Socioeconomic Inequities in the Surgical Management of Moyamoya Disease.

BACKGROUND: Given the vasculopathic nature of moyamoya disease (MMD) and high susceptibility to ischemic events, patients with MMD often require surgical revascularization via an indirect or direct bypass, and analysis of disparities in receipt of appropriate management is critical. METHODS: The 2012-2016 Nationwide Inpatient Sample was queried for patients admitted with a diagnosis of MMD using International Classification of Diseases codes. Patient baseline demographics, hospital characteristics, and associated symptoms were collected. Patients were grouped by receipt of bypass procedure, and propensity score matching was performed to identify socioeconomic disparities between operative and nonoperative groups. RESULTS: Inclusion criteria were met by 4474 patients (827 pediatric patients and 3647 adult patients). Mean (SD) age for pediatric patients was 10.4 (4.6) years and for adult patients was 40.5 (14.4) years. Among pediatric patients, Black and Hispanic/Latino patients were less likely to undergo revascularization surgery (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.21-0.78, P ≤ 0.01; OR 0.47, 95% CI 0.26-0.84, P = < 0.01, respectively); among adult patients, Black and Hispanic/Latino patients were similarly less likely to undergo bypass procedures (OR 0.60, 95% CI 0.49-0.72, P ≤ 0.01; OR 0.73, 95% CI 0.55-0.96, P = 0.01, respectively). Pediatric and adult patients in the lowest and next to lowest income quartiles were also less likely to receive operative treatment (pediatric patients: OR 0.61, 95% CI 0.40-0.94, P = 0.02; OR 0.64, 95% CI 0.42-0.98, P = 0.04, respectively; adult patients: OR 0.82, 95% CI 0.88-0.98, P = 0.03). CONCLUSIONS: Further investigation into socioeconomic disparities in adult and pediatric patients with MMD is warranted given the potential for inequities in access to appropriate intervention.

Implications of achieving TICI 2b vs TICI 3 reperfusion in patients with ischemic stroke: a cost-effectiveness analysis.

BACKGROUND: The benefit of endovascular thrombectomy (EVT) in stroke patients with large-vessel occlusion (LVO) depends on the degree of recanalization achieved. We aimed to determine the health outcomes and cost implications of achieving TICI 2b vs TICI 3 reperfusion in acute stroke patients with LVO. METHODS: A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years (QALY) of EVT-treated patients, and costs based on the degree of reperfusion achieved. The study was performed with a societal perspective in the United States' setting. The base case calculations were performed in three age groups: 55-, 65-, and 75-year-old patients. RESULTS: Within 90 days, achieving TICI 3 resulted in a cost saving of $3676 per patient and health benefit of 11 days in perfect health as compared with TICI 2b. In the long term, for the three age groups, achieving TICI 3 resulted in cost savings of $46,498, $25,832, and $15 719 respectively, and health benefits of 2.14 QALYs, 1.71 QALYs, and 1.23 QALYs. Every 1% increase in TICI 3 in 55-year-old patients nationwide resulted in a cost saving of $3.4 million and a health benefit of 156 QALYs. Among 65-year-old patients, the corresponding cost savings and health benefit were $1.9 million and 125 QALYs. CONCLUSION: There are substantial cost and health implications in achieving complete vs incomplete reperfusion after EVT. Our study provides a framework to assess the cost-benefit analysis of emerging diagnostic and therapeutic techniques that might improve patient selection, and increase the chances of achieving complete reperfusion.

Spontaneous Thrombosis of Giant Dissecting Fusiform Middle Cerebral Aneurysm After Double-Barrel Superficial Temporal Artery-Middle Cerebral Artery Bypass: A Case Report of Decision-Making in a Limited Resource Environment.

BACKGROUND: The treatment of giant fusiform middle cerebral artery (MCA) aneurysms remains daunting owing to their tendency to be associated with precarious end-vessel anatomy and the need for complex microsurgical techniques to appropriately address the aneurysm and the vasculature at risk. Extracranial-intracranial bypass revascularization remains a valuable tool for treating these complex lesions. In the present report, we have described a rare occurrence in which the creation of a double-barrel superficial temporal artery (STA-MCA) bypass facilitated spontaneous obliteration of the aneurysm. We have also highlighted our decision-making process, which was affected by operating in a low-to-middle income country with limited resources. CASE DESCRIPTION: A 32-year-old man had presented with recurrent ischemic events in the left MCA distribution and subsequent subarachnoid hemorrhage due to rupture of a giant complex fusiform MCA aneurysm. The patient underwent double-barrel STA-MCA bypass and was scheduled for second-stage clip reconstruction or partial trapping. Postoperative imaging studies revealed progressive thrombosis of the M1 segment, resulting in occlusion of the aneurysm without subsequent trapping or clipping. The patient recovered remarkably without further repeat hemorrhage or ischemic injury. We also reviewed the reported data. CONCLUSIONS: Double-barrel STA-MCA bypass is a potential salvage surgical technique to treat selected ruptured complex giant fusiform MCA aneurysms. In rare selected cases, the flow alteration induced by the bypass alone can potentially facilitate aneurysm thrombosis.

National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998-2015.

OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998-2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010-2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998-2011, bypass procedures for UIAs in 2012-2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors' findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.

National trends in cerebral bypass surgery in the United States, 2002-2014.

OBJECTIVECerebral bypass procedures are microsurgical techniques to augment or restore cerebral blood flow when treating a number of brain vascular diseases including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. With advances in endovascular therapy and evolving evidence-based guidelines, it has been suggested that cerebral bypass procedures are in a state of decline. Here, the authors characterize the national trends in cerebral bypass surgery in the United States from 2002 to 2014.METHODSUsing the National (Nationwide) Inpatient Sample, the authors extracted for analysis the data on all adult patients who had undergone cerebral bypass as indicated by ICD-9-CM procedure code 34.28. Indications for bypass procedures, patient demographics, healthcare costs, and regional variations are described. Results were stratified by indication for cerebral bypass including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. Predictors of inpatient complications and death were evaluated using multivariable logistic regression analysis.RESULTSFrom 2002 to 2014, there was an increase in the annual number of cerebral bypass surgeries performed in the United States. This increase reflected a growth in the number of cerebral bypass procedures performed for adult moyamoya disease, whereas cases performed for occlusive vascular disease or cerebral aneurysms declined. Inpatient complication rates for cerebral bypass performed for moyamoya disease, vascular occlusive disease, and cerebral aneurysm were 13.2%, 25.1%, and 56.3%, respectively. Rates of iatrogenic stroke ranged from 3.8% to 20.4%, and mortality rates were 0.3%, 1.4%, and 7.8% for moyamoya disease, occlusive vascular disease, and cerebral aneurysms, respectively. Multivariate logistic regression confirmed that cerebral bypass for vascular occlusive disease or cerebral aneurysm is a statistically significant predictor of inpatient complications and death. Mean healthcare costs of cerebral bypass remained unchanged from 2002 to 20014 and varied with treatment indication: moyamoya disease $38,406 ± $483, vascular occlusive disease $46,618 ± $774, and aneurysm $111,753 ± $2381.CONCLUSIONSThe number of cerebral bypass surgeries performed for adult revascularization has increased in the United States from 2002 to 2014. Rising rates of surgical bypass reflect a greater proportion of surgeries performed for moyamoya disease, whereas bypasses performed for vascular occlusive disease and aneurysms are decreasing. Despite evolving indications, cerebral bypass remains an important surgical tool in the modern endovascular era and may be increasing in use. Stagnant complication rates highlight the need for continued interest in advancing available bypass techniques or technologies to improve patient outcomes.

Cost benefits of rapid recanalization using intraarterial thrombectomy.

OBJECTIVES: Thrombolytic therapy is associated with favorable clinical outcomes after successful and rapid recanalization in patients with acute ischemic stroke. This study aimed to evaluate the cost benefits and clinical outcomes at 1 year after intraarterial thrombectomy (IAT) by the rapidity of the successful recanalization. MATERIALS & METHODS: Clinical outcomes of and medical costs incurred by 230 patients with acute ischemic stroke who underwent IAT were compared by the rapidity from symptom onset to successful recanalization (2b/3 thrombolysis in cerebral infarction grade): ≤6-hr (n = 143), >6-hr (n = 31), and no-recanalization (n = 56). Clinical outcomes including functional independence (0-2 modified Rankin Score), mortality, and home-discharge checked at 1 year post-IAT were compared among the three groups. Cost utility was calculated using quality-adjusted life years (QALY) estimated using the EuroQol-5 dimensions-3 levels questionnaire and the fees paid for institutional rehabilitation during the year post-IAT, and, was compared among the groups. RESULTS: Patients in the ≤6-hr group showed higher functional independence (≤6-hr, 70%; >6-hr, 40%; no-recanalization, 6%, p < .001) and home-discharge rate (73%, 52%, 21%, and respectively, p < .001), and lower mortality (10%, 16%, and 43%, respectively, p < .001) at 1 year after IAT than other two groups. The cost utility of the ≤6-hr group was $35,557/QALY higher than that of the >6-hr group, and $27.829/QALY higher than no-recanalization group. CONCLUSIONS: Rapid and successful recanalization of the occluded intracranial vessels within 6 hr after the onset of symptoms resulted in markedly higher cost utility and functional independence at 1 year post-IAT.

Impact of Hospital Caseload and Elective Admission on Outcomes After Extracranial-Intracranial Bypass Surgery.

BACKGROUND: Limited information exists evaluating the impact of hospital caseload and elective admission on outcomes after patients have undergone extracranial-intracranial (ECIC) bypass surgery. Using the Nationwide Inpatient Sample (NIS) for 2001-2014, we evaluated the impact of hospital caseload and elective admission on outcomes after bypass. METHODS: In an observational cohort study, weighted estimates were used to investigate the association of hospital caseload and elective admission on short-term outcomes after bypass surgery using multivariable regression techniques. RESULTS: Overall, 10,679 patients (mean age, 43.39 ± 19.63 years; 59% female) underwent bypass across 495 nonfederal U.S. hospitals. In multivariable models, patients undergoing bypass at high-volume centers were associated with decreased probability of mortality (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.22-0.70; P < 0.001), length of stay (OR, 0.86; 95% CI, 0.82-0.90; P < 0.001), postbypass neurologic complications (OR, 0.66; 95% CI, 0.49-0.89; P = 0.007), venous thromboembolism (OR, 0.69; 95% CI, 0.49-0.97; P = 0.033), and acute renal failure (OR, 0.45; 95% CI, 0.26-0.80; P = 0.007), and higher hospitalization cost (26.3% higher) compared with low-volume centers. Likewise, patients undergoing elective bypass were associated with decreased likelihood of mortality (OR, 0.38; 95% CI, 0.25-0.59; P < 0.001), unfavorable discharge (OR, 0.57; 95% CI, 0.43-0.76; P < 0.001), length of stay (OR, 0.62; 95% CI, 0.59-0.64; P < 0.001), venous thromboembolism (OR, 0.61; 95% CI, 0.49-0.77; P < 0.001), acute renal failure (OR, 0.64; 95% CI, 0.43-0.94; P = 0.022), wound complications (OR, 0.71; 95% CI, 0.53-0.96; P = 0.028), and lower hospitalization cost (34.5% lower) compared with nonelective admissions. CONCLUSIONS: Our findings serve as a framework for strengthening referral networks for complex cases to centers performing high volumes of cerebral bypass. Also, our study supports improved outcomes in select patients undergoing elective bypass procedures.

For-Profit Hospital Status and Carotid Artery Stent Utilization in US Hospitals Performing Carotid Revascularization.

BACKGROUND AND PURPOSE: Carotid artery stenting may be an economically attractive procedure for hospitals and physicians. We sought to identify the association of hospital ownership (nonprofit versus for-profit) on carotid artery stenting (CAS) versus carotid endarterectomy utilization in US hospitals. METHODS: Using the Nationwide Inpatient Sample admissions for cerebrovascular disease from 2008 to 2011, we identified all private, nonfederal US hospitals performing at least 20 carotid revascularization procedures annually, including carotid artery stenting (International Classification of Diseases-Ninth Revision 00.63) or carotid endarterectomy (International Classification of Diseases-Ninth Revision 38.12). We used a multilevel multivariable logistic regression controlling for patient demographics, comorbidities, and hospital characteristics, to assess the effect of hospital ownership on CAS use. RESULTS: Across 723 hospitals (600 nonprofit, 123 for-profit), 66 731 carotid revascularization admissions were identified. Approximately 1 in 5 (n=11 641; 17.4%) revascularizations received CAS. The mean CAS rate among nonprofit hospitals was 17.5 per 100 revascularizations (median, 11.5; interquartile range, 5.2-24.5), and the mean CAS rate among for-profit hospitals was 24.2 per 100 revascularizations (median, 16.0; interquartile range, 6.7-33.3; P<0.001). Adjusting for patient and hospital characteristics, for-profit hospital designation was associated with greater odds of CAS (adjusted odds ratio, 1.45; 95% confidence interval, 1.07-1.98). CONCLUSIONS: For-profit hospital ownership is associated with a higher rate of CAS compared to nonprofit hospitals in those receiving carotid revascularization. Further research is needed to understand the individual- and system-level factors driving this difference.

Cost-effectiveness of stent-retriever thrombectomy in combination with IV t-PA compared with IV t-PA alone for acute ischemic stroke in the UK.

OBJECTIVE: To evaluate the cost-effectiveness of neurothrombectomy with a stent retriever (Solitaire * Revascularization Device) in treating acute ischemic stroke patients from the UK healthcare provider perspective. METHODS: A Markov model was developed to simulate health outcomes and costs of two therapies over a lifetime time horizon: stent-retriever thrombectomy in combination with intravenous tissue-type plasminogen activator (IV t-PA), and IV t-PA alone. The model incorporated an acute phase (0-90 days) and a rest of life phase (90+ days). Health states were defined by the modified Rankin Scale score. During the rest of life phase, patients remained in the same health state until a recurrent stroke or death. Clinical effectiveness and safety data were taken from the SWIFT PRIME study. Resource use and health state utilities were informed by published data. RESULTS: Combined stent-retriever thrombectomy and IV t-PA led to improved quality-of-life and increased life expectancy compared to IV t-PA alone. The higher treatment costs associated with the use of stent-retriever thrombectomy were offset by long-term cost savings due to improved patient health status, leading to overall cost savings of £33 190 per patient and a net benefit of £79 402. Deterministic and probabilistic sensitivity analyses demonstrated that the results were robust to a wide range of parameter inputs. LIMITATIONS: The acute and long-term costs resource use data were taken from a study based on a patient population that was older and may have had additional comorbidities than the SWIFT PRIME population, resulting in costs that may not be representative of the cohort within this model. In addition, the estimates may not reflect stroke care today as no current evidence is available; however, the cost estimates were deemed reasonable by clinical opinion. CONCLUSIONS: Combined stent-retriever neurothrombectomy and IV t-PA is a cost-effective treatment for acute ischemic stroke compared with IV t-PA alone.

Optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction.

OBJECTIVE: There is debate concerning the optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction. Our intent was to stratify clinical and economic outcomes based on the timing of revascularization. METHODS: We performed a retrospective cohort study using the Nationwide Inpatient Sample from 2002 to 2011. Patients were included if they were admitted non-electively with a primary diagnosis of carotid artery stenosis with infarction and subsequently treated with revascularization. Cases were stratified into four groups based upon the timing of revascularization: (1) within 48-h of admission, (2) between 48-h and day four of hospitalization, (3) between days five and seven, and (4) during the second week of admission. RESULTS: 27,839 cases met our inclusion criteria. The lowest odds of iatrogenic complications (OR=0.643, P<.001) and mortality (OR=0.631, P<.001) coincided with revascularization between days five and seven of hospitalization. Treatment with carotid artery stenting (CAS) and administration of recombinant tissue plasminogen activator (rtPA) increased the odds of complications and death. With regards to economic measures, administration of rtPA and utilization of CAS drove cost and length-of-stay up, while lower co-morbidity burden and earlier time to revascularization drove both measures down. CONCLUSIONS: The present study suggests that the optimum timing of revascularization may be near the end of the first week of hospitalization following acute stroke. However, this study must be cautioned with limitations including its inability to control for critical disease specific variables including symptom severity and degree of stenosis. Prospective examination seems warranted.

Stenting versus endarterectomy and the impact of ultra-early revascularization for emergent admissions of carotid artery stenosis.

BACKGROUND: The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated. METHODS: We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention. RESULTS: 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality. CONCLUSIONS: Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted.

Treatment of large and giant intracranial aneurysms: cost comparison of flow diversion and traditional embolization strategies.

OBJECTIVE: Flow diversion has emerged as a promising strategy for management of intracranial aneurysms. The purpose of this study was to determine whether treatment of large and giant aneurysms with the pipeline embolization device (PED) is more economical than traditional embolization strategies. METHODS: We identified 30 consecutive aneurysms larger than 10 mm that were treated with PED at our institution. For each aneurysm treated with PED, theoretical coil embolization was performed by filling volume in a consistent, stepwise fashion until a packing density of 25% was reached. Prices of all equipment and implants were taken from price lists provided by each manufacturer. RESULTS: Median aneurysm volume was 0.90 cm(3). Overall procedure cost was lower with the PED (mean, $23,911) vs. coiling ($30,522, P = .06). Above the median aneurysm volume, PED treatment was significantly less expensive than coiling even if multiple PEDs were used (P = .006). However, below the median aneurysm volume, PED treatment was significantly more expensive than coiling (P = .009). Treatment with multiple PEDs was not cost-beneficial compared with coiling, even above the median aneurysm volume. Potential savings associated with the PED were highly dependent on the type of embolic agent used. CONCLUSIONS: The cost of initial treatment of large and giant aneurysms with PED is economically favorable compared to traditional embolization techniques. However, any potential cost benefit depends on aneurysm volume, coil type, and number of PEDs used. Accordingly, PED therapy is more expensive than coiling in aneurysms <0.9 cm(3) or when multiple devices are used.

When is carotid angioplasty and stenting the cost-effective alternative for revascularization of symptomatic carotid stenosis? A Canadian health system perspective.

BACKGROUND AND PURPOSE: Carotid revascularization procedures can be complicated by stroke. Additional disability adds to the already high costs of the procedure. To weigh the cost and benefit, we estimated the cost-utility of carotid angioplasty and stenting compared with carotid endarterectomy among patients with symptomatic carotid stenosis, with special emphasis on scenario analyses that would yield carotid angioplasty and stenting as the cost-effective alternative relative to carotid endarterectomy. MATERIALS AND METHODS: A cost-utility analysis from the perspective of the health system payer was performed by using a Markov analytic model. Clinical estimates were based on a meta-analysis. The procedural costs were derived from a microcosting data base. The costs for hospitalization and rehabilitation of patients with stroke were based on a Canadian multicenter study. Utilities were based on a randomized controlled trial. RESULTS: In the base case analysis, carotid angioplasty and stenting were more expensive (incremental cost of $6107) and had a lower utility (-0.12 quality-adjusted life years) than carotid endarterectomy. The results are sensitive to changes in the risk of clinical events and the relative risk of death and stroke. Carotid angioplasty and stenting were more economically attractive among high-risk surgical patients. For carotid angioplasty and stenting to become the preferred option, their costs would need to fall from more than $7300 to $4350 or less and the risks of the periprocedural and annual minor strokes would have to be equivalent to that of carotid endarterectomy. CONCLUSIONS: In the base case analysis, carotid angioplasty and stenting were associated with higher costs and lower utility compared with carotid endarterectomy for patients with symptomatic carotid stenosis. Carotid angioplasty and stenting were cost-effective for patients with high surgical risk.

Cost-effectiveness of two endovascular treatment strategies vs intravenous thrombolysis.

OBJECTIVE: To assess the cost-effectiveness of endovascular treatment against intravenous thrombolysis (IVT) when varying assumptions concerning its effectiveness. METHODS: We developed a health economic model including a hypothetical population consisting of patients with ischemic stroke, admitted within 4.5 h from onset, without contraindications for IVT or intra-arterial treatment (IAT). A decision tree and life table were used to assess 6-month and lifetime costs (in Euros) and effects in quality-adjusted life years treatment with IVT alone, IAT alone, and IVT followed by IAT if the patient did not respond to treatment. Several analyses were performed to explore the impact of considerable uncertainty concerning the clinical effectiveness of endovascular treatment. RESULTS: Probabilistic sensitivity analysis demonstrated a 54% probability of positive incremental lifetime effectiveness of IVT-IAT vs IVT alone. Sensitivity analyses showed significant variation in outcomes and cost-effectiveness of the included treatment strategies at different model assumptions. CONCLUSIONS: Acceptable cost-effectiveness of IVT-IAT compared to IVT will only be possible if recanalization rates are sufficiently high (>50%), treatment costs of IVT-IAT do not increase, and complication rates remain similar to those reported in the few randomized studies published to date. Large randomized studies are needed to reduce the uncertainty concerning the effects of endovascular treatment.

Cost-effectiveness analysis of therapy for symptomatic carotid occlusion: PET screening before selective extracranial-to-intracranial bypass versus medical treatment.

UNLABELLED: The St. Louis Carotid Occlusion Study (STLCOS) demonstrated that increased cerebral oxygen extraction fraction (OEF) detected by PET scanning predicted stroke in patients with symptomatic carotid occlusion. Consequently, a trial of extracranial-to-intracranial (EC/IC) arterial bypass for these patients was proposed. The purpose of this study was to examine the cost-effectiveness of using PET in identifying candidates for EC/IC bypass. METHODS: A Markov model was created to estimate the cost-effectiveness of PET screening and treating a cohort of 45 symptomatic patients with carotid occlusion. The primary outcome was incremental cost for PET screening and EC/IC bypass (if OEF was elevated) per incremental quality-adjusted life year (QALY) saved. Rates of stroke and death with surgical and medical treatment were obtained from EC/IC Bypass Trial and STLCOS data. Costs were estimated from the literature. Sensitivity analyses were performed for all assumed variables, including the PET OEF threshold used to select patients for surgery. RESULTS: In the base case, PET screening of the cohort followed by EC/IC bypass on 36 of the 45 patients yielded 23.2 additional QALYs at a cost of $20,000 per QALY, compared with medical therapy alone. A more specific PET threshold, which identified 18 surgical candidates, gained 22.6 QALYs at less cost than medical therapy alone. The results were sensitive to the perioperative stroke rate and the stroke risk reduction conferred by EC/IC bypass surgery. CONCLUSION: If postoperative stroke rates are similar to stroke rates observed in the EC/IC Bypass Trial, EC/IC bypass will be cost-effective in patients with symptomatic carotid occlusion who have increased OEF. A clinical trial of medical therapy versus PET followed by EC/IC bypass (if OEF is elevated) is warranted.

Resource utilization and pathways: meeting the challenge of cost containment.

The 1990s will bring sweeping changes with managed care and capitation. To address this cost/quality paradox, selective intensive care utilization is coupled with clinical pathways as an innovative change for all patients having cerebral revascularization (CVR) or femoral revascularization (FR). From January 1, 1991 through June 30, 1995, data were accumulated on 2023 procedures in 1524 patients. The study was based on 848 CVRs and 1175 FRs. Intensive care unit (ICU) observation was necessary in 73 patients (3.6%) for cardiac or hypertensive management. Twenty-six patients (1.2%) transported to a vascular surgical floor from the postanesthesia recovery room required return to an ICU for complications during hospitalization. There were nine strokes or transient ischemic attacks (0.4%) in the CVR group, four myocardial infarctions (0.2%), and five perioperative deaths (0.3%). In the FR group, there were 14 deaths (0.9%). Readmission during the perioperative period, 30 days, was necessary in 46 patients (3.1%). Financial cost analysis revealed the mean adjusted cost for CVR in 1990 adjusted to 1995 dollars was $7223. The institution of case management reduced this to $4490 (37.8 per cent reduction in total hospital costs). The cost for FR in 1990 dollars adjusted to 1995 was $14,332 reduced to $5541 (a 59 per cent reduction in total hospital costs). This study suggests the use of clinical pathways does not impair quality of care, leads to no higher morbidity or mortality, and can produce significant cost savings to a hospital.

Case management in cerebral revascularization.

PURPOSE: We examined the clinical and financial outcomes of case management coupled with the initiation of selective use of the intensive care unit (ICU) in all cerebral revascularization procedures. METHODS: Three hundred eighty-four procedures in 331 patients were retrospectively reviewed. Morbidity and mortality rates, hospital length of stay, cost, and ICU or hospital readmissions were examined. Hypertension was examined as an independent variable for its effect on patient outcome. RESULTS: Cerebral revascularization, including carotid endarterectomy, vertebral-carotid artery transposition, and subclavian-carotid artery transposition, yielded a 0.78% stroke rate and 0.26% perioperative death rate in this series. ICU admission was necessary in nine patients (2.3%) for cardiac or respiratory instability. Three patients (0.78%) required transfer to the ICU for management of hypertension or hypotension. The mean hospital length of stay after institution of case management was reduced by 2.1 days, and the mean cost was decreased by $1987, a savings of 28.9% of total hospital cost. CONCLUSION: The dual approach of case management and selective use of the ICU promotes quality patient care, conserves financial resources without adversely affecting morbidity or mortality rates, enhances physician/nurse collaboration, and improves patient satisfaction.

Medicare program; withdrawal of coverage of extracranial-intracranial arterial bypass surgery for the treatment or prevention of stroke--HCFA. Final notice.

This notice announces the withdrawal of Medicare coverage of extracranial-intracranial (EC-IC) arterial bypass surgery when used to treat or prevent ischemic cerebrovascular disease of the carotid or middle cerebral arteries. Available evidence does not show that this surgery is effective.

Medicare program; withdrawal of coverage of extracranial-intracranial arterial bypass surgery for the treatment or prevention of stroke--HCFA. Proposed notice.

This notice announces the Medicare program's intent to withdraw Medicare coverage of extracranial-intracranial (EC-IC) arterial bypass surgery when used to treat or prevent ischemic cerebrovascular disease of the carotid or middle cerebral arteries. Available evidence does not show that this surgery is effective.