Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series.

BACKGROUND: Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE: To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS: Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS: The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION: Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

The Effect of Hospital Transfer on Patient Outcomes After Rehabilitation for Spinal Injury.

OBJECTIVE: Spine fractures, including associated spinal cord injury, account for 3%-6% of all skeletal fractures annually in the United States. Patients who undergo interhospital transfer after injury may have a greater likelihood of nonroutine disposition, longer hospital stay, and higher cost. We evaluated the effects of patient transfer on functional outcomes after spine trauma. METHODS: Patients were treated after acute traumatic spine injury at a rehabilitation hospital in 2011-2017. Compared patients were those directly admitted to the tertiary hospital or transferred from a community hospital. RESULTS: A total of 188 patients (mean age 46.1 ± 18.6 years, 77.1% men) were evaluated, including 130 (69.1%) directly admitted and 58 (30.9%) transferred patients. The most common levels of injury were at C5 (19.1%) and C6 (12.2%), and most injuries were American Spinal Injury Association injury severity score grade D (33.2%) or grade A (32.1%). No statistical difference in age, injury pattern, timing from injury to surgery, or rehabilitation length of stay was seen between admitted and transferred patients. A significant improvement in ambulation distances was seen at discharge for directly admitted compared with transferred patients (447.7 ± 724.9 vs. 159.9 ± 359.5 feet; P = 0.005). However, no significant difference primary outcomes, namely American Spinal Injury Association injury severity score distribution (P = 0.2) or Functional Independence Measures (Δ30.9 ± 15.9 vs. 30.1 ± 17.1; P = 0.7), were seen between admitted and transferred patients at time of rehabilitation discharge. CONCLUSIONS: Interhospital transfer status did not diminish time to rehabilitation after injury or reduce functional recovery, suggesting early surgical treatment in community settings may have merit prior to transfer.

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.

Cost Analysis of Inpatient Rehabilitation after Spinal Injury: A Retrospective Cohort Analysis.

Objective The lifetime direct and indirect costs of spinal injury and spinal cord injury (SCI) increase as the severity of injury worsens. Despite the potential for substantial improvement in function with acute rehabilitation, the factors affecting its cost have not yet been evaluated. We used a proprietary hospital database to evaluate the direct costs of rehabilitation after spine injury. Methods A single-center, retrospective cohort cost analysis of patients with acute, traumatic spine injury treated at a tertiary facility from 2011 to 2017 was performed. Results In the 190 patients (mean age 46.1 ± 18.6 years, 76.3% males) identified, American Spinal Injury Association impairment scores on admission were 32.1% A, 14.7% B, 14.7% C, 33.2% D, and 1.1% E. Surgical treatment was performed in 179 (94.2%) cases. Most injuries were in the cervical spine (53.2%). A mean improvement of Functional Impairment Score of 30.7 ± 16.2 was seen after acute rehabilitation. Costs for care comprised facility (86.5%), pharmacy (9.2%), supplies (2.0%), laboratory (1.5%), and imaging (0.8%) categories. Injury level, injury severity, and prior inpatient surgical treatment did not affect the cost of rehabilitation. Higher injury severity (p = 0.0001, one-way ANOVA) and spinal level of injury (p = 0.001, one-way ANOVA) were associated with higher length of rehabilitation stay in univariate analysis. However, length of rehabilitation stay was the strongest independent predictor of higher-than-median cost (risk ratio = 1.56, 95% CI 1.21-2.0, p = 0.001) after adjusting for other factors. Conclusions Spine injury has a high upfront cost of care, with greater need for rehabilitation substantially affecting cost. Improving the efficacy of rehabilitation to reduce length of stay may be effective in reducing cost.

Initial Treatment for Unruptured Intracranial Aneurysm and Its Follow-up: A Cost Analysis of Pipeline Flow Diverters versus Coiling.

Purpose Intracranial aneurysms are relatively common epidemiological problems for which the surveillance, treatment, and follow-up are costly. Although multiple studies have evaluated the treatment cost of aneurysms, the follow-up costs are often not examined. In our study, we analyzed how follow-up costs after treatment affected the overall cost of different endovascular techniques for treating aneurysms. Materials and methods An institutional database was used to evaluate the upfront and follow-up costs incurred by patients who underwent elective coiling or placement of a pipeline embolization device (PED) for the treatment of unruptured intracranial aneurysms from July 2011 to December 2017. Results A total of 114 patients (coiling, n = 37; PED, n = 77 ) were included in the study. There was no significant difference among patients in mean age [61.3 (±12.8 years) vs. 57.0 (±14.5 years); probability value (p) = 0.2], sex (male: 32.4% vs. 22.1%; p = 0.2), American Society of Anesthesiologists (ASA) grade (p = 0.5), discharge disposition (p = 0.1), mean length of stay [3.1 days (±5.5) vs. 2.4 days (±2.6); p = 0.2) or follow-up period [22.7 months (±18.5) vs. 18.6 months (±14.9); p = 0.2). There were no differences in costs during admission (p = 0.5) or in follow-up (p = 0.3) between coiling and PED treatments. Initial costs were predominantly related to supplies/implants (56.1% vs. 63.7%) for both treatments. Follow-up costs mostly comprised facility costs (68.2% vs. 67.5%), and there were no differences in costs of subgroups such as supplies/implants (10.5% vs. 9.4%), imaging (17.0% vs. 17.8%), or facilties between coiling and PED. Conclusion These results suggest that the upfront and follow-up costs are mostly similar for the treatment of intracranial aneurysms irrespective of whether the providers used coiling or PED endovascular techniques. Hence, we conclude that follow-up costs should not be a deciding factor when considering these treatments.

Effect of patient age on glioblastoma perioperative treatment costs: a value driven outcome database analysis.

INTRODUCTION: Identification of groups of patients or interventions with higher associated treatment costs may be beneficial in efforts to decrease the overall financial burden of glioblastoma (GBM) treatment. The authors' objective was to evaluate perioperative surgical treatment cost differences between elderly and nonelderly patients with GBM using the Value Driven Outcome (VDO) database. METHODS: The authors obtained data from a retrospective cohort of GBM patients treated surgically (resection or biopsy) at their institution from August 2011 to February 2018. Data were compiled using medical records and the VDO database. RESULTS: A total of 181 patients with GBM were included. Patients were grouped into age < 70 years at time of surgery (nonelderly; n = 121) and ≥ 70 years (elderly; n = 60). Costs were approximately 38% higher in the elderly group on average (each patient was mean 0.68% of total cohort cost vs. 0.49%, p = 0.044). Higher age significantly, but weakly, correlated with higher treatment cost on linear regression analysis (p = 0.007; R2 = 0.04). Length of stay was significantly associated with increased cost on linear regression (p < 0.001, R2 = 0.84) and was significantly longer in the elderly group (8.7 ± 11.3 vs. 5.2 ± 4.3 days, p = 0.025). The cost breakdown by facility, pharmacy, supply/implants, imaging, and laboratory costs was not significantly different between age groups. Elderly patients with any postoperative complication had 2.1 times greater total costs than those without complication (p = 0.094), 2.9 times greater total costs than nonelderly patients with complication (p = 0.013), and 2.3 times greater total costs than nonelderly patients without complication (p = 0.022). CONCLUSIONS: GBM surgical treatment costs are higher in older patients, particularly those who experience postoperative complications.

Evaluation of cost and survival in intracranial gliomas using the Value Driven Outcomes database: a retrospective cohort analysis.

OBJECTIVE: Gliomas occur in 3-4 individuals per 100,000 individuals and are one of the most common primary brain tumors. Treatment options are limited for gliomas despite the progressive nature of the disease. The authors used the Value Driven Outcomes (VDO) database to identify cost drivers and subgroups that are involved in the surgical treatment of gliomas. METHODS: A retrospective cohort of patients with gliomas treated at the authors' institution from August 2011 to February 2018 was evaluated using medical records and the VDO database. RESULTS: A total of 263 patients with intracranial gliomas met the authors' inclusion criteria and were included in the analysis (WHO grade I: 2.0%; grade II: 18.5%; grade III: 18.1%; and grade IV: 61.4%). Facility costs were the major (64.4%) cost driver followed by supplies (16.2%), pharmacy (10.1%), imaging (4.5%), and laboratory (4.7%). Univariate analysis of cost contributors demonstrated that American Society of Anesthesiologists physical status (p = 0.002), tumor recurrence (p = 0.06), Karnofsky Performance Scale score (p = 0.002), length of stay (LOS) (p = 0.0001), and maximal tumor size (p = 0.03) contributed significantly to the total costs. However, on multivariate analysis, only LOS (p = 0.0001) contributed significantly to total costs. More extensive tumor resection in WHO grade III and IV tumors was associated with significant improvement in survival (p = 0.004 and p = 0.02, respectively). CONCLUSIONS: Understanding care costs is challenging because of the highly complex, fragmented, and variable nature of healthcare delivery. Adopting effective strategies that would reduce facility costs and limit LOS is likely the most important aspect in reducing intracranial glioma treatment costs.

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.

Evaluating the Landscape of Clinical Research in Neurosurgery.

BACKGROUND: Many clinical trials and observational research never reach publication in peer-reviewed journals. Unpublished research results, including neutral study findings, hinder generation of new research questions, utilize healthcare resources without benefit, and may place patients at risk without benefit. OBJECTIVE: To examine the publication of neurosurgery trials listed in ClinicalTrials.gov. METHODS: Clinical neurosurgery research was identified by searching the registry and categorized by study type. Associated publications were identified on Pubmed.gov. RESULTS: Among the 709 studies identified, spine (292, 41.2%) studies were most common, followed by tumor and cranial (each 114, 16.1%). Funding was predominantly private (482, 68.0%), followed by industry (135, 19.0%) and National Institutes of Health (9, 1.3%). A lower proportion of published studies (vs unpublished) received private funding in functional (33.3 vs 65.3%) and tumor (80.0 vs 68.7%). Only 104/464 (22.4%) studies had an associated publication. The mean time from listed study completion to first publication was 31.0 ± 27.5 mo. Most published studies had significant study differences between treatment arms (n = 72, 69.2%); studies with neutral findings were less likely to be published (n = 13, 12.5%). Surgical discipline (P = .1), funding source (P = .8), patient age (P = .4), planned enrollment (P = .1), phase of trial (P = .3), and study type (P = .2) did not affect publication rates. However, the interaction between study category and funding source significantly affected publication rate (P = .04, generalized linear model, R2 = 0.05). Publication timing (1-way analysis of variance, P = .5) and frequency (chi-square, P = .2) did not differ among disciplines. CONCLUSION: Clinical trials and observational research in neurosurgery are often not published promptly, especially if results were nonsignificant or the trial had private funding.