Demographic and socioeconomic disparities of benign and malignant spinal meningiomas in the United States.

INTRODUCTION: Spinal meningiomas constitute the majority of primary spinal neoplasms, yet their pathogenesis remains elusive. By investigating the distribution of these tumors across sociodemographic variables can provide direction in etiology elucidation and healthcare disparity identification. METHODS: To investigate benign and malignant spinal meningioma incidences (per 100,000) with respect to sex, age, income, residence, and race/ethnicity, we queried the largest American administrative dataset (1997-2016), the National (Nationwide) Inpatient Sample (NIS), which surveys 20% of United States (US) discharges. RESULTS: Annual national incidence was 0.62 for benign tumors and 0.056 for malignant. For benign meningiomas, females had an incidence of 0.81, larger (P=0.000004) than males at 0.40; yet for malignant meningiomas, males had a larger (P=0.006) incidence at 0.062 than females at 0.053. Amongst age groups, peak incidence was largest for those 65-84 years old (2.03) in the benign group, but 45-64 years old (0.083) for the malignant group. For benign and malignant meningiomas respectively, individuals with middle/high income had an incidence of 0.67 and 0.060, larger (P=0.000008; P=0.04) than the 0.48 and 0.046 of low income patients. Incidences were statistically similar (P=0.2) across patient residence communities. Examining race/ethnicity (P=0.000003) for benign meningiomas, incidences for Whites, Asian/Pacific Islanders, Hispanics, and Blacks were as follows, respectively: 0.83, 0.42, 0.28, 0.15. CONCLUSIONS: Across sociodemographic strata, healthcare inequalities were identified with regards to spinal meningiomas. For benign spinal meningiomas, incidence was greatest for patients who were female, 65-84 years old, middle/high income, living in rural communities, White, and Asian/Pacific Islander. Meanwhile, for malignant spinal meningiomas incidence was greatest for males, those 45-65 years old, and middle/high income.

Geographical variation in malignant and benign/borderline brain and CNS tumor incidence: a comparison between a high-income and a middle-income country.

PURPOSE: There is large variability in reported incidence rates of primary brain/CNS tumors across the world, with mostly higher rates in higher-income countries. The aim was to compare malignant and benign brain/CNS tumor incidence between Zurich (Switzerland), a high-income country, and Georgia, a lower middle-income country. METHODS: For the period March 2009 to February 2012, we extracted the following tumors based on topography according to ICD-O3: C70.0-C72.9, and C75.1 (pituitary gland). Data were categorized into histology groups based on the WHO 2007 histological classification. Age-standardized rates per 100,000 person-years were calculated by subgroups. RESULTS: We included 1104 and 1476 cases of primary brain/CNS tumors for Zurich and Georgia, respectively. Mean age of patients was significantly lower in Georgia compared to Zurich (50.0 versus 58.3 years). Overall age-standardized incidence rates for malignant and benign brain/CNS tumors were 10.5 (95% CI 9.9-11.0) for Georgia and 23.3 (95% CI 21.9-24.7) for Zurich with a ratio of benign to malignant tumors of 1.656 for Georgia and 1.946 for Zurich. The most frequent histology types were meningiomas in both regions, followed by glioblastomas in Zurich, but pituitary tumors in Georgia. CONCLUSION: Age-adjusted incidence rates of brain/CNS tumors were considerably higher in Zurich compared to Georgia, both for benign and malignant tumors, which is in line with other studies reporting higher rates in high-income than in low- and middle-income countries. The frequency distribution may be related to differences in diagnosing techniques and the population age structure.

Impact of insurance on hospital course and readmission after resection of benign meningioma.

INTRODUCTION: Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies. METHODS: We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015. RESULTS: A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics. CONCLUSIONS: Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.

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.

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.

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.

The ROAM/EORTC-1308 trial: Radiation versus Observation following surgical resection of Atypical Meningioma: study protocol for a randomised controlled trial.

BACKGROUND: Atypical meningiomas are an intermediate grade brain tumour with a recurrence rate of 39-58 %. It is not known whether early adjuvant radiotherapy reduces the risk of tumour recurrence and whether the potential side-effects are justified. An alternative management strategy is to perform active monitoring with magnetic resonance imaging (MRI) and to treat at recurrence. There are no randomised controlled trials comparing these two approaches. METHODS/DESIGN: A total of 190 patients will be recruited from neurosurgical/neuro-oncology centres across the United Kingdom, Ireland and mainland Europe. Adult patients undergoing gross total resection of intracranial atypical meningioma are eligible. Patients with multiple meningioma, optic nerve sheath meningioma, previous intracranial tumour, previous cranial radiotherapy and neurofibromatosis will be excluded. Informed consent will be obtained from patients. This is a two-stage trial (both stages will run in parallel): Stage 1 (qualitative study) is designed to maximise patient and clinician acceptability, thereby optimising recruitment and retention. Patients wishing to continue will proceed to randomisation. Stage 2 (randomisation) patients will be randomised to receive either early adjuvant radiotherapy for 6 weeks (60 Gy in 30 fractions) or active monitoring. The primary outcome measure is time to MRI evidence of tumour recurrence (progression-free survival (PFS)). Secondary outcome measures include assessing the toxicity of the radiotherapy, the quality of life, neurocognitive function, time to second line treatment, time to death (overall survival (OS)) and incremental cost per quality-adjusted life year (QALY) gained. DISCUSSION: ROAM/EORTC-1308 is the first multi-centre randomised controlled trial designed to determine whether early adjuvant radiotherapy reduces the risk of tumour recurrence following complete surgical resection of atypical meningioma. The results of this study will be used to inform current neurosurgery and neuro-oncology practice worldwide. TRIAL REGISTRATION: ISRCTN71502099 on 19 May 2014.

Preoperative charlson comorbidity score predicts postoperative outcomes among older intracranial meningioma patients.

OBJECTIVE: Preoperative determinants of surgical risk in elderly patients with meningioma are not fully defined. This study was undertaken to determine whether the Charlson comorbidity index could be used to accurately predict postoperative outcomes among older patients with meningiomas undergoing neurosurgical resection and thereby make a selection for surgery easier. METHODS: We performed a multi-institutional retrospective cohort analysis via the Nationwide Inpatient Sample (1998-2005). Patients 65 years of age and older who underwent tumor resection of intracranial meningiomas were identified by International Classification of Diseases, 9th revision, coding. The primary independent variable in multivariate regression was the Charlson comorbidity score, and the primary outcome was inpatient death. Secondary outcomes included inpatient complications, length of stay, and total hospital charges. RESULTS: We identified 5717 patients (66.6% female, and 81.8% white) with mean age of 73.6 years. Mean Charlson comorbidity score was 0.99. Inpatient mortality was 3.2%. Mean length of stay was 9.1 days, and mean total charges were $62,983. In multivariate analysis, the only factors consistently associated with worse outcome were increased Charlson comorbidity score and increased patient age (ie, >65 years of age). Only greater Charlson scores were additionally associated with greater odds of all major complications such as neurological, respiratory, and cardiac complications. Elective procedures were consistently associated with less inpatient death, length of stay, and total charges. All associations were statistically significant (P < 0.05). CONCLUSIONS: The safe surgical resection of intracranial meningiomas among older patients is possible through the ninth decade of life. The Charlson comorbidity score has been shown to be a strong, consistent predictor of inpatient outcomes.

A microcosting study of microsurgery, LINAC radiosurgery, and gamma knife radiosurgery in meningioma patients.

The aim of the present study is to determine and compare initial treatment costs of microsurgery, linear accelerator (LINAC) radiosurgery, and gamma knife radiosurgery in meningioma patients. Additionally, the follow-up costs in the first year after initial treatment were assessed. Cost analyses were performed at two neurosurgical departments in The Netherlands from the healthcare providers' perspective. A total of 59 patients were included, of whom 18 underwent microsurgery, 15 underwent LINAC radiosurgery, and 26 underwent gamma knife radiosurgery. A standardized microcosting methodology was employed to ensure that the identified cost differences would reflect only actual cost differences. Initial treatment costs, using equipment costs per fraction, were 12,288 for microsurgery, 1,547 for LINAC radiosurgery, and 2,412 for gamma knife radiosurgery. Higher initial treatment costs for microsurgery were predominantly due to inpatient stay (5,321) and indirect costs (4,350). LINAC and gamma knife radiosurgery were equally expensive when equipment was valued per treatment (2,198 and 2,412, respectively). Follow-up costs were slightly, but not significantly, higher for microsurgery compared with LINAC and gamma knife radiosurgery. Even though initial treatment costs were over five times higher for microsurgery compared with both radiosurgical treatments, our study gives indications that the relative cost difference may decrease when follow-up costs occurring during the first year after initial treatment are incorporated. This reinforces the need to consider follow-up costs after initial treatment when examining the relative costs of alternative treatments.

Non-participant characteristics and the association between socioeconomic factors and brain tumour risk.

BACKGROUND: The aim of the study was to identify demographic and socioeconomic characteristics of participants and non-participants in a Swedish population-based case-control study on brain tumours and to analyse the association between socioeconomic factors and glioma and meningioma risk. METHODS: Record linkage was made to an official register to gather information on socioeconomic status, income, education and demography for all participating and non-participating cases and controls. RESULTS: 494 glioma cases, 321 meningioma cases and 955 controls were eligible and 74%, 85% and 70%, respectively, participated. Working status and income level were positively associated with participation among cases and controls. Among both cases and controls, being married, and having a high education were also associated with participation. Having a family income level in the highest quartile was associated with an increased glioma risk (OR 1.5, 95% CI 1.1 to 2.1). This risk increase diminished when only participating individuals were included in the analysis. Socioeconomic factors were not associated with meningioma risk. CONCLUSIONS: Non-participation, related to socioeconomic factors, is a potential source of bias in case-control studies that should be acknowledged; however, the effect was not large in the present study due to the fact that the level of participation was comparable between cases and controls and participation was similarly influenced by socioeconomic factors among cases and controls. The association between a high income level and an increased glioma risk and possible underlying factors needs to be explored further.

Treatment for childhood rhabdomyosarcoma: the cost of cure.

Survival of children and young people with rhabdomyosarcoma has improved substantially during the past 30 years. The improvement can be attributed to the introduction of coordinated multimodality therapy through the efforts of collaborative clinical-trial groups in the USA and Europe. As survival has improved, important late sequelae of treatment have been characterised, and many relate to the local therapy used. Efforts have since been made by some groups to explore ways in which local treatment, particularly radiotherapy, can be omitted for some patients in an attempt to reduce the risk of late sequelae without compromising prospects for cure. An important issue is the overall cost of cure in relation to the treatment received and the need for better selection of patients most likely to benefit from this approach to therapy.

Diagnosis of meningeoma. A comparison of costs before CT, during CT and after introduction of MR imaging.

OBJECTIVE: To assess whether the capital investment required by advances in radiological technology is offset by savings in the direct costs of diagnostic services. MATERIAL AND METHODS: Meningeoma was used as an indicator case. All meningeoma patients from three study periods were included: Twenty patients in 1976-77 before the introduction of CT, 22 patients in 1984-85 when CT was used and 16 patients in 1992 when MR imaging had replaced CT as the most informative imaging modality. Radiological and other diagnostic investigations, and the hospital stay were identified and cost analyzed. RESULTS: The costs of radiological examinations increased from 293 Euros in 1976-77 to 513 Euros in 1992. The average number of diagnostic examinations per patient decreased from 5.1 in 1976 77 to 2.4 in 1992. The length of hospital stay decreased from 11.5 to 2.7 days and the total costs of the diagnostic work-up decreased to one-third of the original, i.e. from 3423 Euros in 1976-77 to 1282 Euros in 1992. CONCLUSION: The costs of the radiological examinations rose, but the development of radiological technology simplified the diagnostic practice. The hospital stay drastically decreased. The total costs of diagnostic work-up per patient dropped to one-third of the baseline costs.

Clinical utility and cost-effectiveness of interactive image-guided craniotomy: clinical comparison between conventional and image-guided meningioma surgery.

OBJECTIVE: Although interactive image guidance has been determined to be an increasingly important and reliable tool in contemporary neurosurgery, the clinical results and cost-effectiveness of the use of these systems, compared with conventional techniques, remain understudied. The aim of this study was to investigate the possible benefits of image-guided craniotomies to treat meningiomas, in terms of hospital stays, surgical complications, and, consequently, cost-effectiveness, compared with the results of standard surgery (SS). METHODS: During a 3.5-year period, 100 patients were surgically treated for meningiomas using image-guided surgery (IGS) with neuronavigation assistance and 170 were surgically treated using SS. From the consecutive series of the 100 IGS cases, it was possible to statistically match 50 (in terms of the demographic data, the location and size of the tumor, and the experience of the surgeon) with 50 SS cases. The clinical data were collected prospectively for the IGS group and retrospectively for the SS group. RESULTS: The anesthetic (operation) times were similar for the two groups, although surgical times were shorter for the IGS group (P = 0.02). Blood loss during surgery was less for the IGS group (although not statistically significantly, P > 0.05), but more SS cases required transfusions (P = 0.03). The mean intensive therapy unit stay was 1.7 days for the SS group and 1 day for the IGS group (P = 0.12); the mean hospital stays were 13.5 and 8.5 days, respectively (P = 0.017). Severe complications (permanent or requiring additional surgical procedures) were encountered in 14% of the cases in the SS group and 6% of the cases in the IGS group (P = 0.019), whereas the rates of minor complications (resolved within 30 d without further surgery) were similar (8 and 10%, respectively). The most common problems for the control group were postoperative hematomas (n = 3), which required urgent surgery in two cases; intractable postoperative swelling was treated by lobectomy in another case. In the IGS group, the two severe complications included one case of an infected bone flap and one case of a new permanent neurological deficit. The mean cost per patient was approximately 20% higher for SS than for IGS. CONCLUSION: Although this was not a randomized study, the analysis of these results strongly suggests a positive effect of neuronavigation on the complication rate and thus on intensive care unit and hospital stays, with attendant financial implications.

[Diagnostic x-ray computed tomography pf craniocerebral tumors. Apropos of 108 cases collected at the Soweto Center of Dakar]. / Diagnostic tomodensitométrique des tumeurs crânio-encéphaliques. A propos de 108 cas colligés au Centre Soweto de Dakar.

The authors report a retrospective study over two years in order to assess computed tomography (CT) in the diagnosis of intracranial tumors. Results were analysed on the epidemiological, clinical and CT point of view. CT is a sensitive and non invasive exploration which should be performed first when intracranial tumor is suspected. However its cost remain high for most of the patient.

Efficacy of endovascular treatment of meningiomas: evaluation with matched samples.

PURPOSE: To evaluate the clinical efficacy, cost-effectiveness, and safety of presurgical devascularization of meningiomas. METHODS: Matched samples of embolized and nonembolized groups of meningiomas were compared. The study variables for clinical efficacy were estimated blood loss, number of transfusions, surgical resection time, and length of hospitalization. The cost-effectiveness was evaluated by adjusting all hospital costs to 1991 dollar amounts, and adding additional embolization costs and fees to the hospital cost totals for the embolized group. A qualitative comparison of complications was made. RESULTS: All dependent variables evaluating the clinical efficacy of the procedure (estimate blood loss, 533 cc versus 836 cc; number of transfusions, 0.39 units versus 1.56 units; surgical resection time, 305.8 minutes versus 337.5 minutes; and length of hospitalization, 10.6 days versus 15.0 days) displayed trends of higher means in the nonembolized group; however, only the estimated blood loss and number of transfusions variables were significant. The cost-effectiveness of the procedure was not statistically significant. The mean cost was $29,605 for the embolized group and $38,449 for the nonembolized group. There were three major and nine minor complications in the nonembolized group and zero major and six minor complications in the embolized group. There were four additional minor complications caused by the embolization procedure. CONCLUSION: Endovascular devascularization of meningiomas is beneficial for large meningiomas because it diminishes the necessity of intraoperative transfusions and decreases blood loss. The additional day of hospitalization, emolization costs, and costs of complications do not conversely increase treatment costs. There were no major complications or adverse long-term effects caused by the embolization procedure.