing equitable care for GBM patients at SNHs.