A Multicenter, Propensity Score-Matched Assessment of Endoscopic Versus Microscopic Approaches in the Management of Pituitary Adenomas.

BACKGROUND AND OBJECTIVES: There is considerable controversy as to which of the 2 operating modalities (microsurgical or endoscopic transnasal surgery) currently used to resect pituitary adenomas (PAs) is the safest and most effective intervention. We compared rates of clinical outcomes of patients with PAs who underwent resection by either microsurgical or endoscopic transnasal surgery. METHODS: To independently assess the outcomes of each modality type, we sought to isolate endoscopic and microscopic PA surgeries with a 1:1 tight-caliper (0.01) propensity score-matched analysis using a multicenter, neurosurgery-specific database. Surgeries were performed between 2017 and 2020, with data collected retrospectively from 12 international institutions on 4 continents. Matching was based on age, previous neurological deficit, American Society of Anesthesiologists (ASA) score, tumor functionality, tumor size, and Knosp score. Univariate and multivariate analyses were performed. RESULTS: Among a pool of 2826 patients, propensity score matching resulted in 600 patients from 9 surgery centers being analyzed. Multivariate analysis showed that microscopic surgery had a 1.91 odds ratio (OR) ( P = .03) of gross total resection (GTR) and shorter operative duration ( P < .01). However, microscopic surgery also had a 7.82 OR ( P < .01) for intensive care unit stay, 2.08 OR ( P < .01) for intraoperative cerebrospinal fluid (CSF) leak, 2.47 OR ( P = .02) for postoperative syndrome of inappropriate antidiuretic hormone secretion (SIADH), and was an independent predictor for longer postoperative stay (ß = 2.01, P < .01). Overall, no differences in postoperative complications or 3- to 6-month outcomes were seen by surgical approach. CONCLUSION: Our international, multicenter matched analysis suggests microscopic approaches for pituitary tumor resection may offer better GTR rates, albeit with increased intensive care unit stay, CSF leak, SIADH, and hospital utilization. Better prospective studies can further validate these findings as matching patients for outcome analysis remains challenging. These results may provide insight into surgical benchmarks at different centers, offer room for further registry studies, and identify best practices.

Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series.

OBJECTIVE: No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost. METHODS: In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated. RESULTS: Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016. CONCLUSIONS: These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.

Evaluation of disease severity and treatment intensity as cost drivers for ruptured intracranial aneurysms.

BACKGROUND: Previous studies have not evaluated the impact of illness severity and postrupture procedures in the cost of care for intracranial aneurysms. We hypothesize that the severity of aneurysm rupture and the aggressiveness of postrupture interventions play a role in cost. METHODS: The Value Driven Outcomes database was used to assess direct patient cost during the treatment of ruptured intracranial aneurysm with clipping, coiling, and Pipeline flow diverters. RESULTS: One hundred ninety-eight patients (mean age 52.8 ± 14.1 years; 40.0% male) underwent craniotomy (64.6%), coiling (26.7%), or flow diversion (8.6%). Coiling was 1.4× more expensive than clipping (p = .005) and flow diversion was 1.7× more expensive than clipping (p < .001). More severe illness as measured by American Society of Anesthesia, Hunt/Hess, and Fisher scales incurred higher costs than less severe illness (p < .05). Use of a lumbar drain protocol to reduce subarachnoid hemorrhage and use of an external ventricular drain to manage intracranial pressure were associated with reduced (p = .05) and increased (p < .001) total costs, respectively. Patients with severe vasospasm (p < .005), those that received shunts (p < .001), and those who had complications (p < .001) had higher costs. Multivariate analysis showed that procedure type, length of stay, number of angiograms, vasospasm severity, disposition, and year of treatment were independent predictors of cost. CONCLUSIONS: These results show for the first time that disease and vasospasm severity and intensity of treatment directly impact the cost of care for patients with aneurysms in the USA. Strategies to alter these variables may prove important for cost reduction.

EQ-5D Quality-of-Life Analysis and Cost-Effectiveness After Skull Base Meningioma Resection.

BACKGROUND: Skull base meningioma management is complicated by their proximity to intracranial neurovascular structures because complete resection may pose a risk of worsening morbidity. OBJECTIVE: To assess the influence of clinical outcomes and surgical management on patient-perceived quality-of-life outcomes, value, and cost-effectiveness. METHODS: Patients who underwent resection of a skull base meningioma, had adequate clinical follow-up, and completed EQ-5D-3L questionnaires preoperatively and at 1 mo and 1 yr postoperatively were identified in a retrospective review. Cost data from the Value Driven Outcomes database were analyzed. RESULTS: A total of 52 patients (83.0% women, mean age 51.9 yr) were categorized by worsened (n = 7), unchanged (n = 24), or improved (n = 21) EQ-5D-3L index scores at 1-mo follow-up. No difference in subcategory cost contribution or total cost was seen in the 3 groups. Patients with improved scores showed a steady improvement through each follow-up period, whereas those with unchanged or worsened scores did not. Mean quality-adjusted life years (QALYs) and cost per QALY improved for all groups but at a higher rate for patients with better outcomes at 30-d follow-up. Female sex, absence of proptosis, nonfrontotemporal approaches, no optic nerve decompression, and absence of surgical complications demonstrated improved EQ-5D-3L scores at 1-yr follow-up. A mean cost per QALY of $27 731.06 ± 22 050.58 was observed for the whole group and did not significantly differ among patient groups (P = .1). CONCLUSION: Patients undergoing resection of skull base meningiomas and who experience an immediate improvement in EQ-5D are likely to show continued improvement at 1 yr, with improved QALY and reduced cost per QALY.

Analysis of Treatment Cost Variation Among Multiple Neurosurgical Procedures Using the Value-Driven Outcomes Database.

BACKGROUND: Health care costs comprise a substantial portion of total national expenditure. Although interest in cost-effectiveness analysis in neurosurgery has increased, there has been little cross-comparison of neurosurgical procedures. The aim of this study was to compare costs across elective neurosurgical procedures to understand whether drivers of cost differ. METHODS: The Value Driven Outcomes database was used to evaluate treatment costs for resection of vestibular schwannoma, intracranial meningioma, gliomas, and pituitary adenoma; anterior cervical discectomy and fusion and lumbar spinal fusion; and aneurysm treatment. RESULTS: A total of 1997 patients (mean age 54.6 ± 14.5 years; 45.2% male) were evaluated. The mean length of stay (LOS) was 4.0 ± 4.4 days. For cases involving hardware implantation, including spine fusion or aneurysm treatment, supplies and implants (49.1%) accounted for the largest fraction of costs followed by facility costs (37.9%). For cases that did not involve hardware, including tumor cases, facility costs (63.9%) were the largest fraction, followed by supplies and implants (16.2%). Aneurysm treatment and lumbar fusion were 1.5-3 times more costly than cranial tumor resection and anterior cervical discectomy and fusion per patient. Multivariate linear regression demonstrated that LOS (ß = 0.7, P = 0.0001) and patient treatment type (ß = 0.2, P = 0.0001) had the greatest effect on costs. LOS correlated with cost differently depending on case type; its effect was largest for patients with meningioma and smallest for patients with vestibular schwannoma. Costs across time increased similarly for all case types. CONCLUSIONS: Costs for neurosurgical procedures vary widely depending on treatment type and correlated directly with LOS. Strategies to reduce cost may require different approaches depending on procedure type.

Evaluation of Complications and Costs During Overlapping Transsphenoidal Surgery in the Treatment of Pituitary Adenoma.

BACKGROUND: Pituitary adenomas are among the most common primary brain tumors. Recently, overlapping surgery has been curbed in many institutions because of the suggestion there might be more significant adverse events, despite several studies showing that complication rates are equivalent. OBJECTIVE: To assess complications and costs associated with overlapping surgery during the transsphenoidal resection of pituitary adenomas. METHODS: A single-center, retrospective cohort study was performed to evaluate the cases of patients who underwent a transsphenoidal approach for pituitary tumor resection. Patient, surgical, complication, and cost (value-driven outcome) variables were analyzed. RESULTS: A total of 629 patients (302 nonoverlapping, 327 overlapping cases) were identified. No significant differences in age (P = .6), sex (P = .5), tumor type (P = .5), or prior rates of pituitary adenoma resection (P = .5) were seen. Similar presenting symptoms were observed in the 2 groups, and follow-up length was comparable (P = .3). No differences in tumor sizes (P = .5), operative time (P = .4), fat/fascia use (P = .4), or cerebrospinal fluid diversion (P = .8) were seen between groups. The gross total resection rate was not significantly different (P = .9), and no difference in recurrence rate was seen (P = .4). A comparable complication rate was seen between groups (P = .6). No differences in total or subtotal costs were seen either. CONCLUSION: The results of this study offer additional evidence that overlapping surgery does not result in worsened complications, lengthened surgery, or increased patient cost for patients undergoing transsphenoidal resection of pituitary adenomas. Thus, studies and policy aiming to improve patient safety and cost should focus on optimizing other aspects of healthcare delivery.

Assessment of costs in open surgery and stereotactic radiosurgery for vestibular schwannomas.

OBJECTIVE: Microsurgical resection and radiosurgery remain the most widely used interventions in the treatment of vestibular schwannomas. There is a growing demand for cost-effectiveness analyses to evaluate these two treatment modalities and delineate the factors that drive their total costs. Here, the authors evaluated specific cost drivers for microsurgical and radiosurgical management of vestibular schwannoma by using the Value Driven Outcomes system available at the University of Utah. METHODS: The authors retrospectively reviewed all cases involving microsurgical and radiosurgical treatment of vestibular schwannomas at their institution between November 2011 and September 2017. Patient and tumor characteristics, subcategory costs, and potential cost drivers were analyzed. RESULTS: The authors identified 163 vestibular schwannoma cases, including 116 managed microsurgically and 47 addressed with stereotactic radiosurgery (SRS). There were significant differences between the two groups in age, tumor size, and preoperative Koos grade (p < 0.05), suggesting that indications for treatment were markedly different. Length of stay (LOS) and length of follow-up were also significantly different. Facility costs were the most significant contributor to both microsurgical and SRS groups (58.3% and 99.4%, respectively); however, physician professional fees were not specifically analyzed. As expected, microsurgical treatment resulted in an average 4-fold greater overall cost of treatment than for SRS cases (p < 0.05), and there was a greater variation in costs for open cases as well. Costs remained stable over time for both open resection and SRS. Multivariable analysis showed that LOS (ß = 0.7, p = 0.0001), discharge disposition (ß = 0.2, p = 0.004), nonserviceable hearing (ß = 0.1, p = 0.02), and complications (ß = 0.2, p = 0.005) affected cost for open surgery, whereas no specifically examined factor could be identified as driving costs for SRS. CONCLUSIONS: This analysis identified the fact that facility utilization constitutes the majority of total costs for both microsurgery and SRS treatment modalities of vestibular schwannomas. LOS, discharge disposition, nonserviceable hearing, and complications contributed significantly to the total costs for the microsurgical group, whereas none of the factors could be identified as driving total costs for the SRS group. This information may be used to establish policies and protocols to reduce facility costs, with the goal of decreasing the total costs without jeopardizing patient care.

Analysis of an overlapping surgery policy change on costs in a high-volume neurosurgical department.

OBJECTIVE: Overlapping surgery remains a controversial topic in the medical community. Although numerous studies have examined the safety profile of overlapping operations, there are few data on its financial impact. The authors assessed direct hospital costs associated with neurosurgical operations during periods before and after a more stringent overlapping surgery policy was implemented. METHODS: The authors retrospectively reviewed the records of nonemergency neurosurgical operations that took place during the periods from June 1, 2014, to October 31, 2014 (pre-policy change), and from June 1, 2016, to October 31, 2016 (post-policy change), by any of the 4 senior neurosurgeons authorized to perform overlapping cases during both periods. Cost data as well as demographic, surgical, and hospitalization-related variables were obtained from an institutional tool, the Value-Driven Outcomes database. RESULTS: A total of 625 hospitalizations met inclusion criteria for cost analysis; of these, 362 occurred prior to the policy change and 263 occurred after the change. All costs were reported as a proportion of the average total hospitalization cost for the entire cohort. There was no significant difference in mean total hospital costs between the prechange and postchange period (0.994 ± 1.237 vs 1.009 ± 0.994, p = 0.873). On multivariate linear regression analysis, neither the policy change (p = 0.582) nor the use of overlapping surgery (p = 0.273) was significantly associated with higher total hospital costs. CONCLUSIONS: A more restrictive overlapping surgery policy was not associated with a reduction in the direct costs of hospitalization for neurosurgical procedures.

Assessment of Costs in Open Microsurgery and Stereotactic Radiosurgery for Intracranial Meningiomas.

OBJECTIVE: Understanding costs of microsurgical or radiosurgical treatment of intracranial meningioma may offer direction in reducing health care costs and establishing cost-effective algorithms. We used the Value Driven Outcomes database, which identifies cost drivers and tracks changes over time, to evaluate cost drivers for management of intracranial meningioma. METHODS: A single-center, retrospective cohort of patients undergoing microsurgery or radiosurgery of intracranial meningiomas from July 2011 to April 2017 was analyzed. Patient and tumor characteristics, subcategory costs, and potential cost drivers were analyzed within each treatment modality. RESULTS: Of 268 intracranial meningiomas, 198 were treated with microsurgery and 70 with stereotactic radiosurgery. Facility costs were the largest contributor to total costs for microsurgery (59.7%), whereas imaging costs were the largest contributor to stereotactic radiosurgery total costs (98.2%). Patients with non-skull base tumors had larger tumors (3.7 ± 1.9 cm vs. 2.7 ± 1.2 cm, P = 0.0001) and were more likely to undergo microsurgery (81.7% vs. 55.2%) than patients with skull base tumors. Univariate analysis suggested that American Society of Anesthesiologists status, length of stay, discharge disposition, and maximal tumor size impacted cost during microsurgery (P = 0.001), but only length of stay (P = 0.0001) and maximal tumor size (P = 0.01) were drivers of total costs on multivariate analysis. For radiosurgery, age significantly affected cost on univariate (P = 0.001) and multivariate (P = 0.003) analysis. CONCLUSIONS: Implementing protocols to reduce facility usage and imaging would mitigate total costs and improve resource utilization while maintaining high-quality patient care. Additional cost-effectiveness studies evaluating patients with true therapeutic equipoise will provide further guidance in these efforts.

Assessment of cost drivers and cost variation for lumbar interbody fusion procedures using the Value Driven Outcomes database.

OBJECTIVE Efforts to examine the value of care-combining both costs and quality-are gaining importance in the current health care climate. This thrust is particularly evident in treating common spinal disease where both incidences and costs are generally high and practice patterns are variable. It is often challenging to obtain direct surgical costs for these analyses, which hinders the understanding of cost drivers and cost variation. Using a novel tool, the authors sought to understand the costs of posterior lumbar arthrodesis with interbody devices. METHODS The Value Driven Outcomes (VDO) database at the University of Utah was used to evaluate the care of patients who underwent open or minimally invasive surgery (MIS), 1- and 2-level lumbar spine fusion (Current Procedural Terminology code 22263). Patients treated from January 2012 through June 2017 were included. RESULTS A total of 276 patients (mean age 58.9 ± 12.4 years) were identified; 46.7% of patients were men. Most patients (82.2%) underwent 1-level fusion. Thirteen patients (4.7%) had major complications and 11 (4.1%) had minor complications. MIS (ß = 0.16, p = 0.002), length of stay (ß = 0.47, p = 0.0001), and number of operated levels (ß = 0.37, p = 0.0001) predicted costs in a multivariable analysis. Supplies and implants (55%) and facility cost (36%) accounted for most of the expenditure. Other costs included pharmacy (7%), laboratory (1%), and imaging (1%). CONCLUSIONS These results provide direct cost accounting for lumbar fusion procedures using the VDO database. Efforts to improve the value of lumbar surgery should focus on high cost areas, i.e., facility and supplies/implant.

Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion.

OBJECTIVE With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system. METHODS The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient's cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed. RESULTS A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001). CONCLUSIONS Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

Patient-Level Factors Influencing Hospital Costs and Short-Term Patient-Reported Outcomes After Transsphenoidal Resection of Sellar Tumors.

BACKGROUND: Identifying which factors influence treatment costs of transsphenoidal surgery for removal of sellar lesions can be complex. OBJECTIVE: To identify which patient-level factors are associated with higher costs and evaluate the relationship between expenditures and short-term patient-reported outcomes. METHODS: We used an institutional database tool to review prospectively collected data on patients (≥10 yr old) undergoing transsphenoidal sellar surgery. Hospital costs, demographic data, disease-specific variables, hospital-related measures, and patient-reported outcomes (Euro-QOL 5D [EQ-5D] responses) were collected for all patients. RESULTS: One hundred seventeen patients met the inclusion criteria. A multivariable logistic regression model for hospital costs showed a significant association between higher costs and adrenocorticotropic hormone-secreting tumors (odds ratio [OR] 86.34, 95% confidence interval [CI] 3.43-2176.42), larger tumor size (OR 1.13, 95% CI 1.01-1.28), and in-hospital complications (OR 14.98, 95% CI 2.21-101.68). The largest contributor to hospital costs in our cohort was facility cost (75%), followed by pharmacy (13%) and supply (7%) costs. Most patients (65.8%) had stable or improved EQ-5D responses at 1-mo follow-up. Stability or improvement in EQ-5D was more likely in patients with lower preoperative EQ-5D scores (P < .015) and with higher postoperative EQ-5D scores (P < .001) on univariate analysis. CONCLUSION: Most patients undergoing transsphenoidal surgery for sellar tumors experience stable or improved postoperative quality of life, even shortly after surgery. Factors associated with increased costs of surgery included larger tumor size and in-hospital complications. Using these data, further study can be directed at determining which interventions may improve the value of transsphenoidal surgery.

Assessment of Cost Drivers in Transsphenoidal Approaches for Resection of Pituitary Tumors Using the Value-Driven Outcome Database.

BACKGROUND: Reducing health care costs while improving quality of care has become imperative in neurosurgical care. The Value-Driven Outcome database at the University of Utah identifies cost drivers and tracks changes over time. METHODS: Retrospective review was performed for transsphenoidal resections of pituitary adenomas from July 2012 to September 2016. Total cost, subcategory costs, and potential cost drivers were evaluated. RESULTS: There were 272 patients (mean age 51.5 years ± 17.7, 45.6% male) with mean length of stay of 4 days ± 4 evaluated. Total costs included facility utilization (60%), physician professional fees (16%), pharmacy (11%), supplies and implants (7%), laboratory studies (5%), and imaging (1%). Facility costs were driven by neurocritical care unit (30.7%), neurosurgical operating room (16.6%), and neurosurgical floor (11.2%) costs. Multivariable linear regression, after adjusting for length of stay and American Society of Anesthesiologists grade, showed that overall cost was heavily influenced by facility utilization (ρ = 0.98, P = 0.001), pharmacy (ρ = 0.71, P = 0.001), supplies and implants (ρ = 0.51, P = 0.0001), imaging (ρ = 0.51, P = 0.0001), and laboratory (ρ = 0.79, P = 0.001) costs. The top 10 outlier patients accounted for 18.7% of total costs (mean cost for all patients 0.24% ± 0.29). CONCLUSIONS: Our results highlight the importance of facility utilization and pharmaceutical, supply/implant, imaging, and laboratory costs as overall cost drivers during transsphenoidal pituitary tumor resection. Facility utilization was a stronger cost driver than any other aspect of care. Strategies to mitigate cost include stratifying low-risk patients to an intermediate care unit and reducing length of stay.

Is Industry Funding Associated with Greater Scholarly Impact Among Academic Neurosurgeons?

OBJECTIVE: To determine the relationship between industry payments and scholarly impact among academic neurosurgeons. METHODS: Faculty names and academic rank data were obtained from department websites, bibliometric data were obtained from the Scopus database, and industry payment data were obtained from the Center for Medicare and Medicaid Services open payments database (openpayments.cms.gov). The h-index was used to estimate scholarly impact. Payments were classified as "general," "associated research," and "research payments." Subgroup analyses were done for academic rank, fellowship training, and sex. RESULTS: Among 1008 academic neurosurgeons, scholarly impact was greater among individuals receiving associated research industry support compared with those not receiving it. Scholarly impact also was greater among individuals who received more than $10,000 of any type of industry support compared with individuals who received less than that or no payment. This association also was seen in fellowship-trained surgeons. Female neurosurgeons were less likely than male neurosurgeons to get industry funding and were likely to get less funding. CONCLUSIONS: There is a strong association between associated research funding from industry and scholarly impact among academic neurosurgeons. It's unclear whether this association is a result of funding facilitating more research projects that eventually lead to more high-impact publications, if industry is providing more funding to academic neurosurgeons with greater scholarly impact, or whether it represents intrinsic academic activity among a group of neurosurgeons who are more likely to be academically productive and procure funding from all potential sources to increase this activity.

Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States.

BACKGROUND: Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. METHODS: A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. RESULTS: In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. CONCLUSIONS: On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.

Assessing National Institutes of Health funding and scholarly impact in neurological surgery.

OBJECT: Research productivity is increasingly important in academic neurological surgery and can be measured through a variety of methods, such as publications, objective bibliometrics, and securing external grant support. The authors' objectives were to determine whether there is an association between scholarly impact, as measured by the h index, and successful National Institutes of Health (NIH) grant funding awarded to faculty in neurological surgery departments. METHODS: Primary investigators receiving National Institutes of Health (NIH) awards from Fiscal Years 2011-2013 were organized by academic rank, terminal degree, and their h index, as calculated from the Scopus database. These data were also obtained for nonfunded faculty from 15 randomly selected departments for comparison, and the average h index for each group was calculated. RESULTS: National Institutes of Health-funded faculty had higher average h indices than their nonfunded colleagues (23.6 vs 10.8, p < 0.0001), a finding that persisted upon controlling for academic rank. The mean h index increased with successive academic rank in both cohorts; greater funding totals were seen with successive academic position (Kruskal-Wallis, p < 0.05). National Institutes of Health-funded MDs had higher h indices than their PhD colleagues (p = 0.04), although funding levels did not differ significantly. There was a trend of increasing h index with higher NIH-funding ranges (p < 0.05). CONCLUSIONS: The authors' findings demonstrate a strong relationship between scholarly impact and securing NIH funding among faculty in academic neurosurgical departments. Faculty receiving a greater amount of funding tended to have a higher h index. Mean scholarly impact, as measured by the h index, increased with successive academic rank among both NIH-funded and nonfunded faculty, suggesting that this bibliometric may have utility as an adjunct in the academic appointment and promotion process in academic neurological surgery.

Impact of fellowship training on research productivity in academic neurological surgery.

BACKGROUND: An increasing number of neurological surgeons have sought fellowship training in recent years, and previous analyses have suggested these practitioners are more likely to pursue an academic career. Scholarly productivity is a key component in academic advancement. OBJECTIVE: We used the h-index to evaluate whether fellowship training impacts research productivity and whether any differences exist in scholarly output among practitioners in the various neurosurgical subspecialties. METHODS: Online listings from academic neurological surgery departments were used to organize faculty by academic rank and fellowship training. Using the Scopus database, we calculated the h-index for 869 full-time clinical faculty. RESULTS: Mean h-index did not differ between fellowship- and nonfellowship-trained practitioners (h = 12.6 vs. 13.0, P = 0.96). When organized by academic rank, the difference between h-indices of those who completed fellowships was substantially greater at all ranks, with statistical significance at the associate professor rank (P = 0.003). Upon further examination by individual subspecialties, significant differences in relative research impact were noted (P < 0.0001). The stereotactic and functional fellowship was found to have the greatest mean h-index score, whereas the trauma/critical care fellowship had the lowest. CONCLUSION: No significant difference existed between the mean h-index scores of neurological surgeons who completed fellowships and those who did not. However, when stratified by academic rank, a trend was observed showing greater mean h-index scores for those who completed fellowships. This trend persists across nearly all subspecialties. Overall, being a senior faculty member corresponds with a greater h-index score, regardless of whether a fellowship was completed.

Is there a shortage of neurosurgeons in the United States?

BACKGROUND: Neurosurgical workforce decision-making is typically driven by the 1 neurosurgeon per 100,000 population ratio proposed in 1977 in the Study on Surgical Services for the United States report. The actual ratio has always been higher than suggested. OBJECTIVE: We evaluated whether the 1:100,000 ratio from the Study on Surgical Services for the United States report is still valid, whether there are enough neurosurgeons in the United States to meet patient needs, and whether demand is driven by patient need. METHODS: For our analysis, the distribution of practicing US neurosurgeons was merged with census data to yield density indices of neurosurgeons by state; a survey assessing practice characteristics was e-mailed to practicing neurosurgeons; and a compilation of job advertisements for US neurosurgeons was evaluated. RESULTS: Multivariant statistical analyses yielded inconclusive results regarding patient demand because existing data sets are not designed to establish patient demand and many neurosurgeons are subspecialized. The data indicated that the ratio of neurosurgeons to total US population is 1:65,580. In the survey responses, neurosurgeon-to-patient ratios varied dramatically by state and were inconsistently correlated with whether neurosurgeons indicated they were overworked or underworked. The 305 job advertisements may indicate a shortage. Twenty-four percent of advertising practices indicated that they are recruiting only for emergency department coverage, and an additional 26% indicated that they might not be recruiting if not for the need for emergency coverage. CONCLUSION: Demand ratios should be reevaluated by region and subspecialty to consider changes in neurosurgery practice. A "shortage" in the employment market may reflect factors other than patient need.