Comparing Microvascular Decompression with Gamma Knife Radiosurgery for Trigeminal Neuralgia. A Cost-Effectiveness Analysis.

BACKGROUND AND OBJECTIVE: Both microvascular decompression (MVD) and Gamma Knife radiosurgery (GKRS) are time-tested treatment modalities for trigeminal neuralgia (TN). There is little evidence in the literature studying these modalities head to head in a cost-effectiveness comparison. OBJECTIVE: To evaluate the cost-effectiveness of MVD compared with GKRS for treating patients with TN. METHODS: We developed a Markov cost-effectiveness model for the U.S. health care system to account for all costs related to MVD and GKRS as treatment modalities for TN, from the health care system perspective, over a patient lifetime horizon. A base case was estimated using data from previous studies, from our own GKRS experience, and from a current data analysis of patients undergoing MVD. We derived model inputs, including health care costs, survival, and utility estimates, from the literature. We used age-specific, sex-specific, and race-specific mortality from national registries. Costs studied included those for MVD, for GKRS, for treating complications from either procedure, and for medications throughout patient lifetimes. We performed multiple 1-way, 2-way, and probabilistic sensitivity analyses to confirm the robustness of model assumptions and results. The incremental cost-effectiveness ratio (ICER), with a threshold of $50,000 per quality-adjusted life-year (QALY) gained, defined cost-effectiveness. RESULTS: The base case had an ICER of $12,154 per QALY for MVD compared with GKRS. Probabilistic sensitivity (Monte Carlo) analysis showed that MVD was cost-effective in 70% of model iterations. GKRS was favored when the willingness to pay threshold was <$12,000 per QALY gained. CONCLUSIONS: In patients medically eligible for either procedure, we found MVD to be the most cost-effective modality to treat TN, primarily because of its reported greater durability. MVD remained the most cost-effective strategy across a broad range of model input values in sensitivity analyses.

Cost-Effectiveness of a Radio Frequency Hemostatic Sealer (RFHS) in Adult Spinal Deformity Surgery.

BACKGROUND: Patients undergoing posterior spinal fusion surgery can lose a substantial amount of blood. This can prolong operative time and require transfusion of allogeneic blood components, which increases the risk of infection and can be the harbinger of serious complications. Does a saline-irrigated bipolar radiofrequency hemostatic sealer (RFHS) help reduce transfusion requirements? METHODS: In an observational cohort study, we compared transfusion requirements in 30 patients undergoing surgery for adult spinal deformity using the RFHS with that of a historical control group of 30 patients in which traditional hemostasis was obtained with bipolar electrocautery and matched them for blood loss-related variables. Total expense to the hospital for the RFHS, laboratory expenses, and blood transfusions was used for cost calculations. The incremental cost-effectiveness ratio was calculated using the number of blood transfusions avoided as the effectiveness payoff. RESULTS: Using a multivariable linear regression model, we found that only estimated blood loss (EBL) was an independent significant predictor of transfusion requirement in both groups. We evaluated the variables of age, EBL, time duration of surgery, preoperative hemoglobin, hemoglobin nadir during surgery, body mass index, length of stay, and number of levels operated on. Mean EBL was greater in the control group (2201 vs. 1416 mL, P = 0.0099). The number of transfusions also was greater in the control group (14.5 vs. 6.5, P = 0.0008). In the cost-effectiveness analysis, we found that the RFHS cost $108 more (compared with not using the RFHS) to avoid 1 unit of blood transfusion. CONCLUSIONS: The cost-effectiveness analysis revealed that if we are willing to pay $108 to avoid 1 unit of blood transfusion, the use of the RFHS is a reasonable choice to use in open surgery for adult spinal deformity.

Cost of coils for intracranial aneurysms: clinical decision analysis for implementation of a capitation model.

OBJECTIVE The price of coils used for intracranial aneurysm embolization has continued to rise despite an increase in competition in the marketplace. Coils on the US market range in list price from $500 to $3000. The purpose of this study was to investigate potential cost savings with the use of a price capitation model. METHODS The authors built a clinical decision analytical tree and compared their institution's current expenditure on endovascular coils to the costs if a capped-price model were implemented. They retrospectively reviewed coil and cost data for 148 patients who underwent coil embolization from January 2015 through September 2016. Data on the length and number of coils used in all patients were collected and analyzed. The probabilities of a treated aneurysm being ≤/> 10 mm in maximum dimension, the total number of coils used for a case being ≤/> 5, and the total length of coils used for a case being ≤/> 50 cm were calculated, as was the mean cost of the currently used coils for all possible combinations of events with these probabilities. Using the same probabilities, the authors calculated the expected value of the capped-price strategy in comparison with the current one. They also conducted multiple 1-way sensitivity analyses by applying plausible ranges to the probabilities and cost variables. The robustness of the results was confirmed by applying individual distributions to all studied variables and conducting probabilistic sensitivity analysis. RESULTS Ninety-five (64%) of 148 patients presented with a rupture, and 53 (36%) were treated on an elective basis. The mean aneurysm size was 6.7 mm. A total of 1061 coils were used from a total of 4 different providers. Companies A (72%) and B (16%) accounted for the major share of coil consumption. The mean number of coils per case was 7.3. The mean cost per case (for all coils) was $10,434. The median total length of coils used, for all coils, was 42 cm. The calculated probability of treating an aneurysm less than 10 mm in maximum dimension was 0.83, for using 5 coils or fewer per case it was 0.42, and for coil length of 50 cm or less it was 0.89. The expected cost per case with the capped policy was calculated to be $4000, a cost savings of $6564 in comparison with using the price of Company A. Multiple 1-way sensitivity analyses revealed that the capped policy was cost saving if its cost was less than $10,500. In probabilistic sensitivity analyses, the lowest cost difference between current and capped policies was $2750. CONCLUSIONS In comparison with the cost of coils from the authors' current provider, their decision model and probabilistic sensitivity analysis predicted a minimum $407,000 to a maximum $1,799,976 cost savings in 148 cases by adapting the capped-price policy for coils.

Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas: A Cost-Minimization Study.

OBJECTIVE: To perform a cost-minimization study comparing the supraorbital and endoscopic endonasal (EEA) approach with or without craniotomy for the resection of olfactory groove meningiomas (OGMs). METHODS: We built a decision tree using probabilities of gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates with the supraorbital approach versus EEA with and without additional craniotomy. The cost (not charge or reimbursement) at each "stem" of this decision tree for both surgical options was obtained from our hospital's finance department. After a base case calculation, we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses. Probabilistic sensitivity analyses confirmed our results. RESULTS: The probabilities of GTR (0.8) and CSF leak (0.2) for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM. The mean tumor volume was 54.6 cm3 (range, 17-94.2 cm3). Literature-reported rates of GTR (0.6) and CSF leak (0.3) with EEA were applied to our economic analysis. Supraorbital craniotomy was the preferred strategy, with an expected value of $29,423, compared with an EEA cost of $83,838. On multiple 1-way sensitivity analyses, supraorbital craniotomy remained the preferred strategy, with a minimum cost savings of $46,000 and a maximum savings of $64,000. Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be $37,431. CONCLUSION: Compared with EEA, supraorbital craniotomy provides substantial cost savings in the treatment of OGMs. Given the potential differences in effectiveness between approaches, a cost-effectiveness analysis should be undertaken.

A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally Invasive Lateral Lumbar Interbody Fusions Using the Incremental Cost-Effectiveness Ratio at 2-Year Follow-up.

BACKGROUND: Direct cost comparisons between minimally invasive spine surgeries and the open options are rare. OBJECTIVE: To compare healthcare costs associated with open transforaminal lumbar interbody fusion (TLIF) and minimally invasive lateral lumbar interbody fusion (LLIF) by calculating the incremental cost-effectiveness ratio (ICER) and to calculate the thresholds for minimum clinically important difference and minimum cost-effective difference for patient-reported outcome measures at the 2-year follow-up. METHODS: Forty-five patients who underwent single-level TLIF and 29 patients who underwent single-level stand-alone LLIF were included in the comparison. All costs from diagnosis through the 2-year follow-up were available from a comprehensive single-center data bank within a unified hospital system. Payment provided for all spine-related medical resource use from the time of diagnosis through 2 years was recorded. A 0% discount rate was applied. Quality-adjusted life-years (QALYs) were calculated from the EuroQol-5D collected in an unbiased manner. Difference in total cost per QALY gained for LLIF minus that for TLIF was assessed as the estimate of the ICER from a US perspective. RESULTS: Significant improvements were observed at the 2-year follow-up for both TLIF and LLIF with the Short Form-36 physical component summary, Oswestry Disability Index, visual analog scale back pain and leg pain scores, and EuroQol-5D. ICER calculations revealed similar mean cumulative QALYs gained at the 2-year interval (0.67 for TLIF and 0.60 for LLIF; P = .33). Median total costs of care after TLIF and LLIF were $44 068 and $45 574, respectively (P = .96). Minimum cost-effective difference thresholds with an anchor of <$50 000 per QALY were higher than minimum clinically important difference thresholds for all patient-reported outcome measures. Total mean cost and EuroQol-5D were statistically equivalent between the 2 treatment groups. CONCLUSION: TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.