Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors

Ethical Considerations in Complications of Surgical Procedures

Surgical procedures carry certain risks of complications, which need to be considered and discussed when any procedure is suggested to a patient. In this article, some ethical problems will be discussed concerning the communication of problems after they have occurred. Some clinical case studies will serve to clarify the need for having standards of ethical behavior, even in difficult situations. Further information will be given from experience gained from a medicolegal commission for malpractice complaints.

Cost Analysis of Oncological Outpatient Neurosurgery Under General Anesthesia with Hospital-At-Home-Based Postoperative Care

OBJECTIVE

This study evaluates the efficiency and cost-effectiveness of an oncological outpatient neurosurgery protocol using enhanced recovery after surgery principles in a European healthcare setting. Additionally, it assesses the impact of incorporating hospital at home (HaH) for perioperative follow-up on program efficiency and costs.

METHODS

We analyzed a case cohort of patients who underwent oncological outpatient neurosurgery with HaH-based postoperative follow-up for tumor removal or biopsy at a tertiary care center since 2019. A control cohort treated under standard inpatient care was also examined. Costs associated with surgery and postoperative care were meticulously calculated for both groups.

RESULTS

The case (n = 17) and control (n = 38) cohorts had comparable demographics and clinical profiles. Surgical costs, including operating room, anesthesia, and surgeon fees, were similar across groups. However, postoperative monitoring was significantly shorter for the outpatient cohort, leading to reduced observation costs (P < 0.001). While the duration of follow-up care was similar, outpatient follow-up via HaH was more cost-effective, reducing overall surgery costs by approximately €2958 per patient (P < 0.001) compared to inpatient care. No significant differences were observed in costs related to treatment, radiology, or lab tests between groups.

CONCLUSIONS

Outpatient neurosurgery with HaH follow-up offers substantial cost savings without compromising care quality in a public health setting. Inpatient care's higher costs are largely due to bed utilization, while the integration of HaH does not add significant costs, making it a viable alternative for postoperative management.

Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Enhanced Recovery after Cranial Surgery in Elderly: A Review

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited.

METHODS

Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature.

RESULTS

Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures.

CONCLUSIONS

This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

Awake Craniotomy Program Implementation

Importance

Implementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies.

Objective

To assess the cost utility of introducing a standardized program of awake craniotomies.

Design, Setting, and Participants

A retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023.

Exposure

Treatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021).

Main Outcomes and Measures

Patient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis.

Results

A total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis.

Conclusions and Relevance

In this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.

Perioperative Care and Outcomes of Patients with Brain Tumors Undergoing Elective Craniotomy: Experience from an Ethiopian Tertiary-Care Hospital

OBJECTIVE

To describe patients, perioperative care, and outcomes undergoing supratentorial and infratentorial craniotomy for brain tumor resection in a tertiary-care hospital in Ethiopia.

METHODS

A retrospective cohort study of patients consecutively admitted between January 1, 2021, and December 31, 2021, was performed. We characterized patients, perioperative care, and outcomes.

RESULTS

The final sample comprised 153 patients; 144 (94%) were 18 years and over, females (n = 48, 55%) with primarily American Society of Anesthesiologists physical class II (n = 97, 63.4%) who underwent supratentorial (n = 114, 75%), or infratentorial (n = 39, 25%) tumor resection. Patients were routinely admitted (95%) to floor/wards before craniotomy; Inhaled anesthetic (isoflurane 88%/halothane 12%) was used for maintenance of general anesthesia. Propofol (n = 93, 61%), mannitol (n = 73, 48%), and cerebrospinal fluid drain (n = 28, 18%), were used to facilitate intraoperative brain relaxation, while the use of hyperventilation was rare (n = 1). The average estimated blood loss was 1040 ± 727 ml; 37 (24%) patients received tranexamic acid, and 57 (37%) received a blood transfusion. Factors associated with extubation were a) infratentorial tumor location: relative risk (RR) 0.45 (95% confidence interval [CI] 0.29-0.69), preoperative hydrocephalus: RR 0.51, (95% CI 0.34-0.79), shorter total anesthesia duration: 277.8 + 8.8 versus 426.77 + 13.1 minutes, P < 0.0001, lower estimated blood loss: 897 + 68 ml versus 1361.7 + 100 ml, P = 0.0002, and cerebrospinal fluid drainage to facilitate brain relaxation: RR 0.52, 95% CI 0.32-0.84). Approximately one in ten patients experienced postoperative obstructive hydrocephalus, surgical site infections, or pneumonia.

CONCLUSIONS

These findings suggest that certain factors may impact patient outcomes following craniotomy for tumor resection. By identifying these factors, health care providers may be better equipped to develop individualized treatment plans and improve patient outcomes. Additionally, the study highlights the importance of postoperative monitoring and management to prevent complications.

Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges

BACKGROUND

Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC.

OBJECTIVE

To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa.

METHODS

We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included.

RESULTS

Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources.

CONCLUSION

Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.

Reexamining the Role of Postoperative ICU Admission for Patients Undergoing Elective Craniotomy: A Systematic Review

OBJECTIVES

The standard-of-care for postoperative care following elective craniotomy has historically been ICU admission. However, recent literature interrogating complications and interventions during this postoperative ICU stay suggests that all patients may not require this level of care. Thus, hospitals began implementing non-ICU postoperative care pathways for elective craniotomy. This systematic review aims to summarize and evaluate the existing literature regarding outcomes and costs for patients receiving non-ICU care after elective craniotomy.

DATA SOURCES

A systematic review of the PubMed database was performed following PRISMA guidelines from database inception to August 2021.

STUDY SELECTION

Included studies were published in peer-reviewed journals, in English, and described outcomes for patients undergoing elective craniotomies without postoperative ICU care.

DATA EXTRACTION

Data regarding study design, patient characteristics, and postoperative care pathways were extracted independently by two authors. Quality and risk of bias were evaluated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence tool and Risk Of Bias In Non-Randomized Studies-of Interventions tool, respectively.

DATA SYNTHESIS

In total, 1,131 unique articles were identified through the database search, with 27 meeting inclusion criteria. Included articles were published from 2001 to 2021 and included non-ICU inpatient care and same-day discharge pathways. Overall, the studies demonstrated that postoperative non-ICU care for elective craniotomies led to length of stay reduction ranging from 6 hours to 4 days and notable cost reductions. Across 13 studies, 53 of the 2,469 patients (2.1%) intended for postoperative management in a non-ICU setting required subsequent care escalation.

CONCLUSIONS

Overall, these studies suggest that non-ICU care pathways for appropriately selected postcraniotomy patients may represent a meaningful opportunity to improve care value. However, included studies varied greatly in patient selection, postoperative care protocol, and outcomes reporting. Standardization and multi-institutional collaboration are needed to draw definitive conclusions regarding non-ICU postoperative care for elective craniotomy.

Barriers and facilitators in the implementation of a telemedicine-based outpatient brain tumor surgery program

OBJECTIVE

Despite growing evidence on the benefits of outpatient oncological neurosurgery (OON), it is only performed in a few specialized centers and there are no previous descriptions of established OON programs in Europe. Moreover, increasing application of telemedicine strategies, especially after the start of the coronavirus disease 2019 (COVID-19) pandemic, is drastically changing neurosurgical management, particularly in the case of vulnerable populations such as neuro-oncological patients. In this context, the authors implemented an OON program in their hospital with telematic follow-up. Herein, they describe the protocol and qualitatively analyze the barriers and facilitators of the development process.

METHODS

An OON program was developed through the following steps: assessment of hospital needs, specific OON training, multidisciplinary team organization, and OON protocol design. In addition, the implementation phase included training sessions, a pilot study, and continuous improvement sessions. Finally, barriers and facilitators of the protocol’s implementation were identified from the feedback of all participants.

RESULTS

An OON protocol was successfully designed and implemented for resection or biopsy of supratentorial lesions up to 3 cm in diameter. The protocol included the patient’s admission to the day surgery unit, noninvasive anesthetic monitoring, same-day discharge, and admission to the hospital-at-home (HaH) unit for telematic and on-site postoperative care. After a pilot study including 10 procedures in 9 patients, the main barriers identified were healthcare provider resistance to change, lack of experience in outpatient neurosurgery, patient reluctance, and limitations in the recruitment of patients. Key facilitators of the process were the patient education program, the multidisciplinary team approach, and the HaH-based telematic postoperative care.

CONCLUSIONS

Initiating an OON program with telematic follow-up in a European clinical setting is feasible. Nevertheless, it poses several barriers that can be overcome by identifying and maximizing key facilitators of the process. Among them, patient education, a multidisciplinary team approach, and HaH-based postoperative care were crucial to the success of the program. Future studies should investigate the cost-effectiveness of telemedicine to assess potential cost savings, from reduced travel and wait times, and the impact on patient satisfaction.

Enhanced Recovery After Surgery strategies for elective craniotomy: a systematic review

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery.

METHODS

The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction.

RESULTS

A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse.

CONCLUSIONS

A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.

Same day discharge for craniotomy

PURPOSE OF REVIEW

Same-day protocols for craniotomy have been demonstrated to be feasible and safe. Its several benefits include decreased hospital costs, less nosocomial complications, fewer case cancellations, with a high degree of patient satisfaction. This paper reviews the most recent publications in the field of same-day discharge after craniotomy.

RECENT FINDINGS

Since 2019, several studies on same-day neurosurgical procedures were published. Ambulatory craniotomy protocols for brain tumor were successfully implemented in more centers around the world, and for the first time, in a developing country. Additional information emerged on predictors for successful early discharge, and the barriers and enablers of same-day craniotomy programs. Moreover, the cost benefits of same-day craniotomy were reaffirmed.

SUMMARY

Same- day discharge after craniotomy is feasible, safe and continues to expand to a wider variety of procedures, in new institutions and countries. There are several benefits to ambulatory surgery. Well-established protocols for perioperative management are essential to the success of early discharge programs. With continued research, these protocols can be refined and implemented in more institutions globally, ultimately to provide better, more efficient care for neurosurgical patients.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomy

BACKGROUND

There is a growing body of evidence suggesting not all craniotomy patients require postoperative intensive care.

OBJECTIVE

To devise and implement a standardized protocol for craniotomy patients eligible to transition directly from the operating room to the ward-the Non-Intensive CarE (NICE) protocol.

METHODS

We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with age <65 yr and American Society of Anesthesiologists (ASA) class of 1, 2 or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations for the first 8 h. Patient demographics, clinical characteristics, and outcomes were prospectively collected to evaluate the NICE protocol.

RESULTS

From February 2018 to 2019, 63 patients were included in the NICE protocol with a median age of 46 yr and 65% female predominance. Of the operations performed, 38.1% were microvascular decompressions, 31.7% were craniotomy for tumor, 15.9% were cavernous malformation resections, and 14.3% were Chiari decompressions. No patients required transfer to the intensive care unit (ICU). Median length of stay was 2 d. There was an 11.1% overall readmission rate within the median follow-up period of 48 d. Three patients (4.8%) required reoperation at time of readmission within the follow-up period (1 postoperative subdural hematoma, 2 cerebrospinal fluid leak repair). None of these complications could have been identified with a postoperative ICU stay.

CONCLUSION

In our pilot trial of the NICE protocol, no patients required postoperative transfer to the ICU.

Health care resource utilization and treatment of leptomeningeal carcinomatosis in the United States

Background

The economic burden of cancer in the United States is substantial, and better understanding it is essential in informing health care policy and innovation. Leptomeningeal carcinomatosis (LC) represents a late complication of primary cancer spreading to the leptomeninges.

Methods

The IBM MarketScan Research databases were queried for adults diagnosed with LC from 2001 to 2015, secondary to 4 primary cancers (breast, lung, gastrointestinal, and melanoma). Health care resource utilization (HCRU) and treatment utilization were quantified at baseline (1-year pre-LC diagnosis) and 30, 90, and 365 days post-LC diagnosis.

Results

We identified 4961 cases of LC (46.3% breast cancer, 34.8% lung cancer, 13.5% gastrointestinal cancer, and 5.4% melanoma). The median age was 57.0 years, with 69.7% female and 31.1% residing in the South. Insurance status included commercial (71.1%), Medicare (19.8%), and Medicaid (9.1%). Median follow-up was 66.0 days (25th percentile: 24.0, 75th percentile: 186.0) and total cumulative costs were highest for the gastrointestinal subgroup ($167 768) and lowest for the lung cancer subgroup ($145 244). There was considerable variation in the 89.6% of patients who used adjunctive treatments at 1 year, including chemotherapy (64.3%), radiotherapy (57.6%), therapeutic lumbar puncture (31.5%), and Ommaya reservoir (14.5%). The main cost drivers at 1 year were chemotherapy ($62 026), radiation therapy ($37 076), and specialty drugs ($29 330). The prevalence of neurologic impairments was 46.9%, including radiculopathy (15.0%), paresthesia (12.3%), seizure episode/convulsive disorder not otherwise specified (11.0%), and ataxia (8.0%).

Conclusions

LC is a devastating condition with an overall poor prognosis. We present the largest study of LC in this real-world study, including current treatments, with an emphasis on HCRU. There is considerable variation in the treatment of LC and significant health care costs.

Which surgical patients require shared care?

Most hospitalized surgical patients have significant medical comorbidity and are treated with a considerable number of drugs and/or experience significant complications. Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC.