1
|
Jain B, Rahim FO, Thirumala PD, McGarvey ML, Balzer J, Nogueira RG, van der Goes DN, de Havenon A, Sultan I, Ney J. Cost-benefit analysis of intraoperative neuromonitoring for cardiac surgery. J Stroke Cerebrovasc Dis 2024; 33:107576. [PMID: 38232584 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107576] [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: 06/10/2023] [Revised: 12/25/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) can detect large vessel occlusion (LVO) in real-time during surgery. The aim of this study was to conduct a cost-benefit analysis of utilizing IONM among patients undergoing cardiac surgery. METHODS A decision-analysis tree with terminal Markov nodes was constructed to model functional outcome, as measured via the modified Rankin Scale (mRS), among 65-year-old patients undergoing cardiac surgery. Our cost-benefit analysis compares the use of IONM (electroencephalography and somatosensory evoked potential) against no IONM in preventing neurological complications from perioperative LVO during cardiac surgery. The study was performed over a lifetime horizon from a societal perspective in the United States. Base case and one-way probabilistic sensitivity analyses were performed. RESULTS At a baseline LVO rate of 0.31%, the mean attributable lifetime expenditure for IONM-monitored cardiac surgeries relative to unmonitored cardiac surgeries was $1047.41 (95% CI, $742.12 - $1445.10). At a critical LVO rate of approximately 3.67%, the costs of both monitored and unmonitored cardiac surgeries were the same. Above this critical rate, implementing IONM became cost-saving. On one-way sensitivity analysis, variation in LVO rate from 0% - 10% caused lifetime costs attributable to receiving IONM to range from $1150.47 - $29404.61; variations in IONM cost, percentage of intervenable LVOs, IONM sensitivity, and mechanical thrombectomy cost exerted comparably minimal influence over lifetime costs. DISCUSSION We find considerable cost savings favoring the use of IONM under certain parameters corresponding to high-risk patients. This study will provide financial perspective to policymakers, clinicians, and patients alike on the appropriate use of IONM during cardiac surgery.
Collapse
Affiliation(s)
- Bhav Jain
- Stanford University School of Medicine, Stanford, CA, United States; Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Parthasarathy D Thirumala
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michael L McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Balzer
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Raul G Nogueira
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; UPMC Stroke Institute, Pittsburgh, PA, United States
| | - David N van der Goes
- Department of Economics, University of New Mexico, Albuquerque, NM, United States
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States; West Haven VA Medical Center, West Haven, CT, United States.
| |
Collapse
|
2
|
Jahangiri FR, Liang M, Huckabey M, Baloney N, Sharifi S. Carotid Endarterectomy Surgeries: A Multimodality Intraoperative Neurophysiological Monitoring Approach. Cureus 2022; 14:e26556. [PMID: 35936121 PMCID: PMC9348437 DOI: 10.7759/cureus.26556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/14/2022] Open
Abstract
Patients with untreated carotid artery stenosis remain at high risk for stroke. Carotid endarterectomy (CEA) is a surgical procedure for the treatment of symptomatic and severe asymptomatic carotid stenosis. A small percentage of patients who do not have good collateral circulation are at high risk of cerebral ischemia during the cross-clamping of the carotid artery. Aspects of CEA, such as cross-clamping and routine shunting, can also carry the risk of perioperative stroke through dislodgement of emboli causing thrombosis, therefore, selective shunting is highly recommended during the CEA procedure. A multimodality approach of intraoperative neurophysiological monitoring (IONM) techniques such as somatosensory evoked potential (SSEP) and electroencephalography (EEG) can be used to monitor cerebral perfusion throughout the duration of the surgery and to predict the need for a selective shunt after cross-clamping. Additional use of transcranial Doppler (TCD) in the multimodality approach can aid in visualizing the cerebral blood flow and detecting any microemboli that may also cause a stroke. A multimodality IONM approach has been reported as more sensitive and specific for predicting and minimizing any postoperative neurological deficits.
Collapse
|