Feasibility of Bundled Payments in Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma Surgery: MarketScan Analysis of Health Care Utilization and Outcomes

Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality

PURPOSE

Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning.

METHODS

IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis.

RESULTS

A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis.

CONCLUSION

Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.

Personalized Approach to Olfactory Neuroblastoma Care

Olfactory neuroblastoma (ONB) is an uncommon neuroendocrine malignancy arising from the olfactory neuroepithelium. ONB frequently presents with nonspecific sinonasal complaints, including nasal obstruction and epistaxis, and diagnosis can be obtained through a combination of physical examination, nasal endoscopy, and computed tomography and magnetic resonance imaging. Endoscopic resection with negative margins, with or without craniotomy, as necessary, is the standard of care for definitive treatment of ONB. Regional metastasis to the neck is often detected at presentation or may occur in a delayed fashion and should be addressed through elective neck dissection or radiation. Adjuvant radiotherapy should be considered, particularly in the case of high grade or tumor stage, as well as positive surgical margins. Systemic therapy is an area of active investigation in both the neoadjuvant and adjuvant setting, with many advocating in favor of induction chemotherapy for significant orbital or intracranial involvement prior to surgical resection. Various targeted immunotherapies are currently being studied for the treatment of recurrent or metastatic ONB. Prolonged locoregional and distant surveillance are indicated following definitive treatment, given the tendency for delayed recurrence and metastasis.

Incidental Meningiomas: Potential Predictors of Growth and Current State of Management

The rise in availability of neuroimaging has led to an increase in incidentally discovered meningiomas. These tumors are typically asymptomatic and tend to display slow growth. Treatment options include observation with serial monitoring, radiation, and surgery. Although optimal management is unclear, clinicians recommend a conservative approach, which preserves quality of life and limits unnecessary intervention. Several risk factors have been investigated for their potential utility in the development of prognostic models for risk assessment. Herein, the authors review the current literature on incidental meningiomas, focusing their discussion on potential predictive factors for tumor growth and appropriate management practices.

Trends and Impact of Treatment Modalities (Surgery and Radiation Therapy) on Health Care Utilization in Patients With Glomus Jugulare Tumors (GJTs): An Inverse Probability of Treatment Weight Analysis

OBJECTIVES

The trend of practice pattern and impact on health care utilization for surgery and radiation therapy (RT) in patients with glomus jugulare tumors (GJTs) is not well defined.

METHODS

The IBM (Armonk, NY) MarketScan database was queried using the ICD-9/10 and CPT 4th edition, 2000-2020. We included patients ≥18 years of age who underwent either surgery or RT with at-least 1-year follow-up. We compared the health care utilization at 3-month, 6-month, and 1-year follow up using the inverse probability of treatment weight technique.

RESULTS

A cohort of 333 patients was identified. Of these, 72.7% (n = 242) underwent RT and 27.3% (n = 91) underwent surgery. RT use increased from 2002-2004 (50%) to 2017-2019 (91%). Patients in the surgery cohort were younger (median age 49 vs. 56 years, P < 0.0001) and had a higher 3+ comorbidity index (34% vs. 30%, P = 0.43) compared with patients in the RT cohort. Patients who underwent surgery had higher complications at index hospitalization (22% vs. 6%, P < 0.0001) and at 30 days (14% vs. 5%, P = 0.0042). No difference in combined index and 6- or 12-month payments were noted (6-months: surgery, $66m108, RT: $43m509, P = 0.1034; 12-months: surgery, $73,259, RT: $51,576, P = 0.1817). Only 4% of patients who had initial RT underwent RT and none underwent surgery at 12 months, whereas 6% of patients who had initial surgery underwent RT and 2% underwent surgery at 12 months.

CONCLUSIONS

RT plays an increasingly important role in the treatment for patients with GJTs, with fewer complications and a comparable health care utilization at 1 year.

Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series

Background

Meningioma surgery has evolved over the last 20 years with increased use of minimally invasive approaches including the endoscopic endonasal route and endoscope-assisted and gravity-assisted transcranial approaches. As the “keyhole” concept remains controversial, we present detailed outcomes in a cohort series.

Methods

Retrospective analysis was done for all patients undergoing meningioma removal at a tertiary brain tumor referral center from 2008–2021. Keyhole approaches were defined as: use of a minimally invasive “retractorless” approach for a given meningioma in which a traditional larger approach is often used instead. The surgical goal was maximal safe removal including conservative (subtotal) removal for some invasive locations. Primary outcomes were resection rates, complications, length of stay and Karnofsky Performance Scale (KPS). Secondary outcomes were endoscopy use, perioperative treatments, tumor control and acute MRI FLAIR/T2 changes to assess for brain manipulation and retraction injury.

Results

Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30 (15.5%) had prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal (n = 74,35%), supraorbital (n = 73,34%), retromastoid (n = 38,18%), mini-pterional (n = 20,9%), suboccipital (n = 4,2%), and contralateral transfalcine (n = 4,2%). Primary outcomes: Gross total/near total (>90%) resection was achieved in 125(59%) (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% for all other locations). Major complications included: permanent neurological worsening 12(6%), CSF leak 2(1%) meningitis 2(1%). There were no DVTs, PEs, MIs or 30-day mortality. Median LOS decreased from 3 to 2 days in the last 2 years; 94% were discharged to home with favorable 90-day KPS in 176(96%) patients. Secondary outcomes: Increased FLAIR/T2 changes were noted on POD#1/2 MRI in 36/213(17%) cases, resolving in all but 11 (5.2%). Endoscopy was used in 87/139(63%) craniotomies, facilitating additional tumor removal in 55%. Tumor progression occurred in 26(13%) patients, mean follow-up 42±36 months.

Conclusions & relevance

Our experience suggests minimally invasive keyhole transcranial and endoscopic endonasal meningioma removal is associated with comparable resection rates and low complication rates, short hospitalizations and high 90-day performance scores in comparison to prior reports using traditional skull base approaches. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid neurological deficits and other post-operative complications, although longer follow-up is needed. With careful patient selection and requisite experience, these approaches may be considered reasonable alternatives to traditional transcranial approaches.

Incidence and Long-Term Health Care Utilization Associated With Pseudomeningocele Repair Following Vestibular Schwannoma Resection: A National Database Analysis

Introduction

To compare the healthcare utilization in patients who presented with no pseudomeningocele (PSM) following vestibular schwannoma (VS) surgery (nd-PSM), PSM following VS surgery and required surgical repair (s-PSM) and those who presented with PSM and did not require surgical repair (ns-PSM).

Methods

MarketScan database was queried using the International Classification of Diseases, ninth and tenth revisions, and current procedural terminology four, from 2000 to 2018. We included patients ≥18 years of age with a PSM diagnosis with at least two years of continuous enrollment. The hospital admissions, outpatient services, medication refills, and associated payments were analyzed.

Results

Of 1,460 patients, 96.6% (n=1,411) had no PSM following surgery for VS, 2.4% (n=35) were in s-PSM and only 0.95% (n=14) were in ns-PSM cohorts. Patients in the s-PSM cohort incurred higher hospital readmission rate, outpatient payments compared to those in the nd-PSM and ns-PSM cohorts at six months, one-year, and two-years following the following VS resection. At one-year following VS resection, the median combined payments for the s-PSM cohort were $74,683 compared to $42,664 for the ns-PSM and $9,476 for the nd-PSM cohort, p<0.0001. Similarly, at two-years, median combined payments for s-PSM cohort were $83,351 compared to $63,942 for ns-PSM and $18,839 for the nd-PSM cohort, p<0.0001.

Conclusion 

Patients in the s-PSM cohort incurred eight times and 4.4 times the combined payments at one- and two-years, respectively, compared to the nd-PSM cohort. Also, patients in the ns-PSM cohort incurred 4.5 times and 3.4 times the payments compared to the nd-PSM cohort.

90-Day Bundled Payment Simulation, Health Care Utilization, and Complications following Craniopharyngioma Resection in Adult Patients

Context Bundled payment and health care utilization models inform cost optimization and surgical outcomes. Economic analysis of payment plans for craniopharyngioma resection is unknown.

Objective This study aimed to identify impact of endocrine and nonendocrine complications (EC and NEC, respectively) on health care utilization and bundled payments following craniopharyngioma resection.

Design This study is presented as a retrospective cohort analysis (2000–2016) with 2 years of follow-up.

Setting The study included national inpatient hospitalization and outpatient visits.

Patients Patients undergoing craniopharyngioma resection were divided into the following four groups: group 1, no complications (NC); group 2, only EC; group 3, NEC; and group 4, both endocrine and nonendocrine complications (ENEC).

Interventions This study investigated transphenoidal or subfrontal approach for tumor resection.

Main Outcome Hospital readmission, health care utilization up to 24 months following discharge, and 90-day bundled payment performances are primary outcomes of this study.

Results Median index hospitalization payments were significantly lower for patients in NC cohort ($28,672) compared with those in EC ($32,847), NEC ($36,259), and ENEC ($32,596; p < 0.0001). Patients in ENEC incurred higher outpatient services and overall median payments at 6 months (NC: 38,268; EC: 49,844; NEC: 68,237; and ENEC: 81,053), 1 year (NC: 46,878; EC: 58,210; NEC: 81,043; and ENEC: 94,768), and 2 years (NC: 58,391; EC: 70,418; NEC: 98,838; and ENEC: 1,11,841; p < 0.0001). The 90-day median bundled payment was significantly different among the cohorts with the highest in ENEC ($60,728) and lowest in the NC ($33,089; p < 0.0001).

Conclusion ENEC following surgery incurred almost two times the overall median payments at 90 days, 6 months, 1 year. and 2 years compared with those without complications. Bundled payment model may not be a feasible option in this patient population. Type of complications and readmission rates should be considered to optimize payment model prediction following craniopharyngioma resection.

Health Care Utilization in Patients Undergoing Repeat Stereotactic Radiosurgery for Vestibular Schwannoma with 5-Year Follow-up: A National Database Analysis

Background Stereotactic radiosurgery (SRS) has been used as an alternative to microsurgery in patients with small vestibular schwannoma (VS). We compare health care utilization metrics in patients undergoing repeat-SRS (re-SRS) and no repeat SRS (nr-SRS) at long-term follow-up.

Materials and Methods We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had diagnosis of VS and treatment with SRS with at least 5 years of continuous enrollment after the procedure. Outcomes were hospital admissions, outpatient services, and medication refills.

Results Of 1,047 patients, 5.1% (n = 53) had repeat SRS. Majority of re-SRS (74%, n = 39) were done within 2 years of index procedure and 51% were within 1-year of initial procedure. Patients who required re-SRS incurred higher hospital readmission rate, outpatient services, and had higher payments compared with those who did not require re-SRS at 6 months, 1 year, and 2 years following the initial procedures. Re-SRS received 3.0- and 3.1-times higher payments at 1 and 2 years compared with nr-SRS cohort. At 5 years following SRS, median combined payments for re-SRS cohort was $105286 (interquartile range [IQR] $70999, $156569) compared with $44172 (IQR $22956, $84840) for nr-SRS cohort.

Conclusion More than half of the re-SRS procedures were noted within first year of initial SRS for VS. Overall payments at 5 years for repeat SRS was more than double that for nr-SRS. Repeat SRS was also associated with more re-admissions and outpatient services at annual follow-up time points.

Management of incidental anterior skull base large and giant meningiomas in elderly patients

INTRODUCTION

The incidence of meningiomas among the elderly is considered to be high, and are at increased risk of severe morbidity and mortality following surgery due to their aging physiology and unexpected comorbidities. This study aimed to evaluate the optimal management strategies of meningiomas in elderly patients.

METHODS

We retrospectively analyzed 150 patients with incidental large (≥ 3 cm) and giant (≥ 6 cm) anterior skull base meningiomas from 2009 to 2018. These patients were divided into elderly group (≥ 65 years, n = 70) and younger group (< 65 years, n = 80). Information of patients with regard to their medical records, operative details, relevant imaging, and follow-up data were obtained from their respective electronic medical records.

RESULTS

The elderly patients had significantly longer length of hospital stay (15.9 ± 3.5) compared to younger patients (13.6 ± 3.6, P < 0.001). Karnofsky Performance Scale (KPS) at discharge was significantly lower in elderly group when compared to younger group (P = 0.04). However, the KPS at 1-year after surgery was similar between the two groups. In addition, there was no significant difference in the incidence of surgical complications between the two groups. Multivariate regression analysis of postoperative complications revealed blood loss ≥ 800 mL (P = 0.007) and BMI (< 18.5 or ≥ 24, P < 0.001) as risk factors, rather than age.

CONCLUSIONS

Surgical resection in elderly patients with incidental anterior skull base large and giant meningiomas is considered to be a safe and effective therapeutic option owing to acceptable mortality, postoperative complications and postoperative clinical outcomes.