Patient-Level Factors Influencing Hospital Costs and Short-Term Patient-Reported Outcomes After Transsphenoidal Resection of Sellar Tumors

Clinical predictors of survival for patients with atypical teratoid/rhabdoid tumors

PURPOSE

Atypical teratoid/rhabdoid tumors (AT/RTs) are malignant central nervous system (CNS) neoplasms of the young. Our study analyzed a large AT/RT cohort from the National Cancer Database (NCDB) to elucidate predictors of short-term mortality and overall survival (OS).

METHODS

Information was collected on patients with histologically confirmed AT/RT using the NCDB (2004-2016). Kaplan-Meier analysis indicated OS. Prognostic factors for 30-day mortality, 90-day mortality, and OS were determined via multivariate Cox proportional hazards (CPH) and logistic regression models.

RESULTS

Our cohort of 189 patients had a median age of 1 year (IQR [1, 4]) and tumor size of 4.7 ± 2.0 cm at diagnosis. Seventy-two percent were under 3 years old; 55.6% were male and 71.0% were Caucasian. Fifty (27.2%) patients received only surgery (S) (OS = 5.91 months), 51 (27.7%) received surgery and chemotherapy (S + CT) (OS = 11.2 months), and 9 (4.89%) received surgery and radiotherapy (S + RT) (OS = 10.3 months). Forty-five (24.5%) received S + CT + RT combination therapy (OS = 45.4 months), 13 (17.1%) received S + CT + BMT/SCT (bone marrow or stem cell transplant) (OS = 55.5 months), and 16 (8.70%) received S + CT + RT + BMT/SCT (OS = 68.4 months). Bivariate analysis of dichotomized age (HR = 0.550, 95% CI [0.357, 0.847], p = 0.0067) demonstrated significantly increased patient survival if diagnosed at or above 1 year old. On multivariate analysis, administration of S + CT + RT, S + CT + BMT/SCT, or S + CT + RT + BMT/SCT combination therapy predicted significantly (p < 0.05) increased OS compared to surgery alone.

CONCLUSION

AT/RTs are CNS tumors where those diagnosed under 1 year old have a significantly worse prognosis. Our study demonstrates that while traditional CT, RT, and BMT/SCT combination regimens prolong life, overall survival in this population is still low.

Costs and Its Determinants in Pituitary Tumour Surgery

PURPOSE

Value-based healthcare (VBHC) provides a framework to improve care by improving patient outcomes and reducing healthcare costs. To support value-based decision making in clinical practice we evaluated healthcare costs and cost drivers in perioperative care for pituitary tumour patients.

METHODS

We retrospectively assessed financial and clinical data for surgical treatment up to the first year after surgery of pituitary tumour patients treated between 2015 and 2018 in a Dutch tertiary referral centre. Multivariable regression analyses were performed to identify determinants of higher costs.

RESULTS

271 patients who underwent surgery were included. Mean total costs (SD) were €16339 (13573) per patient, with the following cost determinants: surgery time (€62 per minute; 95% CI: 50, 74), length of stay (€1331 per day; 95% CI 1139, 1523), admission to higher care unit (€12154 in total; 95% CI 6413, 17895), emergency surgery (€10363 higher than elective surgery; 95% CI: 1422, 19305) and postoperative cerebrospinal fluid leak (€14232; 95% CI 9667, 18797). Intradural (€7128; 95% CI 10421, 23836) and combined transsphenoidal/transcranial surgery (B: 38494; 95% CI 29191, 47797) were associated with higher costs than standard. Further, higher costs were found in these baseline conditions: Rathke's cleft cyst (€9201 higher than non-functioning adenoma; 95% CI 1173, 17230), giant adenoma (€19106 higher than microadenoma; 95% CI 12336, 25877), third ventricle invasion (€14613; 95% CI 7613, 21613) and dependent functional status (€12231; 95% CI 3985, 20477). In patients with uncomplicated course, costs were €8879 (3210) and with complications €17551 (14250).

CONCLUSIONS

Length of hospital stay, and complications are the main drivers of costs in perioperative pituitary tumour healthcare as were some baseline features, e.g. larger tumors, cysts and dependent functional status. Costs analysis may correspond with healthcare resource utilization and guide further individualized care path development and capacity planning.

Variability drivers of treatment costs in hospitals: A systematic review

OBJECTIVES

Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020.

RESULTS

90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors.

CONCLUSION

Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

Predicting High-Value Care Outcomes After Surgery for Non-Skull Base Meningiomas

OBJECTIVE

A need exists to better understand the prognostic factors that influence high-value care outcomes after meningioma surgery. The goal of the present study was to develop predictive models to determine the patients at risk of experiencing an extended hospital length of stay (LOS), nonroutine discharge disposition, and/or a 90-day hospital readmission after non-skull base meningioma resection.

METHODS

In the present study, we analyzed the data from 396 patients who had undergone surgical resection of non-skull base meningiomas at a single institution between January 1, 2005 and December 31, 2020. The Mann-Whitney U test was used for bivariate analysis of the continuous variables and the Fisher exact test for bivariate analysis of the categorical variables. A multivariate analysis was conducted using logistic regression models.

RESULTS

Most patients had had a falcine or parasagittal meningioma (66.2%), with the remainder having convexity (31.8%) or intraventricular (2.0%) tumors. Nonelective surgery (P < 0.0001) and an increased tumor volume (P = 0.0022) were significantly associated with a LOS >4 days on multivariate analysis. The independent predictors of a nonroutine discharge disposition included male sex (P = 0.0090), nonmarried status (P = 0.024), nonelective surgery (P = 0.0067), tumor location within the parasagittal or intraventricular region (P = 0.0084), and an increased modified frailty index score (P = 0.039). Hospital readmission within 90 days was independently associated with nonprivate insurance (P = 0.010) and nonmarried status (P = 0.0081). Three models predicting for a prolonged LOS, nonroutine discharge disposition, and 90-day readmission were implemented in the form of an open-access, online calculator (available at: https://neurooncsurgery3.shinyapps.io/non_skull_base_meningiomas/).

CONCLUSIONS

After external validation, our open-access, online calculator could be useful for assessing the likelihood of adverse postoperative outcomes for patients undergoing surgery of non-skull base meningioma.

Use of a Surgical Stepdown Protocol for Cost Reduction After Transsphenoidal Pituitary Adenoma Resection: A Case Series

OBJECTIVE

No established standard of care currently exists for the postoperative management of patients with surgically resected pituitary adenomas. Our objective was to quantify the efficacy of a postoperative stepdown unit protocol for reducing patient cost.

METHODS

In 2018-2020, consecutive patients undergoing transsphenoidal microsurgical resection of sellar lesions were managed postoperatively in the full intensive care unit (ICU) or an ICU-based surgical stepdown unit based on preset criteria. Demographic variables, surgical outcomes, and patient costs were evaluated.

RESULTS

Fifty-four patients (27 stepdown, 27 full ICU; no difference in age or sex) were identified. Stepdown patients were also compared with 634 historical control patients. The total hospital length of stay was no different among stepdown, ICU, and historical patients (4.8 ± 1.0 vs. 5.9 ± 2.8 vs. 4.4 ± 4.3 days, respectively, P = 0.1). Overall costs were 12.5% less for stepdown patients (P = 0.01), a difference mainly driven by reduced facility utilization costs of -8.9% (P = 0.02). The morbidity and complication rates were similar in the stepdown and full ICU groups. Extrapolation of findings to historical patients suggested that ∼$225,000 could have been saved from 2011 to 2016.

CONCLUSIONS

These results suggest that use of a postoperative stepdown unit could result in a 12.5% savings for eligible patients undergoing treatment of pituitary tumors by shifting patients to a less acute unit without worsened surgical outcomes. Historical controls indicate that over half of all pituitary patients would be eligible. Further refinement of patient selection for less costly perioperative management may reduce cost burden for the health care system and patients.

Predicting High-Value Care Outcomes After Surgery for Skull Base Meningiomas

BACKGROUND

Although various predictors of adverse postoperative outcomes among patients with meningioma have been established, research has yet to develop a method for consolidating these findings to allow for predictions of adverse health care outcomes for patients diagnosed with skull base meningiomas. The objective of the present study was to develop 3 predictive algorithms that can be used to estimate an individual patient's probability of extended length of stay (LOS) in hospital, experiencing a nonroutine discharge disposition, or incurring high hospital charges after surgical resection of a skull base meningioma.

METHODS

The present study used data from patients who underwent surgical resection for skull base meningiomas at a single academic institution between 2017 and 2019. Multivariate logistic regression analysis was used to predict extended LOS, nonroutine discharge, and high hospital charges, and 2000 bootstrapped samples were used to calculate an optimism-corrected C-statistic. The Hosmer-Lemeshow test was used to assess model calibration, and P < 0.05 was considered statistically significant.

RESULTS

A total of 245 patients were included in our analysis. Our cohort was mostly female (77.6%) and white (62.4%). Our models predicting extended LOS, nonroutine discharge, and high hospital charges had optimism-corrected C-statistics of 0.768, 0.784, and 0.783, respectively. All models showed adequate calibration (P>0.05), and were deployed via an open-access, online calculator: https://neurooncsurgery3.shinyapps.io/high_value_skull_base_calc/.

CONCLUSIONS

After external validation, our predictive models have the potential to aid clinicians in providing patients with individualized risk estimation for health care outcomes after meningioma surgery.

Evaluation of Complications and Costs During Overlapping Transsphenoidal Surgery in the Treatment of Pituitary Adenoma

BACKGROUND

Pituitary adenomas are among the most common primary brain tumors. Recently, overlapping surgery has been curbed in many institutions because of the suggestion there might be more significant adverse events, despite several studies showing that complication rates are equivalent.

OBJECTIVE

To assess complications and costs associated with overlapping surgery during the transsphenoidal resection of pituitary adenomas.

METHODS

A single-center, retrospective cohort study was performed to evaluate the cases of patients who underwent a transsphenoidal approach for pituitary tumor resection. Patient, surgical, complication, and cost (value-driven outcome) variables were analyzed.

RESULTS

A total of 629 patients (302 nonoverlapping, 327 overlapping cases) were identified. No significant differences in age (P = .6), sex (P = .5), tumor type (P = .5), or prior rates of pituitary adenoma resection (P = .5) were seen. Similar presenting symptoms were observed in the 2 groups, and follow-up length was comparable (P = .3). No differences in tumor sizes (P = .5), operative time (P = .4), fat/fascia use (P = .4), or cerebrospinal fluid diversion (P = .8) were seen between groups. The gross total resection rate was not significantly different (P = .9), and no difference in recurrence rate was seen (P = .4). A comparable complication rate was seen between groups (P = .6). No differences in total or subtotal costs were seen either.

CONCLUSION

The results of this study offer additional evidence that overlapping surgery does not result in worsened complications, lengthened surgery, or increased patient cost for patients undergoing transsphenoidal resection of pituitary adenomas. Thus, studies and policy aiming to improve patient safety and cost should focus on optimizing other aspects of healthcare delivery.

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

OBJECTIVE

Gliomas occur in 3-4 individuals per 100,000 individuals and are one of the most common primary brain tumors. Treatment options are limited for gliomas despite the progressive nature of the disease. The authors used the Value Driven Outcomes (VDO) database to identify cost drivers and subgroups that are involved in the surgical treatment of gliomas.

METHODS

A retrospective cohort of patients with gliomas treated at the authors' institution from August 2011 to February 2018 was evaluated using medical records and the VDO database.

RESULTS

A total of 263 patients with intracranial gliomas met the authors' inclusion criteria and were included in the analysis (WHO grade I: 2.0%; grade II: 18.5%; grade III: 18.1%; and grade IV: 61.4%). Facility costs were the major (64.4%) cost driver followed by supplies (16.2%), pharmacy (10.1%), imaging (4.5%), and laboratory (4.7%). Univariate analysis of cost contributors demonstrated that American Society of Anesthesiologists physical status (p = 0.002), tumor recurrence (p = 0.06), Karnofsky Performance Scale score (p = 0.002), length of stay (LOS) (p = 0.0001), and maximal tumor size (p = 0.03) contributed significantly to the total costs. However, on multivariate analysis, only LOS (p = 0.0001) contributed significantly to total costs. More extensive tumor resection in WHO grade III and IV tumors was associated with significant improvement in survival (p = 0.004 and p = 0.02, respectively).

CONCLUSIONS

Understanding care costs is challenging because of the highly complex, fragmented, and variable nature of healthcare delivery. Adopting effective strategies that would reduce facility costs and limit LOS is likely the most important aspect in reducing intracranial glioma treatment costs.

Resection of Pituitary Tumor with Lateral Extension to the Temporal Fossa: The Toothpaste Extrusion Technique

Transsphenoidal resection of the sellar and suprasellar lesions, whether microscopic or endoscopic, has been traditionally limited by tumors extending laterally to the carotid artery and cavernous sinus. Extended endoscopic or transmaxillary approaches may be warranted depending on these tumor extensions. We describe the use of an intraoperative Valsalva maneuver as a surgical adjunct to the transsphenoidal approach to improve the extent of resection for a favorable outcome. The patient was a 65-year-old woman who underwent resection of a giant pituitary tumor that extended laterally to the cavernous sinus to occupy a volume within the middle fossa. It was the senior author's impression that the lateral cavernous wall was intact at the time of surgery although this is difficult to determine definitively. After a transsphenoidal intrasellar resection of the intrasellar tumor, side-angled endoscopic visualization enabled identification of the breach in the medial cavernous wall where the tumor had invaded the cavernous sinus and ultimately grown into the middle fossa. A Valsalva maneuver was then applied, and the tumor was extruded from the cavernous sinus lateral to the carotid. The significant tumor was removed under direct visualization of the abducens nerve, which was well preserved. Postoperative imaging showed a sufficient extent of resection, and there were no postoperative complications. An intraoperative Valsalva maneuver can be a potentially useful technique for extending tumor resection in cases with a soft tumor and visualization of the opening within the cavernous sinus wall.

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

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

EQ-5D Quality-of-Life Analysis and Cost-Effectiveness After Skull Base Meningioma Resection

BACKGROUND

Skull base meningioma management is complicated by their proximity to intracranial neurovascular structures because complete resection may pose a risk of worsening morbidity.

OBJECTIVE

To assess the influence of clinical outcomes and surgical management on patient-perceived quality-of-life outcomes, value, and cost-effectiveness.

METHODS

Patients who underwent resection of a skull base meningioma, had adequate clinical follow-up, and completed EQ-5D-3L questionnaires preoperatively and at 1 mo and 1 yr postoperatively were identified in a retrospective review. Cost data from the Value Driven Outcomes database were analyzed.

RESULTS

A total of 52 patients (83.0% women, mean age 51.9 yr) were categorized by worsened (n = 7), unchanged (n = 24), or improved (n = 21) EQ-5D-3L index scores at 1-mo follow-up. No difference in subcategory cost contribution or total cost was seen in the 3 groups. Patients with improved scores showed a steady improvement through each follow-up period, whereas those with unchanged or worsened scores did not. Mean quality-adjusted life years (QALYs) and cost per QALY improved for all groups but at a higher rate for patients with better outcomes at 30-d follow-up. Female sex, absence of proptosis, nonfrontotemporal approaches, no optic nerve decompression, and absence of surgical complications demonstrated improved EQ-5D-3L scores at 1-yr follow-up. A mean cost per QALY of $27 731.06 ± 22 050.58 was observed for the whole group and did not significantly differ among patient groups (P = .1)

CONCLUSION

Patients undergoing resection of skull base meningiomas and who experience an immediate improvement in EQ-5D are likely to show continued improvement at 1 yr, with improved QALY and reduced cost per QALY.

Analysis of Treatment Cost Variation Among Multiple Neurosurgical Procedures Using the Value-Driven Outcomes Database

BACKGROUND

Health care costs comprise a substantial portion of total national expenditure. Although interest in cost-effectiveness analysis in neurosurgery has increased, there has been little cross-comparison of neurosurgical procedures. The aim of this study was to compare costs across elective neurosurgical procedures to understand whether drivers of cost differ.

METHODS

The Value Driven Outcomes database was used to evaluate treatment costs for resection of vestibular schwannoma, intracranial meningioma, gliomas, and pituitary adenoma; anterior cervical discectomy and fusion and lumbar spinal fusion; and aneurysm treatment.

RESULTS

A total of 1997 patients (mean age 54.6 ± 14.5 years; 45.2% male) were evaluated. The mean length of stay (LOS) was 4.0 ± 4.4 days. For cases involving hardware implantation, including spine fusion or aneurysm treatment, supplies and implants (49.1%) accounted for the largest fraction of costs followed by facility costs (37.9%). For cases that did not involve hardware, including tumor cases, facility costs (63.9%) were the largest fraction, followed by supplies and implants (16.2%). Aneurysm treatment and lumbar fusion were 1.5-3 times more costly than cranial tumor resection and anterior cervical discectomy and fusion per patient. Multivariate linear regression demonstrated that LOS (β = 0.7, P = 0.0001) and patient treatment type (β = 0.2, P = 0.0001) had the greatest effect on costs. LOS correlated with cost differently depending on case type; its effect was largest for patients with meningioma and smallest for patients with vestibular schwannoma. Costs across time increased similarly for all case types.

CONCLUSIONS

Costs for neurosurgical procedures vary widely depending on treatment type and correlated directly with LOS. Strategies to reduce cost may require different approaches depending on procedure type.

Improved Surgical Safety via Intraoperative Navigation for Transnasal Transsphenoidal Resection of Pituitary Adenomas

Objectives  Intraoperative navigation during neurosurgery can aid in the detection of critical structures and target lesions. The safety and efficacy of intraoperative, stereotactic computed tomography (CT) in the transnasal transsphenoidal resection of pituitary adenomas were explored. Design  Retrospective chart review Setting  Tertiary care hospital Participants  Patients who underwent transsphenoidal resection of pituitary adenomas from February 2002 to May 2017. Intraoperative stereotactic CT navigation was used for all patients after mid-October 2013. Main Outcome Measures  Operative time, estimated blood loss, gross total resection rate. Results  Of 634 patients included, 175 underwent surgery with intraoperative navigation and 444 had no intraoperative navigation during surgery. There was no difference in mean age, sex, tumor type, or tumor size between the two groups. Operative time, endoscope use, cerebrospinal fluid diversion, and estimated blood loss were also similar. Two patients showed intraoperative, iatrogenic misdirection in the absence of stereotactic CT navigation ( p  = 0.99) but similar numbers of patients having navigated and non-navigated surgery returned to the operating room, underwent gross total resection, and showed endocrinological normalization. Conclusions  These results suggest that intraoperative navigation can reduce injury without resulting in increased operative time, estimated blood loss, or reduction in gross total resection.

Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample

OBJECTIVE

Epidemiology in upper extremity peripheral nerve injury (PNI) has not been comprehensively evaluated. The aim of this study was to calculate updated incidence of upper extremity PNIs in the United States and examine clinical trends and costs using a national database.

METHODS

The National (Nationwide) Inpatient Sample was used to evaluate patients with upper extremity PNI (International Classification of Diseases, Ninth Revision, Clinical Modification 9534, 9550-9559) in 2001-2013.

RESULTS

A weighted total of 170,579 patients experienced upper extremity PNI, representing a mean incidence of 43.8/1 million people annually. Mean (± SEM) age of patients was 38.1 ± 0.05 years, 74.3% of patients were male, and 49.0% were Caucasian. PNIs occurred to the ulnar (17.8%), radial (15.1%), digital (18.0%), median (13.0%), multiple (11.5%), and other (10.1%) nerves and brachial plexus (14.5%). The number of upper extremity PNIs decreased overall. Average care charge was $47,004 ± $185, with an average increase of $4623/year and compound annual growth rate of 9.59%. Although surgical nerve repair and home disposition were common with isolated PNIs, patients with brachial plexus PNIs did not have nerve surgery and were more likely to be discharged to skilled nursing facilities. Multivariate analysis showed that length of stay (β = 0.677, P = 0.0001) and number of procedures (β = 0.188, P = 0.0001) most affected total patient charges.

CONCLUSIONS

These results suggest an overall decrease in number of PNIs, suggesting lower incidence or frequency of detection; however, the cost of care has increased. Despite advances in nerve repair techniques, nerve surgery rates have not increased, especially for brachial plexus injuries, which may be undertreated.