Global Economic Evaluation of the Reported Costs of Deep Brain Stimulation.

INTRODUCTION: Despite the known benefits of deep brain stimulation (DBS), the cost of the procedure can limit access and can vary widely. Our aim was to conduct a systematic review of the reported costs associated with DBS, as well as the variability in reporting cost-associated factors to ultimately increase patient access to this therapy. METHODS: A systematic review of the literature for cost of DBS treatment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Embase databases were queried. Olsen & Associates (OANDA) was used to convert all reported rates to USD. Cost was corrected for inflation using the US Bureau of Labor Statistics Inflation Calculator, correcting to April 2022. RESULTS: Twenty-six articles on the cost of DBS surgery from 2001 to 2021 were included. The median number of patients across studies was 193, the mean reported age was 60.5 ± 5.6 years, and median female prevalence was 38.9%. The inflation- and currency-adjusted mean cost of the DBS device was USD 21,496.07 ± USD 8,944.16, the cost of surgery alone was USD 14,685.22 ± USD 8,479.66, the total cost of surgery was USD 40,942.85 ± USD 17,987.43, and the total cost of treatment until 1 year of follow-up was USD 47,632.27 ± USD 23,067.08. There were no differences in costs observed across surgical indication or country. CONCLUSION: Our report describes the large variation in DBS costs and the manner of reporting costs. The current lack of standardization impedes productive discourse as comparisons are hindered by both geographic and chronological variations. Emphasis should be put on standardized reporting and analysis of reimbursement costs to better assess the variability of DBS-associated costs in order to make this procedure more cost-effective and address areas for improvement to increase patient access to DBS.

Cost considerations for vestibular schwannoma screening and imaging: a systematic review.

Vestibular schwannomas (VS) account for approximately 8% of all intracranial neoplasms. Importantly, the cost of the diagnostic workup for VS, including the screening modalities most commonly used, has not been thoroughly investigated. Our aim is to conduct a systematic review of the published literature on costs associated with VS screening. A systematic review of the literature for cost of VS treatment was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The terms "vestibular schwannoma," "acoustic neuroma," and "cost" were queried using the PubMed and Embase databases. Studies from all countries were considered. Cost was then corrected for inflation using the US Bureau of Labor Statistics Inflation Calculator, correcting to April 2022. The search resulted in an initial review of 483 articles, of which 12 articles were included in the final analysis. Screening criteria were used for non-neurofibromatosis type I and II patients who complained of asymmetric hearing loss, tinnitus, or vertigo. Patients included in the studies ranged from 72 to 1249. The currency and inflation-adjusted mean cost was $418.40 (range, $21.81 to $487.03, n = 5) for auditory brainstem reflex and $1433.87 (range, $511.64 to $1762.15, n = 3) for non-contrasted computed tomography. A contrasted magnetic resonance imaging (MRI) scan was found to have a median cost of $913.27 (range, $172.25-$2733.99; n = 8) whereas a non-contrasted MRI was found to have a median cost of $478.62 (range, $116.61-$3256.38, n = 4). In terms of cost reporting, of the 12 articles, 1 (8.3%) of them separated out the cost elements, and 10 (83%) of them used local prices, which include institutional costs and/or average costs of multiple institutions. Our findings describe the limited data on published costs for screening and imaging of VS. The paucity of data and significant variability of costs between studies indicates that this endpoint is relatively unexplored, and the cost of screening is poorly understood.

Gender Differences in Medicare Practice and Payments to Neurosurgeons.

Importance: Despite efforts to promote diversity within the neurosurgical workforce, individuals from underrepresented groups face significant challenges. Objective: To compare practice metrics and earning potential between female and male neurosurgeons and investigate factors associated with gender disparity in Medicare reimbursement. Design, Setting, and Participants: This retrospective cross-sectional study used publicly accessible Medicare data on reimbursements to female and male neurosurgeons for procedural and evaluation and management services delivered in both inpatient and outpatient settings between January 1, 2013, and December 31, 2020. Data were analyzed from December 9, 2021, to December 5, 2022. Main Outcomes and Measures: The primary outcome was the mean annual payments received and charges submitted by female and male neurosurgeons for services rendered between 2013 and 2020. Secondary outcomes included the total number and types of services rendered each year and the number of beneficiaries treated. Univariate and multivariable analyses quantified differences in payment, practice volume, and composition. Results: A total of 6052 neurosurgeons (5540 men [91.54%]; 512 women [8.46%]) served the Medicare fee-for-service patient population. Female neurosurgeons billed for lesser Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) and were reimbursed substantially less (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001). Multivariable regression controlling for practice volume metrics revealed a persistent reimbursement gap (-$24 885.29 [95% CI, -$27 964.72 to -$21 805.85]; P < .001). Females were reimbursed $24.61 less per service than males even after matching services by code (P = .02). Conclusions and Relevance: This study found significant gender-based variation in practice patterns and reimbursement among neurosurgeons serving the Medicare fee-for-service population. Female surgeons were reimbursed less than male surgeons when both performed the same primary procedure. Lower mean reimbursement per service may represent divergence in billing and coding practices among females and males that could be the focus of future research or educational initiatives.

The cost of a plastic surgery team assisting with cranioplasty.

OBJECTIVES: Cranioplasty is a commonly performed neurosurgical procedure that restores cranial anatomy. While plastic surgeons are commonly involved with cranioplasties, the cost of performing a cranioplasty with neurosurgery alone (N) vs. neurosurgery and plastic surgery (N + P) is unknown. METHODS: A single-center, multi-surgeon, retrospective cohort study was undertaken on all cranioplasties performed from 2012 to 22. The primary exposure variable of interest was operating team, comparing N vs. N + P. Cost data was inflation-adjusted to January 2022 using Healthcare Producer Price Index as calculated by the US Bureau of Labor Statistics. RESULTS: 186 patients (105 N vs. 81 N + P) underwent cranioplasties. The N + P group has a significantly longer length-of-stay (LOS) 4.5 ± 1.6days, vs. 6.0 ± 1.3days (p < 0.001), but no significant difference in reoperation, readmission, sepsis, or wound breakdown. N was significantly less expensive than N + P during both the initial cranioplasty cost ($36,739 ± $4592 vs. $41,129 ± $4374, p 0.014) and total cranioplasty costs including reoperations ($38,849 ± $5017 vs. $53,134 ± $6912, p < 0.001). Univariable analysis (threshold p = 0.20) was performed to justify inclusion into a multivariable regression model. Multivariable analysis for initial cranioplasty cost showed that sepsis (p = 0.024) and LOS (p = 0.003) were the dominant cost contributors compared to surgeon type (p = 0.200). However, surgeon type (N vs. N + P) was the only significant factor (p = 0.011) for total cost including revisions. CONCLUSIONS: Higher costs to N + P involvement without obvious change in outcomes were found in patients undergoing cranioplasty. Although other factors are more significant for the initial cranioplasty cost (sepsis, LOS), surgeon type proved the independent dominant factor for total cranioplasty costs, including revisions.

A Retrospective Cohort Study of Longitudinal Audiologic Assessment in Single and Fractionated Stereotactic Radiosurgery for Vestibular Schwannoma.

BACKGROUND: Fractionated stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) has been theorized to allow for tumor control with higher rates of hearing preservation in selected patients with useful hearing. However, there is a paucity of literature with formal audiologic measures of hearing preservation to support the standard use of fractionated SRS in VS. We hypothesized that fractionation would diminish the amount of hearing damage. OBJECTIVE: To evaluate the relationship between audiologic performance and SRS fractionation scheme. METHODS: We performed an IRB-approved retrospective review of patients treated with 1, 3, or 5 fraction SRS for VS at our institution from 1998 to 2016. Pre- and post-SRS audiograms with speech awareness threshold (SAT) in treated and contralateral ears were obtained. Contralateral ear measurements were used for hearing normalization to account for presbycusis. RESULTS: Fifty-six patients with median audiologic follow-up 2.0 yr (mean 2.66 yr, min-max 0.50-9.45 yr) were included. Patients treated with single fractionation had a significantly worsened SAT (dB) compared to patients treated with 5 fractions (P = .008) and compared to all multifraction patients (P = .009) at 12 to 24 mo follow-up. CONCLUSION: This retrospective analysis supports the use of fractionated SRS to preserve hearing in patients with VS. SAT can be used as an objective metric of hearing response to radiosurgery.

Machine learning ensemble models predict total charges and drivers of cost for transsphenoidal surgery for pituitary tumor.

OBJECTIVE: Efficient allocation of resources in the healthcare system enables providers to care for more and needier patients. Identifying drivers of total charges for transsphenoidal surgery (TSS) for pituitary tumors, which are poorly understood, represents an opportunity for neurosurgeons to reduce waste and provide higher-quality care for their patients. In this study the authors used a large, national database to build machine learning (ML) ensembles that directly predict total charges in this patient population. They then interrogated the ensembles to identify variables that predict high charges. METHODS: The authors created a training data set of 15,487 patients who underwent TSS between 2002 and 2011 and were registered in the National Inpatient Sample. Thirty-two ML algorithms were trained to predict total charges from 71 collected variables, and the most predictive algorithms combined to form an ensemble model. The model was internally and externally validated to demonstrate generalizability. Permutation importance and partial dependence analyses were performed to identify the strongest drivers of total charges. Given the overwhelming influence of length of stay (LOS), a second ensemble excluding LOS as a predictor was built to identify additional drivers of total charges. RESULTS: An ensemble model comprising 3 gradient boosted tree classifiers best predicted total charges (root mean square logarithmic error = 0.446; 95% CI 0.439-0.453; holdout = 0.455). LOS was by far the strongest predictor of total charges, increasing total predicted charges by approximately $5000 per day.In the absence of LOS, the strongest predictors of total charges were admission type, hospital region, race, any postoperative complication, and hospital ownership type. CONCLUSIONS: ML ensembles predict total charges for TSS with good fidelity. The authors identified extended LOS, nonelective admission type, non-Southern hospital region, minority race, postoperative complication, and private investor hospital ownership as drivers of total charges and potential targets for cost-lowering interventions.

Socioeconomic status does not affect prognosis in patients with glioblastoma multiforme.

BACKGROUND: Glioblastoma multiforme (GBM) is an aggressive malignancy, but there is marked heterogeneity in survival time. Health care disparities have demonstrated significance in oncologic outcomes but have not been clearly examined in this patient population. We investigated the role of sociodemographic variables in the prognosis of adult patients diagnosed with GBM. METHODS: This retrospective analysis included patients with a histologically confirmed diagnosis of GBM, who underwent resection or biopsy at a single institution from 2000 to 2014. Socioeconomic status (SES) was determined by household income according to the US Census zip code tabulation areas and the US national poverty level. Multivariate Cox proportional hazards analysis calculated effects on patient survival. RESULTS: Thirty percent of 218 subjects were of low SES, 57% mid, and 13% high. Low SES patients tended to be male (62%), Caucasian (92%), unmarried (91%), have dependents (100%), and limited to high school education (55%). SES did not predict insurance or employment status. SES was associated with marital status and number of cohabitants (P < 0.0001) but not clinical trial enrollment. Multivariate analysis demonstrated no relationship between SES and survival. Shorter prognosis was associated with history of military service (hazard ratio [HR] 2.06, P = 0.0125), elderly patients (HR 1.70, P = 0.0158), and multifocal disease (HR 1.75, P = 0.0119). Longer prognosis was associated with gross total resection (HR 0.49, P = 0.0009), radiation therapy (HR 0.12, P < 0.0001), and temozolomide (HR 0.28, P < 0.0001). CONCLUSIONS: SES alone does not predict prognosis in patients with newly diagnosed GBM. Sociodemographic variables such as old age, military service record, and insurance type may have a prognostication role.

Short-term postoperative surveillance imaging may be unnecessary in elderly patients with resected WHO Grade I meningiomas.

The optimal timing and frequency of postoperative imaging surveillance after a meningioma resection are not well-established. The low recurrence rates and slow growth of World Health Organization (WHO) Grade I meningiomas in particular have raised doubts about the utility of postoperative imaging surveillance. We sought to analyze the cost and utility of asymptomatic surveillance imaging in elderly patients after the resection of a WHO Grade I meningioma. We conducted a retrospective cohort study on 45 patients who had a primary WHO Grade I meningioma resected at our institution between 2001-2013 at or above the age of 60 with a minimum of 2 years of follow-up. All postoperative clinic notes were reviewed alongside imaging results to verify that patients were asymptomatic during the surveillance period. MRI and CT scan costs (all $USD) were estimated at $599.61 and $334.31 respectively based on the Centers for Medicare and Medicaid national averages. During an average follow-up period of 4.5 years, the average number of total imaging studies performed per asymptomatic patient was 3.58 with an average total cost of $2086.30 per patient. Forty-two (93%) patients had no new abnormal findings on any of their imaging. Three (7%) patients demonstrated either a new meningioma or progressive growth of the postoperative residual tumor on imaging. No asymptomatic patient underwent a reoperation. Our data suggest that elderly patients with resected WHO Grade I meningiomas are at low risk for recurrence and may not need asymptomatic surveillance imaging for the first several postoperative years.

Imaging of Resected Nonfunctioning Pituitary Adenomas: The Cost of Surveillance.

Objectives To determine the cost of annual magnetic resonance imaging (MRI) surveillance after resection of nonfunctioning pituitary adenomas (NFPAs) and its effectiveness in reducing visual compromise due to tumor recurrence. Design Retrospective case series. Setting Vanderbilt University Medical Center (2003-2011). Participants A total of 120 patients underwent primary transsphenoidal resection and surveillance of NFPAs between 2003 and 2011. Main Outcome Measures Time from initial surgery to most recent imaging or progression. Surveillance MRI costs according to Centers for Medicare and Medicaid database and visual field deficits. Results Patients received 382 surveillance scans at a total cost of $218,477.30. The median follow-up was 47 months (interquartile range [IQR]: 26-76), and the median interval between scans was 357 days (IQR: 225-434). Overall, 50 scans (13%) revealed tumor growth. The cost per scan revealing growth was $4,369.55. The cost to identify 19 patients (16%) with clinically significant growth was $11,498.80 per patient. A total of 5 of 19 patients (26%) experienced new visual deficits prior to intervention. Patients with visual decline tended to have longer scan intervals than those with preserved vision (mean: 239 versus 794 days; p = 0.0584). No patient with annual surveillance imaging experienced visual decline. Conclusions Annual MRI scans are a sensitive and cost-conscious method to identify NFPA recurrence prior to visual decline.