Cost determinants in management of brain arteriovenous malformations.

INTRODUCTION: There is little data on the cost of treating brain arteriovenous malformations (AVMs). The goal of this study then is to identify cost determinants in multimodal management of brain AVMs. METHODS: One hundred forty patients with brain AVMs prospectively enrolled in the UCSF brain AVM registry and treated between 2012 and 2015 were included in the study. Patient and AVM characteristics, treatment type, and length of stay and radiographic evidence of obliteration were collected from the registry. We then calculated the cost of all inpatient and outpatient encounters, interventions, and imaging attributable to the AVM. We used generalized linear models to test whether there was an association between patient and AVM characteristics, treatment type, and cost and length of stay. We tested whether the proportion of patients with radiographic evidence of obliteration differed between treatment modalities using Fisher's exact test. RESULTS: The overall median cost of treatment and interquartile range was $77,865 (49,566-107,448). Surgery with preoperative embolization was the costliest treatment at $91,948 (79,914-140,600), while radiosurgery was the least at $20,917 (13,915-35,583). In multi-predictor analyses, hemorrhage, Spetzler-Martin grade, and treatment type were significant predictors of cost. Patients who had surgery had significantly higher rates of obliteration compared with radiosurgery patients. CONCLUSIONS: Hemorrhage, AVM grade, and treatment modality are significant cost determinants in AVM management. Surgery with preoperative embolization was the costliest treatment and radiosurgery the least; however, surgical cases had significantly higher rates of obliteration.

Surgical Clipping of Previously Ruptured, Coiled Aneurysms: Outcome Assessment in 53 Patients.

BACKGROUND: Occasionally, previously coiled aneurysms will require secondary treatment with surgical clipping, representing a more complicated aneurysm to treat than the naïve aneurysm. Patients who initially presented with a ruptured aneurysm may pose an even riskier group to treat than those with unruptured previously coiled aneurysms, given their potentially higher risk for rerupture. The objective of this study was to assess the clinical outcomes of patients who undergo microsurgical clipping of ruptured previously coiled cerebral aneurysms. In addition, we present a thorough review of the literature. METHODS: A total of 53 patients from a single institution who initially presented with a subarachnoid hemorrhage and underwent surgical clipping of a previously coiled aneurysm between December 1997 and December 2014 were studied. Clinical features, hospital course, and preoperative and most recent functional status (Glasgow Outcome Scale score) were reviewed retrospectively. RESULTS: The mean time interval from coiling to clipping was 2.6 years, and mean follow-up was 5.5 years (range, 0.1-14.7 years). Five patients (9.8%) presented with rebleed prior to clipping. Most patients (79.3%, 42/53) experienced good neurologic outcomes. Most showed no change (81%, 43/53) or improvement (13%, 7/53) in functional status after microsurgical clipping. One patient (2%) deteriorated clinically, and there were 2 mortalities (4%). CONCLUSIONS: Microsurgical clipping of previously ruptured, coiled aneurysms is a promising treatment method with favorable clinical outcomes.

Social worker assessment of bad news delivery by emergency medicine residents: a novel direct-observation milestone assessment.

The skill of delivering bad news is difficult to teach and evaluate. Residents may practice in simulated settings; however, this may not translate to confidence or competence during real experiences. We investigated the acceptability and feasibility of social workers as evaluators of residents' delivery of bad news during patient encounters, and assessed the attitudes of both groups regarding this process. From August 2013 to June 2014, emergency medicine residents completed self-assessments after delivering bad news. Social workers completed evaluations after observing these conversations. The Assessment tools were designed by modifying the global Breaking Bad News Assessment Scale. Residents and social workers completed post-study surveys. 37 evaluations were received, 20 completed by social workers and 17 resident self-evaluations. Social workers reported discussing plans with residents prior to conversations 90 % of the time (18/20, 95 % CI 64.5, 97.8). Social workers who had previously observed the resident delivering bad news reported that the resident was more skilled on subsequent encounters 90 % of the time (95 % CI 42.2, 99). Both social workers and residents felt that prior training or experience was important. First-year residents valued advice from social workers less than advice from attending physicians, whereas more experienced residents perceived advice from social workers to be equivalent with that of attending physicians (40 versus 2.9 %, p = 0.002). Social worker assessment of residents' abilities to deliver bad news is feasible and acceptable to both groups. This formalized self-assessment and evaluation process highlights the importance of social workers' involvement in delivery of bad news, and the teaching of this skill. This method may also be used as direct-observation for resident milestone assessment.