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Guinto G, Guinto-Nishimura GY, Sangrador-Deitos MV, Uribe-Pacheco R, Soto-Martinez R, Gallardo D, Guinto P, Vargas A, Aréchiga N. Current and Future Perspectives of Microscopic and Endoscopic Transsphenoidal Surgery for Pituitary Adenomas: A Narrative Review. Arch Med Res 2023; 54:102872. [PMID: 37633807 DOI: 10.1016/j.arcmed.2023.102872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/09/2023] [Indexed: 08/28/2023]
Abstract
Transsphenoidal resection remains the standard treatment for most pituitary adenomas. However, the ideal surgical approach to safely access these lesions, either microsurgical or endoscopic, continues to be debated. Since the introduction of endoscopic transsphenoidal surgery, centers around the world have increasingly adopted this technique, experiencing a shift away from the conventional microsurgical approach. Large series reporting the efficacy and safety of endoscopic surgery have fueled a growing interest in comparing clinical outcomes between both approaches. Still, proving superiority of either surgical approach remains an elusive task due to the inherent drawbacks of surgical observational studies, as we are still faced with a growing body of evidence reporting conflicting results. Thus, a comprehensive discussion regarding the reach and limitations of both techniques becomes necessary. In this narrative review, we perform a critical appraisal of the literature and provide an expert opinion on the state-of-the-art in transsphenoidal surgery for pituitary adenomas. The advantages and limitations of each approach are assessed and compared from a technical standpoint, and their reported outcomes evaluated in the framework of this transition phase. Available evidence should be interpreted in light of individual patient characteristics and within the context of each medical center, taking into consideration the known impact that surgical expertise and multidisciplinary management hold on clinical outcomes.
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Affiliation(s)
| | - Gerardo Y Guinto-Nishimura
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico; Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | | | - Rodrigo Uribe-Pacheco
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | - Rene Soto-Martinez
- Hospital de Especialidades Centro Médico Nacional SXXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Miranda SP, Blue R, Parasher AK, Lerner DK, Glicksman JT, Detchou D, Dimentberg R, Thurlow J, Lebold D, Hudgins J, Ebesutani D, Lee JYK, Storm PB, O'Malley BW, Palmer JN, Yoshor D, Adappa ND, Grady MS. Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery. World Neurosurg 2023; 172:e357-e363. [PMID: 36640831 DOI: 10.1016/j.wneu.2023.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. METHODS We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. RESULTS One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021). CONCLUSIONS A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Blue
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Arjun K Parasher
- Department of Otolaryngology: Head and Neck Surgery, University of South Florida, Tampa, Florida, USA; College of Public Health, University of South Florida, Tampa, Florida, USA
| | - David K Lerner
- Department of Otolaryngology: Head and Neck Surgery, Icahn School of Mount Sinai, New York, New York, USA
| | - Jordan T Glicksman
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA; New England Ear Nose and Throat, Newton, Massachusetts, USA
| | - Donald Detchou
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ryan Dimentberg
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Thurlow
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lebold
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justine Hudgins
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darren Ebesutani
- Office of Clinical Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bert W O'Malley
- Department of Otolaryngology - Head and Neck Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - James N Palmer
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Yoshor
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M Sean Grady
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Caulley L, Krijkamp E, Doyle MA, Thavorn K, Alkherayf F, Sahlollbey N, Dong SX, Quinn J, Johnson-Obaseki S, Schramm D, Kilty SJ, Hunink MGM. Cost-effectiveness of direct surgery versus preoperative octreotide therapy for growth-hormone secreting pituitary adenomas. Pituitary 2022; 25:868-881. [PMID: 36030360 PMCID: PMC9675692 DOI: 10.1007/s11102-022-01270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE The objective of this study was to compare the cost-effectiveness of preoperative octreotide therapy followed by surgery versus the standard treatment modality for growth-hormone secreting pituitary adenomas, direct surgery (that is, surgery without preoperative treatment) from a public third-party payer perspective. METHODS We developed an individual-level state-transition microsimulation model to simulate costs and outcomes associated with preoperative octreotide therapy followed by surgery and direct surgery for patients with growth-hormone secreting pituitary adenomas. Transition probabilities, utilities, and costs were estimated from recent published data and discounted by 3% annually over a lifetime time horizon. Model outcomes included lifetime costs [2020 United States (US) Dollars], quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). RESULTS Under base case assumptions, direct surgery was found to be the dominant strategy as it yielded lower costs and greater health effects (QALYs) compared to preoperative octreotide strategy in the second-order Monte Carlo microsimulation. The ICER was most sensitive to probability of remission following primary therapy and duration of preoperative octreotide therapy. Accounting for joint parameter uncertainty, direct surgery had a higher probability of demonstrating a cost-effective profile compared to preoperative octreotide treatment at 77% compared to 23%, respectively. CONCLUSIONS Using standard benchmarks for cost-effectiveness in the US ($100,000/QALY), preoperative octreotide therapy followed by surgery may not be cost-effective compared to direct surgery for patients with growth-hormone secreting pituitary adenomas but the result is highly sensitive to initial treatment failure and duration of preoperative treatment.
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Affiliation(s)
- Lisa Caulley
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada.
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
- Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Eline Krijkamp
- Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mary-Anne Doyle
- Department of Medicine, Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fahad Alkherayf
- The Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Neurosurgery, University of Ottawa, Ottawa, Canada
| | - Nick Sahlollbey
- Department of Undergraduate Medicine, University of Ottawa, Ottawa, Canada
| | - Selina X Dong
- Department of Undergraduate Medicine, University of Ottawa, Ottawa, Canada
| | - Jason Quinn
- Department of Pathology, Dalhousie University, Halifax, Canada
| | - Stephanie Johnson-Obaseki
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - David Schramm
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Shaun J Kilty
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Myriam G M Hunink
- Department of Epidemiology and Biostatistics and Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, USA
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Parasher AK, Lerner DK, Glicksman JT, Lin T, Miranda SP, Ebesutani D, Kohanski M, Lee JYK, Storm PB, O’Malley BW, Yosher D, Palmer JN, Grady S, Adappa ND. In-Hospital Costs Associated With an Expanded Endonasal Approach to Anterior Skull Base Tumors. Ann Otol Rhinol Laryngol 2022. [DOI: 10.1177/00034894211067583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To determine in-hospital costs associated with performing an EEA to anterior skull base pathology and to identify drivers of cost variability for patients undergoing endoscopic anterior skull base surgery. Methods: All endoscopic anterior skull base surgeries performed over a period from January 1st, 2015 to October 24th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using Stata software. Results: An EEA was associated with an average total in-hospital cost of $44 545. Compared to patients undergoing a transsphenoidal approach to pituitary tumor resection, EEA patients incurred higher in-hospital costs across all variables including a total cost increase of $15 921 (95% confidence interval $5720-26 122, P = .002). Univariate analysis of all endoscopic anterior skull base surgery patients showed a cost increase of $30 616 associated with post-operative cerebrospinal fluid (CSF) leak ($10 420-50 811, P = .004), $14 610 with post-operative diabetes insipidus (DI) ($4610-24 609, P = .004), and $11 522 with African-American patients relative to Caucasian patients ($3049-19 995, P = .008). Conclusions: Patients who undergo endoscopic EEA for resection of anterior skull base tumors typically incur greater in-hospital costs than patients undergoing a standard TSA. Post-operative complications such as CSF leak and DI, as well as ethnicity, are significant drivers of cost-variability.
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Affiliation(s)
- Arjun K. Parasher
- Department of Otolaryngology—Head and Neck Surgery, University of South Florida, Tampa, FL, USA
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - David K. Lerner
- Department of Otolaryngology—Head and Neck Surgery, Icahn School of Mount Sinai, New York City, NY, USA
| | - Jordan T. Glicksman
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- New England Ear Nose and Throat, Newton, MA, USA
| | - Theodore Lin
- Department of Otolaryngology—Head and Neck Surgery, Temple University, Philadelphia, PA, USA
| | - Stephen P. Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Darren Ebesutani
- Office of Clinical Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Kohanski
- Department of Otorhinolaryngology—Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John Y. K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Phillip B. Storm
- Division of Neurosurgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Bert W. O’Malley
- Department of Otolaryngology—Head and Neck Surgery, University of Maryland, College Park, MD, USA
| | - Daniel Yosher
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - James N. Palmer
- Department of Otorhinolaryngology—Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Nithin D. Adappa
- Department of Otorhinolaryngology—Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Bitner BF, Lehrich BM, Abiri A, Yasaka TM, Hsu FPK, Kuan EC. Characteristics and overall survival in pediatric versus adult pituitary adenoma: a National Cancer Database analysis. Pituitary 2021; 24:714-723. [PMID: 33939058 DOI: 10.1007/s11102-021-01146-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Pituitary adenomas in the pediatric population are extremely rare, resulting in limited information in the literature on these patients. In this study, data from the National Cancer Database (NCDB) to compare pituitary adenoma clinical presentations, treatment management patterns, and overall survival between pediatric and adult patients. METHODS The NCDB was queried for all cases of histologically confirmed pituitary adenoma treated between 2004 and 2015. Patients were primarily stratified as either pediatric (< 18 years) or adult (≥ 18 years). Patient demographics/socioeconomics and resulting outcomes were then compared. RESULTS 1893 pediatric and 77,993 adult patients with pituitary adenomas were evaluated. Average tumor size for pediatric and adult patients was 13.6 ± 13.2 mm and 20.1 ± 13.1 mm, respectively (p < 0.001). Pediatric patients were more likely to undergo gross total resection, less likely to receive adjuvant radiation, more likely to receive medical therapy, more likely to undergo active surveillance, and exhibited improved 5-year and 10-year overall survival (OS) (all p < 0.001). Temporal analysis demonstrated a significant increase in endoscopic approach over time (from 48 to 65%) in the pediatric population (R2 = 0.722, p = 0.03). On univariate analysis in the pediatric population, African American race compared to Caucasians (HR: 5.85, 95% CI 1.79-19.2, p < 0.003), patients with government insurance compared to those with private insurance (HR: 5.07, 95% CI 1.31-19.6, p < 0.02) and uninsured patients compared to those with private insurance (HR: 14.4, 95% CI 2.41-86.5, p < 0.003) were associated with decreased OS. Lastly, patients who underwent GTR had improved OS compared to those who underwent subtotal resection (HR: 0.08, 95% CI 0.008-0.93, p < 0.04) in the pediatric population. CONCLUSIONS Compared to adults, children with pituitary adenomas more commonly underwent GTR, less frequently underwent adjuvant radiotherapy, more frequently underwent medical management and active surveillance, and had improved survival. Temporal analysis demonstrated increasing utilization of the endoscopic approach for surgical treatment of pediatric and adult pituitary adenoma patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Benjamin F Bitner
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Drive South, Irvine, Orange, CA, 92868, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, PA, USA
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Drive South, Irvine, Orange, CA, 92868, USA
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Drive South, Irvine, Orange, CA, 92868, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, 101 The City Drive South, Irvine, Orange, CA, 92868, USA.
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA.
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Dede MİC, Kiper G, Ayav T, Özdemirel B, Tatlıcıoğlu E, Hanalioglu S, Işıkay İ, Berker M. Human–Robot Interfaces of the NeuRoboScope: A Minimally Invasive Endoscopic Pituitary Tumor Surgery Robotic Assistance System. J Med Device 2021. [DOI: 10.1115/1.4049394] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Endoscopic endonasal surgery is a commonly practiced minimally invasive neurosurgical operation for the treatment of a wide range of skull base pathologies including pituitary tumors. A common shortcoming of this surgery is the necessity of a third hand when the endoscope has to be handled to allow active use of both hands of the main surgeon. The robot surgery assistant NeuRoboScope system has been developed to take over the endoscope from the main surgeon's hand while providing the surgeon with the necessary means of controlling the location and direction of the endoscope. One of the main novelties of the NeuRoboScope system is its human–robot interface designs which regulate and facilitate the interaction between the surgeon and the robot assistant. The human–robot interaction design of the NeuRoboScope system is investigated in two domains: direct physical interaction (DPI) and master–slave teleoperation (MST). The user study indicating the learning curve and ease of use of the MST is given and this paper is concluded via providing the reader with an outlook of possible new human–robot interfaces for the robot assisted surgery systems.
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Affiliation(s)
- Mehmet İsmet Can Dede
- Department of Mechanical Engineering, Izmir Institute of Technology, Urla, Izmir 35430, Turkey
| | - Gökhan Kiper
- Department of Mechanical Engineering, Izmir Institute of Technology, Urla, Izmir 35430, Turkey
| | - Tolga Ayav
- Department of Computer Engineering, Izmir Institute of Technology, Urla, Izmir 35430, Turkey
| | - Barbaros Özdemirel
- Department of Electrical and Electronics Engineering, Izmir Institute of Technology, Urla, Izmir 35430, Turkey
| | - Enver Tatlıcıoğlu
- Department of Electrical and Electronics Engineering, Ege University, Bornova, Izmir 35040, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Altındağ, Ankara 06230, Turkey
| | - İlkay Işıkay
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Altındağ, Ankara 06230, Turkey
| | - Mustafa Berker
- Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Altındağ, Ankara 06230, Turkey
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Parasher AK, Lerner DK, Glicksman JT, Miranda SP, Dimentberg R, Ebesutani D, Kohanski M, Lee JYK, Storm PB, O'Malley BW, Palmer JN, Grady MS, Adappa ND. Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery. Laryngoscope 2020; 131:760-764. [PMID: 32830866 DOI: 10.1002/lary.29041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/06/2020] [Accepted: 07/30/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery. METHODS All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software. RESULTS The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant. CONCLUSIONS Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives. LEVEL OF EVIDENCE 3 Laryngoscope, 131:760-764, 2021.
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Affiliation(s)
- Arjun K Parasher
- Department of Otolaryngology-Head and Neck Surgery, University of South Florida, Tampa, Florida, U.S.A.,College of Public Health, University of South Florida, Tampa, Florida, U.S.A
| | - David K Lerner
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Mount Sinai, New York City, New York, U.S.A
| | - Jordan T Glicksman
- Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Dimentberg
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Darren Ebesutani
- Office of Clinical Research, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Michael Kohanski
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - M Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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9
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Goshtasbi K, Lehrich BM, Abouzari M, Abiri A, Birkenbeuel J, Lan MY, Wang WH, Cadena G, Hsu FPK, Kuan EC. Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study. J Neurosurg 2020; 134:816-824. [PMID: 32168478 DOI: 10.3171/2020.1.jns193062] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/02/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE For symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA. METHODS The National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES. RESULTS Of 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04). CONCLUSIONS There is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.
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Affiliation(s)
- Khodayar Goshtasbi
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Brandon M Lehrich
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Mehdi Abouzari
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Arash Abiri
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Jack Birkenbeuel
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Ming-Ying Lan
- 2Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Hsin Wang
- 3Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Gilbert Cadena
- 4Department of Neurological Surgery, University of California, Irvine, California
| | - Frank P K Hsu
- 4Department of Neurological Surgery, University of California, Irvine, California
| | - Edward C Kuan
- 1Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
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10
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Caulley L, Rodin D, Kilty S, Randolph G, Hunink MG, Shin JJ. Evidence-Based Medicine in Otolaryngology Part 10: Cost-Effectiveness Analyses in Otolaryngology. Otolaryngol Head Neck Surg 2019; 161:375-387. [DOI: 10.1177/0194599819852104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Clinicians seek to pursue the most clinically effective treatment strategies, but costs have also become a key determinant in contemporary health care. Economic analyses have thus emerged as a valuable resource to both quantify and qualify the value of existing and emerging interventions and programs. Cost-effectiveness analyses estimate the benefits gained per monetary unit, providing insights to guide resource allocation. Herein, we delineate the related concepts and considerations to facilitate understanding and appraisal of these analyses, so as to better inform the stakeholders in our otolaryngology community.
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Affiliation(s)
- Lisa Caulley
- Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danielle Rodin
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Shaun Kilty
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Otolaryngology–Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Gregory Randolph
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Myriam G. Hunink
- Department of Epidemiology and Department of Radiology, Erasmus MC, Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jennifer J. Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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11
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Asemota AO, Ishii M, Brem H, Gallia GL. Costs and Their Predictors in Transsphenoidal Pituitary Surgery. Neurosurgery 2018; 85:695-707. [DOI: 10.1093/neuros/nyy441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/17/2018] [Indexed: 12/29/2022] Open
Abstract
Abstract
BACKGROUND
Contemporary surgical approaches to pituitary pathologies include transsphenoidal microsurgical and, more recently, endoscopic techniques. Data reporting direct costs in transsphenoidal pituitary surgery are limited.
OBJECTIVE
To examine direct costs (including overall total, hospital/facility, and physician payments) of microscopic and endoscopic pituitary surgery and evaluate predictors of differential costs in transsphenoidal pituitary surgery using a national database.
METHODS
The Truven MarketScan® database 2010-2014 (IBM, Armonk, New York) was queried and patients undergoing microscopic and/or endoscopic transsphenoidal pituitary surgery identified. Mean costs and predictors of differential costs were analyzed using analysis of variance and generalized linear models. Beta-coefficients (β) assessed relative contributions of independent predictors.
RESULTS
Mean overall total ($34 943.13 [SD ± 19 074.54]) and hospital/facility ($26 505.93 [SD ± 16 819.52]) payments were higher in endoscopic compared to microscopic surgeries (both P < .001). Lengths of hospital stay (LOS) were similar between groups. Predictors of overall total and hospital/facility payments were similar including surgical technique, age, geographical region, comorbidity index, postoperative surgical and medical complications, and LOS with LOS being the most significant predictor (β = 0.27 and β = 0.29, respectively). Mean physician payments ($4549.24 [SD ± 3956.27]) were similar in microscopic and endoscopic cohorts (P = .26). Predictors of physician payments included age, health plan, geographical region, postoperative surgical complications, and LOS with health plan being the most significant predictor (β = –0.21).
CONCLUSION
Higher overall total and hospital/facility costs are associated with endoscopic transsphenoidal pituitary surgery compared to microsurgery. In contrast, physician reimbursements are similar between techniques. Whereas LOS was the strongest predictor of overall total and hospital/facility costs, health plan was the strongest predictor of differential physician reimbursements.
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Affiliation(s)
- Anthony O Asemota
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Masaru Ishii
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
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12
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Ryu WHA, Yang MMH, Muram S, Jacobs WB, Casha S, Riva-Cambrin J. Systematic review of health economic studies in cranial neurosurgery. Neurosurg Focus 2018; 44:E2. [PMID: 29712519 DOI: 10.3171/2018.2.focus17792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE As the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures. METHODS The authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion. RESULTS In total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection. CONCLUSIONS There is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.
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Affiliation(s)
- Won Hyung A Ryu
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Michael M H Yang
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Sandeep Muram
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - W Bradley Jacobs
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Steven Casha
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
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13
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Guo Z, Liu C, Hou H, Li R, Su J, Zhang F, Xing G, Qian L, Qiu J, Xie Y, Zhu N. Preoperative Computed Tomography (CT) Evaluation of Anatomical Abnormalities in Endonasal Transsphenoidal Approach in Pituitary Adenoma. Med Sci Monit 2018; 24:1268-1275. [PMID: 29497027 PMCID: PMC5844192 DOI: 10.12659/msm.904402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study aimed to retrospectively analyze patient clinical data to investigate the effects of computed tomography (CT) reconstruction and the measurement of abnormal structures in the endonasal sphenoidal sinus approach on the operative effects in patients undergoing pituitary adenoma resection. MATERIAL AND METHODS The records of 53 patients who underwent pituitary adenoma resection via the endonasal transsphenoidal approach in the Neurosurgery Department of Tai'an City Central Hospital from December 2010 to June 2016 were analyzed retrospectively. All cases showed anatomical abnormalities in the endonasal transsphenoidal approach that were detected by conventional CT scans. The clinical data of the patients were reviewed. After review, 26 patients who underwent preoperative CT reconstruction and measurement of abnormal structures before surgery were included in the observation group (CT reconstruction group), and 27 patients who did not undergo CT reconstruction and measurement of abnormal structures were included in the control group. Data on intraoperative blood loss, surgical time, hospital stay, and postoperative complications were collected to assess the quality of the surgery. RESULTS Compared with the control group, the observation group showed less blood loss (p<0.001), a shorter operation time (p<0.001), fewer postoperative complications (p<0.001), and a shorter hospital stay (p<0.001). CONCLUSIONS Preoperative CT reconstruction and measurement of abnormal structures in patients undergoing pituitary adenoma resection by the endonasal transsphenoidal approach can improve operative quality and reduce complications.
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Affiliation(s)
- Zhengyi Guo
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Chunli Liu
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Haifeng Hou
- Taishan Medical University, Taian, Shandong, China (mainland)
| | - Ruiying Li
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Jichun Su
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Fuyong Zhang
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Guoqiang Xing
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Linlin Qian
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Jianfeng Qiu
- Taishan Medical University, Taian, Shandong, China (mainland)
| | - Yuanzhong Xie
- Taian City Central Hospital, Taian, Shandong, China (mainland)
| | - Ningxi Zhu
- Taian City Central Hospital, Taian, Shandong, China (mainland)
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14
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Cost-Effectiveness of Endoscopic Versus Microscopic Transsphenoidal Surgery for Pituitary Adenoma. World Neurosurg 2018; 110:e496-e503. [DOI: 10.1016/j.wneu.2017.11.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/05/2017] [Accepted: 11/07/2017] [Indexed: 12/17/2022]
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15
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Assessment of Cost Drivers in Transsphenoidal Approaches for Resection of Pituitary Tumors Using the Value-Driven Outcome Database. World Neurosurg 2017; 105:818-823. [DOI: 10.1016/j.wneu.2017.05.148] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 02/07/2023]
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16
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Rudmik L, Mattos JL, Stokken JK, Soler ZM, Manes RP, Higgins TS, Setzen M, Lee J, Schneider J. Rhinology-specific priority setting for quality improvement: a modified Delphi study from the Quality Improvement Committee of the American Rhinologic Society. Int Forum Allergy Rhinol 2017; 7:937-944. [PMID: 28799731 DOI: 10.1002/alr.21998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Improving the quality of healthcare is a complex and resource intensive process. To optimize the allocation of scarce resources, quality improvement (QI) should focus on high-value diseases that will produce the largest improvement in health system performance. Given the breadth and multidisciplinary nature of sinonasal disease management, the purpose of this study was to transparently develop a prioritized list of sinonasal diseases for QI from the perspective of the specialty of rhinology and the American Rhinologic Society (ARS). METHODS The RAND modified Delphi methodology was used to rank the priority of nine sinonasal disease categories from 1 (lowest priority) to 9 (highest priority). Two rounds of ranking along with a teleconference meeting was performed by a panel of 9 experts from the ARS Quality Improvement Committee. RESULTS The final QI-prioritized list of sinonasal diseases are as follows: chronic rhinosinusitis (CRS) (mean score = 8.9), recurrent acute rhinosinusitis (RARS) (mean score = 7.9), sinonasal neoplasms (mean score = 7.0), anatomic nasal obstruction (mean score = 5.9), refractory epistaxis (mean score = 5.2), complicated acute rhinosinusitis (mean score = 5.2), chronic nonallergic rhinitis (mean score = 4.4), orbital disease (mean score = 4.3), uncomplicated acute rhinosinusitis (mean score = 4.1), and allergy/allergic rhinitis (mean score = 3.7). CONCLUSION The three most important disease categories for QI from the perspective of the specialty of rhinology were CRS, RARS, and sinonasal neoplasms. Future studies need to define and validate quality metrics for each of these important disease categories in order to facilitate appropriate measurement and improvement initiatives.
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Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Jose L Mattos
- Department of Otolaryngology-Head and Neck Surgery; University of Virginia School of Medicine, Charlotteville, VA
| | - Janalee K Stokken
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - R Peter Manes
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Thomas S Higgins
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, Louisville, KY
| | - Michael Setzen
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY
| | - Jivianne Lee
- Department of Otolaryngology-Head and Neck Surgery University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - John Schneider
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St. Louis, MO
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17
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Eseonu CI, ReFaey K, Garcia O, Salvatori R, Quinones-Hinojosa A. Comparative Cost Analysis of Endoscopic versus Microscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas. J Neurol Surg B Skull Base 2017; 79:131-138. [PMID: 29868317 DOI: 10.1055/s-0037-1604484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/17/2017] [Indexed: 12/14/2022] Open
Abstract
Objective This study presents a comparative analysis of cost efficacy between the microscopic and endoscopic transsphenoidal approaches, evaluating neurological outcome, extent of resection (EOR), and inpatient hospital costs. Design This study was a retrospective chart review. Setting This study was conducted at a tertiary care center. Participants The study group consisted of 68 patients with transsphenoidal surgeries between January 2007 and January 2014. Main Outcome Measures Two-sample t -tests and Pearson's chi-square test evaluated inpatient costs, quality-adjusted life years (QALYs), volumetric EOR, and neurological outcomes. Results Total inpatient costs per patient was $22,853 in the microscopic group and less ($19,736) in the endoscopic group ( p = 0.049). Operating room costs were $5,974 in the microscopic group and lower in the endoscopic group ($5,045; p = 0.038). Operative time was 203.6 minutes in the microscopic group and 166.3 minutes in the endoscopic group ( p = 0.032). The QALY score, length of hospital stay, and postoperative outcomes were found to be similar between the two cohorts. Multivariate linear regression modeling suggested that length of stay ( p < 0.001) and operative time ( p = 0.008) were important factors that influenced total inpatient costs following transsphenoidal surgery. Conclusion This study shows that transsphenoidal surgery is more cost effective with the endoscopic approach than with the microscopic approach and depends on efficiency in the operating room as well as reduction in the length of hospitalization.
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Affiliation(s)
| | - Karim ReFaey
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Oscar Garcia
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States
| | - Roberto Salvatori
- Department of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, Maryland, United States
| | - Alfredo Quinones-Hinojosa
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States.,Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, United States
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18
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Azad TD, Lee YJ, Vail D, Veeravagu A, Hwang PH, Ratliff JK, Li G. Endoscopic vs. Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes. Front Surg 2017; 4:33. [PMID: 28691009 PMCID: PMC5479879 DOI: 10.3389/fsurg.2017.00033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 06/06/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce, with conflicting reports of cost and clinical outcome advantages. OBJECTIVE To determine if the proposed benefits of endoscopic resection are realized on a population level. METHODS We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions. Coarsened matching was applied to estimate the effects of surgical approach on complication rates, length of stay (LOS), costs, and likelihood of postoperative radiation. RESULTS We found that LOS, readmission, and revision rates did not differ significantly between approaches. The overall complication rate was higher for endoscopy (47% compared to 39%, OR 1.37, 95% CI 1.22-1.53). Endoscopic approach was associated with greater risk of neurological complications (OR 1.32, 95% CI 1.11-1.55), diabetes insipidus (OR 1.65, 95% CI 1.37-2.00), and cerebrospinal fluid rhinorrhea (OR 1.83, 95% CI 1.07-3.13) compared to the microscopic approach. Although the total index payment was higher for patients receiving endoscopic resection ($32,959 compared to $29,977 for microscopic resection), there was no difference in long-term payments. Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery (OR 0.67, 95% CI 0.49-0.90) and intensity-modulated radiation therapy (OR 0.78, 95% CI 0.65-0.93). CONCLUSION Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation. Although there are evident advantages to transsphenoidal endoscopy, our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yu-Jin Lee
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, CA, United States
| | - Daniel Vail
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Peter H Hwang
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, CA, United States
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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19
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Nishioka H. Recent Evolution of Endoscopic Endonasal Surgery for Treatment of Pituitary Adenomas. Neurol Med Chir (Tokyo) 2017; 57:151-158. [PMID: 28239067 PMCID: PMC5409268 DOI: 10.2176/nmc.ra.2016-0276] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
For the treatment of pituitary tumors, microscopic transsphenoidal surgery has been considered the "gold standard" since the late 1960s. Over the last two decades, however, a worldwide shift towards endoscopic endonasal surgery is in progress for many reasons. These include a wide panoramic view, improved illumination, an ability to look around anatomical corners using angled tip and, in addition, application to the extended approaches for parasellar tumors. Both endoscopic and microscopic approaches appear equally effective for nonfunctioning adenomas without significant suprasellar or lateral extensions, whereas the endoscopic approach may improve outcomes associated with the extent of resection and postoperative complications for larger tumors. Despite many theoretical benefits in the endoscopic surgery, remission rates of functioning adenomas do not substantially differ between the approaches in experienced hands. The endoscopic approach is a valid alternative to the microscopic approach for adenomas. The benefits will be more appreciated in the extended surgery for parasellar tumors.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Research
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20
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Efficacy of Microsurgical Sublabial Approach (MSA) Versus Endoscopic Endonasal Approach (EEA) for the Treatment of Pituitary Adenomas Based on Radiological and Hormonal Outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017; 124:101-106. [PMID: 28120060 DOI: 10.1007/978-3-319-39546-3_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The purpose of this study was to compare the surgical efficacy of the microsurgical sublabial approach (MSA) versus the endoscopic endonasal approach (EEA) for the treatment of pituitary adenomas, based on short-term (12 months) radiological and endocrinological follow-up. METHODS One hundred and fourteen patients affected by pituitary adenoma were enrolled at our Unit between January 2007 and February 2012; 72 were treated with MSA, and 42 with EEA. The preoperative parameters considered were: type of lesion (secreting or nonsecreting), lesion size, presence of intralesional hemorrhage, lesion perimeter (nodular vs. uniform), intrasellar vs. suprasellar, involvement of cavernous sinus, and osteodural infiltration. Hormonal assays and magnetic resonance imaging (MRI) scans were performed at 12 months after the surgical procedure. RESULTS Univariate analysis of the data documented a statistically significant difference in favor of MSA for the subgroups of secreting adenomas (90.9 % vs. nonsecreting 48.3 %), microadenomas (100 % vs. macroadenomas 57.1 %), adenomas without osteodural infiltration (87.5 % vs. 55.5 % with the infiltration) or those without intralesional hemorrhage (75 % vs. 45.9 % with the hemorrhage), and growth hormone (GH) adenomas (88.8 % vs. 43.7 %). Multivariate analysis confirmed the greater effectiveness of MSA for the treatment of micro-secreting adenomas. CONCLUSIONS Recent advances in the EEA for treating pituitary adenomas could lead to this modality replacing the microsurgical technique. In our experience the MSA allowed us to achieve better results in the treatment of microadenomas.
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21
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Hojjat H, Svider PF, Davoodian P, Hong RS, Folbe AJ, Eloy JA, A. Shkoukani M. To image or not to image? A cost-effectiveness analysis of MRI for patients with asymmetric sensorineural hearing loss. Laryngoscope 2016; 127:939-944. [DOI: 10.1002/lary.26231] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/23/2016] [Accepted: 07/18/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Houmehr Hojjat
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Pedram Davoodian
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Robert S. Hong
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Michigan Ear Institute; Farmington Hills Michigan U.S.A
| | - Adam J. Folbe
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Department of Neurosurgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Department of Neurological Surgery; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Department of Ophthalmology and Visual Science; Rutgers New Jersey Medical School; Newark New Jersey U.S.A
- Center for Skull Base and Pituitary Surgery; Neurological Institute of New Jersey; Newark New Jersey U.S.A
| | - Mahdi A. Shkoukani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Surgical Service, Section of Otolaryngology; John D. Dingell VA Medical Center; Detroit Michigan U.S.A
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Hojjat H, Svider PF, Folbe AJ, Raza SN, Carron MA, Shkoukani MA, Merati AL, Mayerhoff RM. Cost-effectiveness of routine computed tomography in the evaluation of idiopathic unilateral vocal fold paralysis. Laryngoscope 2016; 127:440-444. [DOI: 10.1002/lary.26152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 05/07/2016] [Accepted: 05/31/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Houmehr Hojjat
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Adam J. Folbe
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
- Department of Neurosurgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Syed N. Raza
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
| | - Michael A. Carron
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Surgical Service, Section of Otolaryngology; John D. Dingell VA Medical Center; Detroit Michigan U.S.A
| | - Mahdi A. Shkoukani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
- Surgical Service, Section of Otolaryngology; John D. Dingell VA Medical Center; Detroit Michigan U.S.A
| | - Albert L. Merati
- Department of Otolaryngology-Head and Neck Surgery; University of Washington School of Medicine; Seattle Washington U.S.A
| | - Ross M. Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
- Surgical Service, Section of Otolaryngology; John D. Dingell VA Medical Center; Detroit Michigan U.S.A
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Qureshi T, Chaus F, Fogg L, Dasgupta M, Straus D, Byrne RW. Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors. Br J Neurosurg 2016; 30:637-642. [PMID: 27332969 DOI: 10.1080/02688697.2016.1199786] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The transsphenoidal endoscopic approach is a relatively new procedure compared to the microscopic approach in pituitary adenoma resection. The endoscopic approach has shown to significantly decrease the rate of complications, time in the operating room and hospital, and patient post-op discomfort. However, this procedure requires the surgeon to make use of different visual and tactile clues that must be developed with experience. Therefore, it is important to understand the learning curve that the surgeon must overcome to become proficient with the endoscopic approach. METHODS Retrospective review of a single-surgeon consecutive series of 78 patients undergoing endoscopic pituitary tumor surgery from 2006 to 2012 at Rush University Medical Center has been used in this study. Patients were grouped according to an early (n = 9) and late group (n = 68) determined by a significant difference in outcomes. Our primary outcome measures were: duration of operation, CSF leak, hospital length of stay, visual field improvement, diabetes insipidus, panhypopituitarism, and subtotal resection. RESULTS There was a significant reduction in OR time and intraoperative CSF leaks between the early and late groups. There was no difference in hospital LOS or visual field improvement between the groups. With regards to complication rates, there was no difference found for DI, panhypopituitarism, lumbar drain placement, sinusitis, or subtotal resection between the two groups. CONCLUSION This study indicates that there may be a learning curve of approximately 9 cases before a surgical team can decrease OR times and reduce the rate of intraoperative CSF leaks for the endonasal endoscopic approach to pituitary adenoma resection.
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Affiliation(s)
- Talha Qureshi
- a Rush University Medical Center , Chicago , IL , USA
| | - Fahad Chaus
- a Rush University Medical Center , Chicago , IL , USA
| | - Louis Fogg
- a Rush University Medical Center , Chicago , IL , USA
| | - Mona Dasgupta
- a Rush University Medical Center , Chicago , IL , USA
| | - David Straus
- b Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
| | - Richard W Byrne
- b Department of Neurosurgery , Rush University Medical Center , Chicago , IL , USA
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Resection of pituitary tumors: endoscopic versus microscopic. J Neurooncol 2016; 130:309-317. [DOI: 10.1007/s11060-016-2124-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 04/07/2016] [Indexed: 11/27/2022]
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Jethwa PR, Patel TD, Hajart AF, Eloy JA, Couldwell WT, Liu JK. Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States. World Neurosurg 2015; 87:65-76. [PMID: 26548828 DOI: 10.1016/j.wneu.2015.10.090] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 10/22/2015] [Accepted: 10/24/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. METHODS A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. RESULTS In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. CONCLUSIONS On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.
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Affiliation(s)
- Pinakin R Jethwa
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Tapan D Patel
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Aaron F Hajart
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Jean Anderson Eloy
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James K Liu
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Newark, New Jersey, USA.
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Chung TK, Riley KO, Woodworth BA. The use of image-guidance during transsphenoidal pituitary surgery in the United States. Am J Rhinol Allergy 2015; 29:215-20. [PMID: 25975254 PMCID: PMC5554330 DOI: 10.2500/ajra.2015.29.4166] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intraoperative image guidance is a useful modality for transsphenoidal pituitary surgery. However, the outcomes associated with this technology have not been systematically evaluated. OBJECTIVE The purpose of the study was to quantify complication rates with and without the use of image guidance during transsphenoidal pituitary surgery using a nationwide database with broadly applicable results. METHODS A retrospective analysis of the Nationwide Inpatient Sample was performed from 2007 to 2011. Transsphenoidal pituitary resections for adenomas were identified by International Classification of Diseases-9th Revision, Clinical Modification code. The effect of image guidance on cerebrospinal fluid (CSF) leak complications and cost-benefit was analyzed. RESULTS A total of 48,848 transsphenoidal pituitary resections were identified, of which 77.5% were partial resections and 22.5% were complete. Pathologic indications included benign (89.3%), malignant primary (0.6%), and malignant secondary (0.4%). Complications included same-stay death (0.4%), CSF leak (8.8%), postoperative CSF rhinorrhea (1.9%), diabetes insipidus (12.4%), and meningitis (0.4%). Image guidance was employed in 7% (n = 3401) of all cases. When analyzed by modality, computed tomography (CT)-assisted procedures had lower CSF rhinorrhea rates (1.1%) compared with cases with no image guidance (1.9%), whereas magnetic resonance (MR)-assisted procedures had the highest rates (2.7%, χ2 p < 0.001). Rates of CSF leak demonstrated a similar pattern (CT 6.4%, no image guidance 8.9%, MR 9.2%, χ2 p < 0.001). CT-assisted surgery had significantly shorter length of stay (2.9 days) versus no image guidance (3.7 days, p < 0.001), lower total charges ($47,589 versus $62,629, p < 0.001), and lower total cost ($16,748 versus $20,530, p < 0.001). CONCLUSIONS CT-assisted surgery is associated with a lower rate of CSF leak, shorter length of stay, and lower cost compared with patients without image guidance. Further studies that control for severity and extent of disease are warranted to confirm this finding.
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Affiliation(s)
- Thomas K. Chung
- From the Departments of Surgery/Division of Otolaryngology and
| | - Kristen O. Riley
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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