1
|
Hoshikuma Y, Shimizu T, Toyota S, Murakami T, Achiha T, Takahara M, Touhara K, Hagioka T, Kobayashi M, Kishima H. Statistical Analysis of the Factors that Affect Postoperative Length of Hospital Stay after Unruptured Intracranial Aneurysm Treatment in Japan: A 20-year Nationwide Multicenter Study. Neurol Med Chir (Tokyo) 2024; 64:154-159. [PMID: 38355130 PMCID: PMC11099163 DOI: 10.2176/jns-nmc.2023-0142] [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: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 02/16/2024] Open
Abstract
Treatment strategies for unruptured intracranial aneurysms (UIAs) should be carefully considered with reference to rupture and complication rates. It is also important to minimize the length of hospital stay (LOS) and to ensure a high quality of medical care. In this study, we aim to clarify the factors that affect the LOS of patients treated for UIAs using the Inpatient Clinico-Occupational Database of the Rosai Hospital Group (ICOD-R). This was a nationwide-multicenter study based on ICOD-R data from 2000 to 2019. Patients diagnosed with UIAs who were treated with clipping or coiling were included in the study. Multivariate analysis was performed to identify the factors affecting LOS. LOS was also compared between groups classified by surgical procedure or treatment period. We identified 3294 patients on the database who underwent clipping or coiling of UIAs during the study period. Multivariate analysis revealed hospital admission during the early 2000s and the late 2010s, age, and treating institution to be significantly correlated with LOS (p < 0.05). There was a significant difference between the mean LOS of the clipping group (20.3 days) and the coiling group (9.65 days) (p < 0.001). Compared by treatment period, LOS significantly shortened over time. Our results suggest that the type of treatment, time of treatment, patient age, and the treating institution affect postoperative LOS for UIAs. Although coiling was found to lead to a lower average LOS than clipping, treatment selection should take the characteristics of each patient's aneurysm into consideration.
Collapse
|
2
|
Charalambous LT, Adil SM, Rajkumar S, Gramer R, Kirsch E, Liu B, Zomorodi A, McClellan M, Lad SP. A Nationwide Analysis of Aneurysmal Subarachnoid Hemorrhage Mortality, Complications, and Health Economics in the USA. Transl Stroke Res 2023; 14:347-356. [PMID: 35881231 PMCID: PMC10149048 DOI: 10.1007/s12975-022-01065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 06/21/2022] [Accepted: 07/13/2022] [Indexed: 11/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition. Endovascular coiling or surgical clipping have equivocal success rates, but relatively little is known regarding the health economics and complications of these procedures at the population level. We aimed to analyze the complication profiles and healthcare resource utilization (HRCU) associated with the treatment of aSAH in the USA. We performed a retrospective analysis utilizing the IBM MarketScan database between 2008 and 2015. Primary outcomes included economic analysis stratified by post-operative complication; determination of the effect of several factors on total cost by multivariable regression; and analysis of the incidence, timing, and associated HCRU of aSAH-related post-operative complications. Of the 2374 patients meeting inclusion criteria for economic analysis, 1783 (75.1%) patients had at least one of the ten complications. The most common complications included hydrocephalus (43.8%), transient cerebral ischemia (including vasospasm) (30.6%), ischemic stroke (29.1%), syndrome of inappropriate antidiuretic hormone (SIADH)/hyposmolarity/hyponatremia (22.1%), and seizures (14.9%). Patients who experienced complications had higher median 90-day total costs [$161,127 (Q1 to Q3, $101,411 to $257,662)] than those who did not [$97,376 (Q1 to Q3, $55,692 to $147,447)]. Length of stay was longest for those with pulmonary embolism and pneumonia (27 days) and shortest for those with SIADH/hyposmolarity/hyponatremia (16 days). Brain compression/herniation had the highest mortality rate (19.5%). In total, 14.6% of all patients experienced a readmission within 30 days. In conclusion, patients with aSAH have high post-operative complication rates and costs. Development of novel interventions to reduce complications and improve outcomes is crucial.
Collapse
Affiliation(s)
- Lefko T Charalambous
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
| | - Syed M Adil
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shashank Rajkumar
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Robert Gramer
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Elayna Kirsch
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Ali Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Mark McClellan
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Duke University, Box 3807, Durham, NC, 27710, USA.
- Duke-Robert J. Margolis Center for Health Policy, Duke University, Box 3807, Durham, NC, 27710, USA.
| |
Collapse
|
3
|
Nowicki KW, Mittal AM, Abou-Al-Shaar H, Rochlin EK, Lang MJ, Gross BA, Friedlander RM. A Future Blood Test to Detect Cerebral Aneurysms. Cell Mol Neurobiol 2023:10.1007/s10571-023-01346-4. [PMID: 37046105 DOI: 10.1007/s10571-023-01346-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023]
Abstract
Intracranial aneurysms are reported to affect 2-5% of the population. Despite advances in the surgical management of this disease, diagnostic technologies have marginally improved and still rely on expensive or invasive imaging procedures. Currently, there is no blood-based test to detect cerebral aneurysm formation or quantify the risk of rupture. The aim of this review is to summarize current literature on the mechanism of aneurysm formation, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future blood-based test. Efforts should be focused on clinical-translational approaches to create an assay to screen for cerebral aneurysm presence and risk-stratify patients to allow for superior treatment timing and management. Cerebral Aneurysm Blood Test Considerations: There are multiple caveats to development of a putative blood test to detect cerebral aneurysm presence.
Collapse
Affiliation(s)
- Kamil W Nowicki
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emma K Rochlin
- Loyola University Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
4
|
Labib MA, Rumalla K, Karahalios K, Srinivasan VM, Nguyen CL, Rahmani R, Catapano JS, Zabramski JM, Lawton MT. Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis. Neurosurgery 2022; 91:470-476. [PMID: 35876676 DOI: 10.1227/neu.0000000000002061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center. METHODS All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. RESULTS Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance. CONCLUSION Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.
Collapse
Affiliation(s)
- Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Cras TY, Hunink MMG, Dammers R, van Es ACGM, Volovici V, Burke JF, Kremers FCC, Dippel DWJ, Roozenbeek B. Surveillance of Unruptured Intracranial Aneurysms: Cost-Effectiveness Analysis for 3 Countries. Neurology 2022; 99:e890-e903. [PMID: 35654593 DOI: 10.1212/wnl.0000000000200785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES No consensus exists on adequate surveillance of conservatively managed unruptured intracranial aneurysms (UIAs). We aimed to determine optimal MRI surveillance strategies for the growth of UIAs using cost-effectiveness analysis. A secondary aim was to develop a clinical tool for personalizing UIA surveillance. METHODS We designed a microsimulation model from a health care perspective simulating 100,000 55-year-old women to estimate costs and quality-adjusted life years (QALYs) over a lifetime horizon in the United States, the United Kingdom, and the Netherlands, using literature-derived model parameters. Country-specific costs and willingness-to-pay thresholds ($100,000/QALY for the United States, £30,000/QALY for the United Kingdom, and €80,000/QALY for the Netherlands) were used. Lifetime costs and QALYs were annually discounted at 3% for the United States, 3.5% for the United Kingdom, or 4% (costs) and 1.5% (QALYs) for the Netherlands. Strategies were no follow-up surveillance, follow-up with MRI in the first and fifth year after UIA discovery, every 5 years, every 2 years, or annually, or immediate intervention (i.e., clipping or coiling). Using the microsimulation model, we developed a tool for personalizing UIA surveillance for men and women, with different ages and varying aneurysm characteristics. Uncertainty in the input parameters was modeled with probabilistic sensitivity analysis. RESULTS Among 55-year-old women, 2,222 individuals in the United States, 1,910 in the United Kingdom, and 2,040 in the Netherlands needed to undergo an annual MRI scan to prevent 1 case of subarachnoid hemorrhage per year. No surveillance MRI was most cost-effective in the United States (in 47% of the simulations) and United Kingdom (in 54% of simulations), whereas annual MRI was most cost-effective in the Netherlands (in 53% of simulations). In the United States and United Kingdom, annual surveillance or surveillance in the first and fifth year after discovery was cost-effective in patients <60 years and at increased risk of aneurysm growth. The optimal, personalized, surveillance strategies were summarized in a look-up table for use in clinical practice. DISCUSSION Generally, the US and UK physicians should refrain from assigning patients, particularly older patients and those with few risk factors for aneurysm growth or rupture, to frequent MRI surveillance. In the Netherlands, annual follow-up is generally most cost-effective.
Collapse
Affiliation(s)
- Tim Yannick Cras
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Myriam M G Hunink
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Ruben Dammers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Adriaan C G M van Es
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Victor Volovici
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - James F Burke
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Femke C C Kremers
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Diederik W J Dippel
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor
| | - Bob Roozenbeek
- From the Departments of Neurology (T.Y.C., F.C.C.K., D.W.J.D., B.R.), Epidemiology (M.M.G.H.), Radiology & Nuclear Medicine (M.M.G.H., B.R.), Neurosurgery (R.D., V.V.), and Erasmus MC University Medical Center (T.Y.C., F.C.C.K., D.W.J.D., B.R., R.D.), Rotterdam, the Netherlands; Centre for Health Decision Sciences (M.M.G.H.), Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA; Department of Radiology (A.C.G.M.v.E.), Leiden University Medical Center, the Netherlands; and Department of Neurology (J.F.B.), University of Michigan, Ann Arbor.
| |
Collapse
|
6
|
Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:4909-4915. [DOI: 10.1007/s10072-022-06039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
|
7
|
Waqas M, Monteiro A, Cappuzzo JM, Tutino VM, Levy EI. Evolution of the patient-first approach: a dual-trained, single-neurosurgeon experience with 2002 consecutive intracranial aneurysm treatments. J Neurosurg 2022; 137:1751-1757. [PMID: 35364567 DOI: 10.3171/2022.2.jns22105] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The paradigm for intracranial aneurysm (IA) treatment is shifting toward a hybrid approach involving open and endovascular techniques. The authors chronicled the evolution of IA treatment by retrospectively examining a large series of IA cases treated by a single dual-trained neurosurgeon, focusing on evolving technology relative to the choice of treatment options, perioperative morbidity, and mortality. METHODS The aneurysm database at the authors' institution was searched to identify consecutive patients treated with endovascular or open microsurgical approaches by one neurosurgeon during an 18-year time span. Patients were included regardless of IA rupture status, location or morphology, or treatment modality. Data collected were baseline clinical characteristics, aneurysm size, treatment modality, operative complications, in-hospital mortality, and retreatment rate. RESULTS A total of 1858 patients with 2002 IA treatments were included in the study. Three-hundred fifty IAs (17.5%) were ruptured. Open microsurgery was performed in 504 aneurysms (25.2%) and endovascular surgery in 1498 (74.8%). Endovascular IA treatments trended toward a growing use of flow diversion during the last 11 years. In-hospital mortality was 1.7% overall, including 7.0% in ruptured and 0.5% in unruptured cases. The overall complication rate was 3.3%, including 3.4% for microsurgical cases and 3.3% for endovascular cases. The rate of retreatment was 3.6% after clipping and 10.7% for endovascular treatment. CONCLUSIONS This study demonstrates complementary use of open and endovascular approaches for IA treatment. By customizing treatment to the patient, comparable rates of procedural complications, mortality, and retreatment were achieved for both endovascular and microsurgical approaches.
Collapse
Affiliation(s)
- Muhammad Waqas
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Andre Monteiro
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Justin M Cappuzzo
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Vincent M Tutino
- Departments of1Neurosurgery and.,3Department of Biomedical Engineering and.,4Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo; and.,5Canon Stroke and Vascular Research Center, University at Buffalo
| | - Elad I Levy
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo.,5Canon Stroke and Vascular Research Center, University at Buffalo.,6Jacobs Institute, Buffalo, New York.,7Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo
| |
Collapse
|
8
|
Ridwan S, Kandyba JA, Schug A, Malsagov E, Karageorgos N, Hans FJ. Delayed Leukoencephalopathy and Foreign Body Reaction After Endovascular Treatment in Patients With Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage-A Systematic Review of the Literature. Front Surg 2022; 8:732603. [PMID: 35004833 PMCID: PMC8733731 DOI: 10.3389/fsurg.2021.732603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Delayed leukoencephalopathy and foreign body reaction are rare complications after endovascular treatment of intracranial aneurysms. However, cases are increasingly being described, given the rising case numbers and complexity. Methods: Clinical presentation, differentials, diagnostics, treatment, and formerly published data were reviewed in light of available cases. A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Results: This article provides an extensive literature review of previously described cases, and discusses the causes and management of this rare and delayed complication by referring to 17 articles on this topic, with a total of 50 cases with sufficient data in the literature. Furthermore, we present the case of a 53-year-old female patient with subarachnoid hemorrhage from a large anterior communicating artery aneurysm with tortuous cervical vessels who was treated with endovascular coiling and has suffered delayed leukoencephalopathy 6 weeks after discharge. Diagnostics, treatment, and clinical course of this rare complication are presented on this case and based on formerly published literature. The patient timely recovered under high dose corticosteroid treatment and follow up MRI showed almost complete remission of the described lesions within 10 days in accordance with previously published data. Conclusion: Foreign body reaction might result in delayed leukoencephalopathy, especially following complex endovascular aneurysm treatment. Early high dose followed by low dose ongoing corticosteroid treatment might result in timely remission.
Collapse
Affiliation(s)
- Sami Ridwan
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | - Jörg Andreas Kandyba
- Department of Interventional Neuroradiology, Marien-Hospital Osnabrueck, Osnabrueck, Germany
| | - Anita Schug
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | - Elina Malsagov
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| | | | - Franz-Josef Hans
- Department of Neurosurgery, Paracelsus-Klinik Osnabrueck, Osnabrueck, Germany
| |
Collapse
|
9
|
Chen Y. Prediction and Analysis of Length of Stay Based on Nonlinear Weighted XGBoost Algorithm in Hospital. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:4714898. [PMID: 34900191 PMCID: PMC8654524 DOI: 10.1155/2021/4714898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/18/2022]
Abstract
An improved nonlinear weighted extreme gradient boosting (XGBoost) technique is developed to forecast length of stay for patients with imbalance data. The algorithm first chooses an effective technique for fitting the duration of stay and determining the distribution law and then optimizes the negative log likelihood loss function using a heuristic nonlinear weighting method based on sample percentage. Theoretical and practical results reveal that, when compared to existing algorithms, the XGBoost method based on nonlinear weighting may achieve higher classification accuracy and better prediction performance, which is beneficial in treating more patients with fewer hospital beds.
Collapse
Affiliation(s)
- Yong Chen
- The Affiliated Hospital of Chengde Medical College, Chengde, Hebei 067000, China
| |
Collapse
|
10
|
Lo YL, Bih ZL, Yu YH, Li MC, Chen HM, Wu SY. Long-Term Medical Resource Consumption between Surgical Clipping and Endovascular Coiling for Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched, Nationwide, Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115989. [PMID: 34199671 PMCID: PMC8199713 DOI: 10.3390/ijerph18115989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
Purpose: To estimate long-term medical resource consumption in patients with subarachnoid aneurysmal hemorrhage (SAH) receiving surgical clipping or endovascular coiling. Patients and methods: From Taiwan’s National Health Insurance Research Database, we enrolled patients with aneurysmal SAH who received clipping or coiling. After propensity score matching and adjustment for confounders, a generalized linear mixed model was used to determine significant differences in the accumulative hospital stay (days), intensive care unit (ICU) stay, and total medical cost for aneurysmal SAH, as well as possible subsequent surgical complications and recurrence. Results: The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping, respectively) who were eligible for further analysis. The mean accumulative hospital stay significantly differed between coiling (31.2 days) and clipping (46.8 days; p < 0.0001). After the generalized linear model adjustment of gamma distribution with a log link, compared with the surgical clipping procedure, the adjusted odds ratios (aOR; 95% confidence interval [CI]) of the medical cost of accumulative hospital stay for the endovascular coil embolization procedure was 0.63 (0.60, 0.66; p < 0·0001). The mean accumulative ICU stay significantly differed between the coiling and clipping groups (9.4 vs. 14.9 days; p < 0.0001). The aORs (95% CI) of the medical cost of accumulative ICU stay in the endovascular coil embolization group was 0.61 (0.58, 0.64; p < 0.0001). The aOR (95% CI) of the total medical cost of index hospitalization in the endovascular coil embolization group was 0·85 (0.82, 0.87; p < 0.0001). Conclusions: Medical resource consumption in the coiling group was lower than that in the clipping group.
Collapse
Affiliation(s)
- Yang-Lan Lo
- Department of Neurosurgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Zen Lang Bih
- Department of Emergency Medicine, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan;
| | - Ying-Hui Yu
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ming-Chang Li
- Department of Colorectal Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan; (Y.-H.Y.); (M.-C.L.)
| | - Ho-Min Chen
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung 413, Taiwan;
- Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan 256, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung 413, Taiwan
- Graduate Institute of Business Administration, Fu Jen Catholic University, Taipei 242062, Taiwan
- Centers for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan
- Correspondence: or
| |
Collapse
|
11
|
Pontes FGDB, da Silva EM, Baptista-Silva JC, Vasconcelos V. Treatments for unruptured intracranial aneurysms. Cochrane Database Syst Rev 2021; 5:CD013312. [PMID: 33971026 PMCID: PMC8109849 DOI: 10.1002/14651858.cd013312.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unruptured intracranial aneurysms are relatively common lesions in the general population, with a prevalence of 3.2%, and are being diagnosed with greater frequency as non-invasive techniques for imaging of intracranial vessels have become increasingly available and used. If not treated, an intracranial aneurysm can be catastrophic. Morbidity and mortality in aneurysmal subarachnoid hemorrhage are substantial: in people with subarachnoid hemorrhage, 12% die immediately, more than 30% die within one month, 25% to 50% die within six months, and 30% of survivors remain dependent. However, most intracranial aneurysms do not bleed, and the best treatment approach is still a matter of debate. OBJECTIVES To assess the risks and benefits of interventions for people with unruptured intracranial aneurysms. SEARCH METHODS We searched CENTRAL (Cochrane Library 2020, Issue 5), MEDLINE Ovid, Embase Ovid, and Latin American and Caribbean Health Science Information database (LILACS). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform from inception to 25 May 2020. There were no language restrictions. We contacted experts in the field to identify further studies and unpublished trials. SELECTION CRITERIA Unconfounded, truly randomized trials comparing conservative treatment versus interventional treatments (microsurgical clipping or endovascular coiling) and microsurgical clipping versus endovascular coiling for individuals with unruptured intracranial aneurysms. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion according to the above criteria, assessed trial quality and risk of bias, performed data extraction, and applied the GRADE approach to the evidence. We used an intention-to-treat analysis strategy. MAIN RESULTS We included two trials in the review: one prospective randomized trial involving 80 participants that compared conservative treatment to endovascular coiling, and one randomized controlled trial involving 136 participants that compared microsurgical clipping to endovascular coiling for unruptured intracranial aneurysms. There was no difference in outcome events between conservative treatment and endovascular coiling groups. New perioperative neurological deficits were more common in participants treated surgically (16/65, 24.6%; 15.8% to 36.3%) versus 7/69 (10.1%; 5.0% to 19.5%); odds ratio (OR) 2.87 (95% confidence interval (CI) 1.02 to 8.93; P = 0.038). Hospitalization for more than five days was more common in surgical participants (30/65, 46.2%; 34.6% to 58.1%) versus 6/69 (8.7%; 4.0% to 17.7%); OR 8.85 (95% CI 3.22 to 28.59; P < 0.001). Clinical follow-up to one year showed 1/48 clipped versus 1/58 coiled participants had died, and 1/48 clipped versus 1/58 coiled participants had become disabled (modified Rankin Scale > 2). All the evidence is of very low quality. AUTHORS' CONCLUSIONS There is currently insufficient good-quality evidence to support either conservative treatment or interventional treatments (microsurgical clipping or endovascular coiling) for individuals with unruptured intracranial aneurysms. Further randomized trials are required to establish if surgery is a better option than conservative management, and if so, which surgical approach is preferred for which patients. Future studies should include consideration of important characteristics such as participant age, gender, aneurysm size, aneurysm location (anterior circulation and posterior circulation), grade of ischemia (major stroke), and duration of hospitalizations.
Collapse
Affiliation(s)
| | - Edina Mk da Silva
- Emergency Medicine and Evidence Based Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Evidence Based Medicine, Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
12
|
Ridwan S, Urbach H, Greschus S, Hagen JV, Esche J, Boström A. Health Economic Aspects of Aneurysmal Subarachnoid Hemorrhage: Factors Determining First Year In-Hospital Treatment Expenses. J Neurol Surg A Cent Eur Neurosurg 2021; 82:204-210. [PMID: 33486751 DOI: 10.1055/s-0040-1720982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Spontaneous aneurysmal subarachnoid hemorrhage (SAH) is a common neurosurgical emergency with a high case fatality rate. The clinical course of SAH generates high health economic expenses. Here we highlight possible cost-driving factors for in-hospital care expenses for the first year. Furthermore, results are compared with ischemic stroke treatment. METHODS One hundred and one patients with aneurysmal SAH treated in our hospital from 2007 through 2009 were included. The Hunt and Hess (HH) scale, World Federation of Neurosurgical Societies (WFNS) scale, Fisher Scale, and further outcome-relevant data were recorded. Expenses were calculated using the German fixed case rate classification system consisting of Diagnosis-Related Groups (DRG) and the Operation and Procedure catalogue (OPS). Overall acute length of stay (LOS) and LOS on the intensive care unit (ICU) were separately evaluated. Expenses were compared with formerly published first-year costs of ischemic stroke. RESULTS Fifty-four percent of the patients (median age 52 years, 69% females) received coiling and 46% clipping. Acute in-hospital treatment accounted for 82% of total in-hospital expenses, while consequential in-hospital treatment accounted only for 18%. Altogether, the total first-year in-hospital expenses for all patients were as high as €2,650,002, resulting in average SAH in-hospital treatment expenses of €26,238 per patient for the first year. Poor clinical condition on admission and longer stay in ICU are the main cost-driving factors. The impact of the aneurysm treatment method is debatable. Only a poor HH grade and longer ICU stay are independent cost-driving factors. SAH treatment expenses are far higher than treatment costs for ischemic stroke in the literature (€6,731 for first-year inpatient and €3,287 for outpatient treatment). CONCLUSIONS Clinical condition and LOS determine in-hospital expenses after SAH. Aneurysmal SAH prevalently results in a relevant economic impact on the health system exceeding formerly published treatment expenses for ischemic stroke.
Collapse
Affiliation(s)
- Sami Ridwan
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany.,Department of Neurosurgery, Paracelsus Hospital Osnabruck, Osnabruck, Germany
| | - Horst Urbach
- Department of Radiology, University Hospital Bonn, Bonn, Germany.,Department of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
| | - Susanne Greschus
- Department of Radiology, University Hospital Bonn, Bonn, Germany.,Department of Radiology, Evangelische Kliniken Johanniter- und Waldkrankenhaus Bonn gGmbH, Bonn, Germany
| | | | - Jonas Esche
- Department of Nutrition and Food Science, Universität Bonn, Bonn, Germany
| | - Azize Boström
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany.,Department of Neurosurgery, MediClin Robert Janker Hospital, Bonn, Germany
| |
Collapse
|
13
|
Koo AB, Elsamadicy AA, Lin IH, David WB, Sujijantarat N, Santarosa C, Cord BJ, Zetchi A, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Predictors of Extended Length of Stay Following Treatment of Unruptured Adult Cerebral Aneurysms: A Study of The National Inpatient Sample. J Stroke Cerebrovasc Dis 2020; 29:105230. [PMID: 33066916 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In an unprecedented era of soaring healthcare costs, payers and providers alike have started to place increased importance on measuring the quality of surgical procedures as a surrogate for operative success. One metric used is the length of hospital stay (LOS) during index admission. For the treatment of unruptured cerebral aneurysms, the determinants of extended length of stay are relatively unknown. The aim of this study was to identify the patient- and hospital-level factors associated with extended LOS following treatment for unruptured cerebral aneurysms. METHODS The National Inpatient Sample years 2010 - 2014 was queried. Adults (≥18 years) with unruptured aneurysms undergoing either clipping or coiling were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Extended LOS was defined as greater than 75th percentile for the entire cohort (>5 days). Weighted patient demographics, comorbidities, complications, LOS, disposition and total cost were recorded. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted extended LOS. The primary outcome was the degree which patient comorbidities or postoperative complications correlated with extended LOS. RESULTS A total of 46,880 patients were identified for which 9,774 (20.8%) patients had extended LOS (Normal LOS: 37,106; Extended LOS: 9,774). Patients in the extended LOS cohort presented with a greater number of comorbidities compared to the normal LOS cohort. A greater proportion of the normal LOS cohort was coiled (Normal LOS: 63.0% vs. Extended LOS: 33.5%, P<0.001), while more patients in the extended LOS cohort were clipped (Normal LOS: 37.0% vs. Extended LOS: 66.5%, P<0.001). The overall complication rate was higher in the extended LOS cohort (Normal LOS: 7.3% vs. Extended LOS: 43.8%, P<0.001). On average, the extended LOS cohort incurred a total cost nearly twice as large (Normal LOS: $26,050 ± 13,430 vs. Extended LOS: $52,195 ± 37,252, P<0.001) and had more patients encounter non-routine discharges (Normal LOS: 8.5% vs. Extended LOS: 52.5%, P<0.001) compared to the normal LOS cohort. On weighted multivariate logistic regression, multiple patient-specific factors were associated with extended LOS. These included demographics, preadmission comorbidities, choice of procedure, and inpatient complications. The odds ratio for extended LOS was 5.14 (95% CI, 4.30 - 6.14) for patients with 1 complication and 19.58 (95% CI, 15.75 - 24.34) for patients with > 1 complication. CONCLUSIONS Our study demonstrates that extended LOS after treatment of unruptured aneurysms is influenced by a number of patient-level factors including demographics, preadmission comorbidities, type of aneurysm treatment (open surgical versus endovascular), and, importantly, inpatient complications. A better understanding of these independent predictors of prolonged length of hospital stay may help to improve patient outcomes and decrease overall healthcare costs.
Collapse
Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - I-Hsin Lin
- Yale Center for Analytical Sciences, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | | | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Akli Zetchi
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
14
|
Park HR, Kim JH, Park S, Chang JC, Park SQ. National Trends in the Treatment of Ruptured Cerebral Aneurysms in Korea Using an Age-adjusted Method. J Korean Med Sci 2020; 35:e323. [PMID: 33045768 PMCID: PMC7550236 DOI: 10.3346/jkms.2020.35.e323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/04/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Two primary treatment methods are used for ruptured cerebral aneurysms, surgical clipping and endovascular coiling. In recent decades, endovascular coiling has shown remarkable progress compared to surgical clipping, along with technological developments. The aim of this study was to investigate the recent trends in treatments for ruptured cerebral aneurysms in Korea. METHODS The data were obtained from the National Health Insurance database. We evaluated the trends in endovascular coiling and surgical clipping for ruptured aneurysms for the period 2000-2017. We obtained the number of prescriptions with International Classification of Diseases, 9th Revision, clinical modification codes related to nontraumatic subarachnoid hemorrhage and prescription codes S4641/4642 for surgical clipping and M1661/1662 for endovascular coiling. The medical expenses for each prescription were also obtained. The primary outcomes included the cumulative number of patients, patient rates per 100,000 people, and the correlation between patient rates and the percentage of the population in each age group. RESULTS In the case of surgical clipping, there were no increasing or decreasing trends in the cumulative number of patients when the population/age group was ignored. When examining the trends in patient rates per 100,000 population at each year in male, there was no increasing or decreasing trend in the number of surgical clippings between the age groups, in spite of a decreasing tendency in the number of surgical clipping in male in their 40s and older than 60. In females, the surgical clipping rates tended to decrease only in patients older than 60 years, but there was no tendency to increase or decrease in the other ages. In contrast, the cumulative number of patients who underwent endovascular coiling for ruptured cerebral aneurysms increased year by year regardless of the population/age group. In both male and female, there was no increasing or decreasing trend only in the group aged 40 or younger and there was an increasing tendency in the rest of the age groups. In the trend of medical expenses, both the cost of surgical clipping and endovascular coiling showed increases. Specifically, the medical expense trend in endovascular coiling increased more rapidly than that for surgical clipping. CONCLUSION There was a significant increase in the proportion of patients with ruptured aneurysms undergoing endovascular coiling between 2010 and 2017, whereas the use of surgical clipping decreased. The endovascular coiling was significantly increased in all age groups and surgical clipping was decreased in all age groups, especially in patients under 50 years of age.
Collapse
Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Chil Chang
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
| |
Collapse
|
15
|
Xia D, Zhou P, Li L, Xia Y, Hao Z, Zhang Y, Xu S. Application of a novel shape-memory alloy concentrator in displaced olecranon fractures: a report of the technique and mid-term clinical results. J Orthop Surg Res 2020; 15:453. [PMID: 33008473 PMCID: PMC7531136 DOI: 10.1186/s13018-020-01982-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/23/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose Olecranon fracture is a common upper limb fracture, and several surgical approaches have been advocated for its fixation. To overcome the complications associated with common techniques, we present a novel shape-memory alloy concentrator, an alternative for tension band compression, to fix olecranon fracture. Methods Fifty-seven patients (26 men and 31 women) with olecranon fracture, with a mean age of 45 years, were included in this study. Each patient had undergone open reduction and internal fixation using the Nitinol (Ni-Ti) arched shape-memory connector (ASC). The clinical assessments were performed using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Mayo Elbow Performance (MEP) score, which were both recorded at the final follow-up visit. Results The patients were followed up for 44 months on average (range, 31 to 56 months). No patients were lost to follow-up, and all of the olecranon fractures healed in an average of 15 weeks (range, 10 to 34 weeks). The mean DASH score was 8.6 (range, 0 to 32.4), and the mean MEP score was 92.5 (range, 74 to 100). Nine patients showed postoperative complications: prominent hardware (2), infection (1), loss of the range of functional motion (5), and heterotopic ossification (1). Conclusion The ASC may serve as a favorable device for multi-fragmented and comminuted fractures with rare hardware irritation and may also provide continuous concentrative compression to accelerate osseous healing, thereby aiding the restoration and permitting an early rehabilitation with a low incidence of postoperative complications.
Collapse
Affiliation(s)
- Demeng Xia
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China.,Department of Orthopaedics, Eastern Theater Naval Hospital, No. 98, Wenhua St, Zhoushan, Zhejiang, 316000, People's Republic of China
| | - Panyu Zhou
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China
| | - Lei Li
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China
| | - Yan Xia
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China
| | - Zichen Hao
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China
| | - Yuntong Zhang
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China.
| | - Shuogui Xu
- Department of Emergency, Changhai Hospital, the Naval Medical University, No.168, Changhai St, Shanghai, 200433, People's Republic of China.
| |
Collapse
|
16
|
Roark CD, Beseler C, Wiley LK, Case D, Folzenlogen Z, Hosokawa P, Seinfeld J. Predictors of 90-Day Readmission Rate After Unruptured Intracranial Aneurysm Repair. World Neurosurg 2020; 141:e728-e735. [PMID: 32525089 DOI: 10.1016/j.wneu.2020.05.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The repair of unruptured intracranial aneurysms has increased since 2000. In this study, we analyzed the Nationwide Readmission Database (NRD) to determine the rate of 90-day readmission. Our objective is to examine readmission trends after unruptured aneurysm repair. METHODS This study used the 2013 and 2014 NRD. Patient data included standard demographic, comorbidity, and payer information. We selected patients who had undergone microsurgical or endovascular repair for a nonruptured aneurysm. We excluded patients who were under 18 years of age, had a subarachnoid hemorrhage, or were discharged to home the same day. Readmission was calculated by counting the number of days between the end of the index visit and earliest readmission date. RESULTS A total of 2180 of 29,694 patients (7.34%) were readmitted within 90 days of their initial hospitalization. They were younger (mean, 52.6 years; 95% confidence interval [CI], 51.4-53.8) than patients not readmitted (mean, 57.4 years; 95% CI, 57.1-57.8; P < 0.0001). In total, endovascular repair was more frequent than microsurgery (79.8% vs. 20.2%, respectively). Mean days to readmission was 41.8 (95% CI, 39.7-43.9) and was higher for women (P < 0.0001). The odds ratio for readmission after an endovascular repair was 1.54 (95% CI, 1.27-1.86). CONCLUSIONS In this study of over 28,000 patients treated for an unruptured aneurysm, the 90-day readmission rate was 7.34%. Endovascular patients had higher odds of readmission than microsurgical patients. Patients with common medical comorbidities (hypertension, obesity, renal failure, and diabetes) were less likely to be readmitted than patients without those conditions.
Collapse
Affiliation(s)
| | - Cheryl Beseler
- Department of Psychology, Colorado State University, Fort Collins, Colorado, USA
| | - Laura K Wiley
- Division of Bioinformatics and Personalized Medicine, University of Colorado, Aurora, Colorado, USA
| | - David Case
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, USA
| | - Zach Folzenlogen
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, USA
| | - Patrick Hosokawa
- Adult and Child Center for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, Colorado, USA
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado, Aurora, Colorado, USA; Department of Radiology, University of Colorado, Aurora, Colorado, USA
| |
Collapse
|
17
|
Outcome of Microsurgical Clipping for Multiple Versus Single Intracranial Aneurysms: A Single-Institution Retrospective Comparative Cohort Study. World Neurosurg 2020; 143:e590-e603. [PMID: 32781147 DOI: 10.1016/j.wneu.2020.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the results of microsurgical clipping for single intracranial aneurysm (SIA) and multiple intracranial aneurysms (MIA) and compare the outcomes. METHODS All patients who underwent surgery for intracranial aneurysm (IA) at our institution over a 3-year period (June 2013 to May 2016) were included in this study. RESULTS A total of 157 patients with 225 IAs were included. Forty-one of these patients had MIA (109 IAs, mean, 2.7 ± 1.2; range, 2-7), and remaining 116 had SIA. In the patients with MIA, all aneurysms were secured during the same admission whenever possible. Depending on the locations of the IAs and condition of brain during surgery (tense/lax), all aneurysms were secured on same day (in a single session, single or multiple craniotomy in 28 patients) or on different days (multiple sessions in 13 patients). Postoperative control angiography (DSA) before discharge could be done for 216 aneurysms (MIA, n = 105; SIA, n = 111). Successful occlusion of the aneurysm from circulation was noted in 96.2% (101/105) of MIA and 93.7% (104/111) of SIA. Follow-up of 6 months or longer was available for 146 patients. A modified Rankin Scale score ≤2 was considered a good outcome. Univariate analysis of the entire group revealed no significant difference in clinical outcomes between patients with SIA and MIA both at discharge (good outcome: MIA, 82.9%; SIA, 93.1%; P = 0.068) and at a final follow-up of ≥6 months (good outcome: MIA, 87.2%; SIA, 94.4%; P = 0.164). Clipping for MIA was not associated with poor outcome in multivariate analysis. CONCLUSIONS Comparable clinical outcomes and high rates of complete aneurysm occlusion following microsurgical clipping can be expected in patients with SIA and patients with MIA.
Collapse
|
18
|
Luther E, McCarthy DJ, Brunet MC, Sur S, Chen SH, Sheinberg D, Hasan D, Jabbour P, Yavagal DR, Peterson EC, Starke RM. Treatment and diagnosis of cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era: trends and outcomes. J Neurointerv Surg 2020; 12:682-687. [PMID: 31959634 DOI: 10.1136/neurintsurg-2019-015418] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Following publication of the International Subarachnoid Aneurysm Trial (ISAT), treatment paradigms for cerebral aneurysms (CAs) shifted from open surgical clipping to endovascular embolization as primary therapy in a majority of cases. However, comprehensive analyses evaluating more recent CA diagnosis patterns, patient populations and outcomes as a function of treatment modality remain rare. METHODS The National Inpatient Sample from 2004 to 2014 was reviewed. Aneurysmal subarachnoid hemorrhages (aSAHs) and unruptured intracranial aneurysms (UIAs) with a treatment of surgical clipping or endovascular therapy (EVT) were identified. Time trend series plots were created. Linear and logistic regressions were utilized to quantify treatment changes. RESULTS 114 137 aSAHs and 122 916 UIAs were reviewed. aSAH (+732/year, p=0.014) and UIA (+2550/year, p<0.0001) discharges increased annually. The annual caseload of surgical clippings for aSAH decreased (-264/year, p=0.0002) while EVT increased (+366/year, p=0.0003). For UIAs, the annual caseload for surgical clipping remained stable but increased for EVT (+615/year, p<0.0001). The rate of incidentally diagnosed UIAs increased annually (+1987/year; p<0.0001). Inpatient mortality decreased for clipping (p<0.0001) and EVT in aSAH (p<0.0001) (2004 vs 2014-clipping 13% vs 11.7%, EVT 15.8% vs 12.7%). Mortality rates for clipped UIAs decreased over time (p<0.0001) and remained stable for EVT (2004 vs 2014-clipping 1.57% vs 0.40%, EVT 0.59% vs 0.52%). CONCLUSION Ruptured and unruptured CAs are increasingly being treated with EVT over clipping. Incidental unruptured aneurysm diagnoses are increasing dramatically. Mortality rates of ruptured aneurysms are improving regardless of treatment modality, whereas mortality in unruptured aneurysms is only improving for surgical clipping.
Collapse
Affiliation(s)
- Evan Luther
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David J McCarthy
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA .,Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Marie-Christine Brunet
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Samir Sur
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stephanie H Chen
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dallas Sheinberg
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David Hasan
- Neurological Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dileep R Yavagal
- Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
19
|
Surgical Versus Endovascular Management of Ruptured and Unruptured Intracranial Aneurysms: Emergent Issues and Future Directions. World Neurosurg 2019; 136:17-27. [PMID: 31899398 DOI: 10.1016/j.wneu.2019.12.127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/20/2019] [Accepted: 12/21/2019] [Indexed: 12/25/2022]
Abstract
Ideal management of unruptured intracranial aneurysms (UIAs) and ruptured intracranial aneurysms (RIAs) is a controversial issue. Over the last few decades, a significant paradigm shift has occurred away from open microsurgical clipping toward endovascular coil embolization. Multiple studies have been performed with mixed results. Some studies suggest that endovascular treatment produces better clinical and functional outcomes, but is associated with increased need for retreatment. Other studies report increased durability in aneurysms treated with microsurgical clipping, but that clipping may be associated with worse functional outcomes in some cases. Further complicating the dialogue are variable costs associated with different treatment modalities, including country-dependent cost differences. Here we provide a review of some of the major studies comparing open surgery versus endovascular treatment for both RIAs and UIAs to distill their key findings and corresponding implications for clinical practice. We relate these research results to our institution's experience with RIAs and UIAs and describe our approach to treatment of these conditions. Finally, we discuss implications of the paradigm shift for both open and endovascular surgery, including educational initiatives directed toward preserving important microsurgical tenets in the setting of diminishing surgical volume.
Collapse
|
20
|
Northam W, Chandran A, Adams C, Barczak-Scarboro NE, Quinsey C. Cranioplasty length of stay: Relationship with indication, surgical decision-making factors, and sex. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408619892141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Cranioplasty is being performed more often due to rising rates of decompressive craniectomy. Hospital length of stay is a quality metric which has not been directly studied after cranioplasty. This study aims to identify factors associated with length of stay after cranioplasty to better understand their outcomes. Patients and methods A retrospective review was conducted at a single academic center from 2007 to 2015 for all patients >18 years of age who received cranioplasty. Baseline data from 148 patients were recorded including demographics, clinical characteristics, and surgeon decision-making factors for cranioplasty. Post-operative complications within 30 days after cranioplasty were recorded in addition to disposition and discharge data. Weibull accelerated failure time models were used to identify significant associations with length of stay after cranioplasty. Results The overall post-operative complication rate was 27.0%, and the most frequent indication for craniectomy was traumatic brain injury. The majority (72.3%) of patients returned home, compared to other disposition, and median length of stay was 2.0 days (interquartile range = 2.0). Average length of stay was 7.7 days in men, as compared with 2.4 days in women, and even upon adjusting for covariate effects, length of stay was longer in men than in women irrespective of post-operative complications. When time-to-cranioplasty fell between 0 and 30 days, average length of stay was 19.2 days, as compared with 10.3 days when time-to-cranioplasty fell between 30 and 90 days, and 2.5 days when time-to-cranioplasty was >90 days. After adjustment for covariate effects, the association between time-to-cranioplasty and length of stay was maintained only in patients without post-operative complications. Conclusions Length of stay can inform our understanding of outcomes after cranioplasty. In our study, length of stay was associated with sex, indication for craniectomy, and surgical decision-making (time-to-cranioplasty and implant material), but time-to-cranioplasty was only associated in patients without post-operative complications. These relationships should be seen not as direct causation, but rather as tools to add to our understanding of this relatively complicated procedure.
Collapse
Affiliation(s)
- Weston Northam
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Avinash Chandran
- Matthew Gfeller Sport-Related TBI Research Center, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Crystal Adams
- Department of Neurosurgery, The GW School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| |
Collapse
|
21
|
Sonig A, Shallwani H, Natarajan SK, Shakir HJ, Hopkins LN, Snyder KV, Siddiqui AH, Levy EI. Better Outcomes and Reduced Hospitalization Cost are Associated with Ultra-Early Treatment of Ruptured Intracranial Aneurysms: A US Nationwide Data Sample Study. Neurosurgery 2019; 82:497-505. [PMID: 28541411 DOI: 10.1093/neuros/nyx241] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The benefit of surgical treatment of ruptured aneurysms is well established. OBJECTIVE To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost. METHODS Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses. RESULTS A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treated >admission day 0 (P < .0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P < .0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treated >day 0 ($272 989.56, P < .001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P < .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899). CONCLUSION Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.
Collapse
Affiliation(s)
- Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Hussain Shallwani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Sabareesh K Natarajan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Hakeem J Shakir
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - L Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York.,Jacobs Institute, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York.,Jacobs Institute, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sci-ences, University at Buffalo, State Uni-versity of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buf-falo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo New York
| |
Collapse
|
22
|
Jung YJ, Chang CH, Kim JH. Advantages of Coil Embolization Performed Immediately After Diagnostic Cerebral Digital Subtraction Angiography in Unruptured Intracranial Aneurysms: Patients' Perspective. World Neurosurg 2019; 130:e573-e576. [PMID: 31254708 DOI: 10.1016/j.wneu.2019.06.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND We are inevitably faced with the need to perform coil embolization immediately after diagnostic cerebral digital subtraction angiography (DSA) for economic reasons, patient convenience, fear of rupture, and other reasons. Here we report the advantages of coil embolization performed immediately after diagnostic cerebral DSA for unruptured intracranial aneurysms (UIAs) from the patients' perspective. METHODS Between January 2017 and October 2018, 145 patients were treated for UIAs with endovascular coil embolization at the Yeungnam University Medical Center. There were 87 patients in the group in which coil embolization was to be performed at least 1 week after diagnostic cerebral DSA (regular [R] group) and 58 patients in the group in which coil embolization was to be performed immediately after diagnostic cerebral DSA (immediate [I] group). RESULTS There were no statistically significant between group differences in any factor analyzed expect for medical expenses (out-of-pocket costs), 2,218,416 KRW (1963 USD) for the R group and 1,128,906 KRW (999 USD) for the I group (P < 0.001). There were no statistically significant differences in the rate of complications between the 2 groups, with 4 minor complications and 1 death in the R group and 3 minor complications and 1 death in the I group. CONCLUSIONS Our findings indicate that coil embolization performed immediately after diagnostic cerebral DSA can be a relatively safe alternative approach to treating patients with UIAs.
Collapse
Affiliation(s)
- Young-Jin Jung
- Department of Neurosurgery, College of Medicine, Yeungnam University, Namgu, Daegu, Korea
| | - Chul-Hoon Chang
- Department of Neurosurgery, College of Medicine, Yeungnam University, Namgu, Daegu, Korea
| | - Jong-Hoon Kim
- Department of Neurosurgery, College of Medicine, Yeungnam University, Namgu, Daegu, Korea.
| |
Collapse
|
23
|
Abecassis IJ, Sen R, Kelly CM, Levy S, Barber J, Ghodke B, Levitt M, Kim LJ, Sekhar LN. Clinical outcomes and cost-effectiveness analysis for the treatment of basilar tip aneurysms. J Neurointerv Surg 2019; 11:1210-1215. [DOI: 10.1136/neurintsurg-2019-014747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/24/2019] [Accepted: 04/28/2019] [Indexed: 12/27/2022]
Abstract
BackgroundEndovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up.ObjectiveTo characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping.Materials and methodsWe obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios.ResultsAverage index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 ± $47 100) compared with coil embolization ($33 500 ± $22 600), balloon-assisted coiling ($26 200 ± $11 600), and stent-assisted coiling ($38 500 ± $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width.ConclusionsCoil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year.
Collapse
|
24
|
Modi S, Shah K, Schultz L, Tahir R, Affan M, Varelas P. Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States. Clin Neurol Neurosurg 2019; 182:167-170. [PMID: 31151045 DOI: 10.1016/j.clineuro.2019.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/13/2019] [Accepted: 05/19/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost. PATIENTS AND METHODS Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs. RESULTS From 2002-2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11-23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40-59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60-79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost. CONCLUSION aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.
Collapse
Affiliation(s)
- Sumul Modi
- Department of Neurology, Henry Ford Macomb Hospital, 15855 19 Mile Road, Clinton Township, MI, 48038, United States
| | - Kavit Shah
- Department of Neurology, University of Pittsburgh Medical Center, 811 Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA, 15213, United States
| | - Lonni Schultz
- Departments of Public Health Sciences, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Rizwan Tahir
- Departments of Neurosurgery, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States.
| | - Muhammad Affan
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| | - Panayiotis Varelas
- Departments of Neurology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI, 48202, United States
| |
Collapse
|
25
|
Malhotra A, Wu X, Brinjikji W, Miller T, Matouk CC, Sanelli P, Gandhi D. Pipeline Endovascular Device vs Stent-Assisted Coiling in Small Unruptured Aneurysms: A Cost-Effectiveness Analysis. Neurosurgery 2019; 85:E1010-E1019. [DOI: 10.1093/neuros/nyz130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
AbstractBACKGROUNDBoth stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (<10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established.OBJECTIVETo analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence.METHODSA decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed.RESULTSIn base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED > 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by <55% and when those of SAC decreased by <37%. SAC only became cost-effective when the total cost of PED is >$73000 more expensive than the total cost of SAC.CONCLUSIONWith increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.
Collapse
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Waleed Brinjikji
- Department of Radiology and Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Timothy Miller
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Pina Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Dheeraj Gandhi
- Interventional Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
26
|
Pontes FGDB, Vasconcelos V, Baptista-Silva JCC, da Silva EMK. Treatments for unruptured intracranial aneurysms. Hippokratia 2019. [DOI: 10.1002/14651858.cd013312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Felipe Gomes de Barros Pontes
- University Hospital Prof. Alberto Antunes (Federal University of Alagoas); Department of Surgery; Maceio Alagoas Brazil 57036-730
| | - Vladimir Vasconcelos
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo Brazil 04038-001
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Edina MK da Silva
- Universidade Federal de São Paulo; Emergency Medicine and Evidence Based Medicine; Rua Borges Lagoa 564 cj 64 Vl. Clementino São Paulo São Paulo Brazil 04038-000
| |
Collapse
|
27
|
Engele T, Brettschneider C, Emami P, König HH. Cost Comparison of Surgical Clipping and Endovascular Coiling of Unruptured Intracranial Aneurysms: A Systematic Review. World Neurosurg 2019; 125:461-468. [PMID: 30743038 DOI: 10.1016/j.wneu.2019.01.195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Rupture of unruptured intracranial aneurysms (UIA) is the main cause for subarachnoid hemorrhage. UIA are widespread among the population. Advanced technology enables us to diagnose UIAs with increasing reliability and subsequently treat them. There are 2 main treatment options: surgical clipping and endovascular treatment of the aneurysm. This article aims to analyze costs of neurosurgical clipping and the endovascular approach to treat UIA, and to give an overview over the existing literature. METHODS A systematic literature search was conducted using the databases Ovid MEDLINE, PubMed, and NHS EED. Articles were divided into 2 groups based on the perspective from which costs were evaluated (health care provider or payer). Costs were inflated to the year 2015 and converted to international dollars. RESULTS The literature search yielded 137 different articles out of which 15 have been considered relevant and have been included in this review. Not only absolute numbers but also the cost ratio of both treatment modalities showed substantial variations. The coiling procedure tends to be more expensive for health care providers but cheaper for cost bearers. Without any exception, the authors determined shorter lengths of stay for patients who underwent the coiling procedure. CONCLUSIONS Due to different definitions of hospital costs and hardly reproducible calculations, comparability of the stated numbers is limited. Besides the economic impact, outcomes must be considered when making a treatment decision. The 2 treatment modalities are not equally suitable in every patient nor for every aneurysm location.
Collapse
Affiliation(s)
- Tobias Engele
- Department of Health Economics and Health Services Research, Hamburg, Germany
| | | | - Pedram Emami
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg, Germany
| |
Collapse
|
28
|
Zheng J, Xu R, Guo Z, Sun X. Alanine Aminotransferase Predicts Outcomes in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage. Curr Neurovasc Res 2019; 16:89-95. [PMID: 30706813 DOI: 10.2174/1567202616666190130094631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/12/2019] [Accepted: 01/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE With the aging of the world population, the number of elderly patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) is gradually growing. We aim to investigate the potential association between plasma ALT level and clinical complications of elderly aSAH patients, and explore its predictive value for clinical outcomes of elderly aSAH patients. METHODS Between January 2013 and March 2018, 152 elderly aSAH patients were analyzed in this study. Clinical information, imaging findings and laboratory data were reviewed. According to the Glasgow Outcome Scale (GOS), clinical outcomes at 3 months were classified into favorable outcomes (GOS 4-5) and poor outcomes (GOS 1-3). Logistic regression analysis was used to assess the indicators associated with poor outcomes, and receiver curves (ROC) and corresponding area under the curve (AUC) were used to detect the accuracy of the indicator. RESULTS A total of 48 (31.6 %) elderly patients with aSAH had poor outcome at 3 months. In addition to ICH, IVH, Hunt-Hess 4 or 5 Grade and Modified Fisher 3 or 4 Grade, plasma ALT level was also strongly associated with poor outcome of elderly aSAH patients. After adjusting for other covariates, plasma ALT level remained independently associated with pulmonary infection (OR 1.05; 95% CI 1.00-1.09; P = 0.018), cardiac complications (OR 1.05; 95% CI 1.01-1.08; P = 0.014) and urinary infection (OR 1.04; 95% CI 1.00-1.08; P = 0.032). Besides, plasma ALT level had a predictive ability in the occurrence of systemic complications (AUC 0.676; 95% CI: 0.586- 0.766; P<0.001) and poor outcome (AUC 0.689; 95% CI: 0.605-0.773; P<0.001) in elderly aSAH patients. CONCLUSION Plasma ALT level of elderly patients with aSAH was significantly associated with systemic complications, and had additional clinical value in predicting outcomes. Given that plasma ALT levels on admission could help to identify high-risk elderly patients with aSAH, these findings are of clinical relevance.
Collapse
Affiliation(s)
- Jianfeng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Rui Xu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Zongduo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, NO.1 of Youyi Rd, Yuzhong District, Chongqing, China
| |
Collapse
|
29
|
Jutras M, Khosa F. The Physician Payment Sunshine Act: Evaluating Industrial Payments in Radiology. Acad Radiol 2019; 26:86-92. [PMID: 29958777 DOI: 10.1016/j.acra.2018.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/10/2018] [Accepted: 04/12/2018] [Indexed: 10/28/2022]
Abstract
RATIONALE AND OBJECTIVES The characterization of payments made to physicians by pharmaceutical companies, device manufacturers, and group purchasing organizations is crucial for assessing potential conflicts of interest and their impact on practice patterns. This study examines the compensation received by general radiologists (GR) in the United States, as well as radiologists in the following five subspecialties: body imaging, neuroradiology, pediatric radiology, nuclear radiology and radiological physics, and vascular and interventional radiology. MATERIALS AND METHODS Data were extracted from the Open Payments database for radiology subspecialists in the United States who received installments in calendar year 2015 from pharmaceutical and device manufacturing companies. RESULTS In 2015, a total of $43,685,052 was paid in 65,507 payments (mean $667/payment; median $32/payment) to radiologists, including 9826 GR, 362 body imaging radiologists, 479 neuroradiologists, 127 pediatric radiologists, 175 physicians in nuclear radiology and radiological physics, and 1584 vascular and interventional radiologists. Payments were unequally distributed across these six major subspecialties of radiology (p < 0.01), with GR receiving the largest number of total payments (44,695), and neuroradiologists receiving significantly higher median payments than any other subspecialty ($80 vs $32 for all radiologists; p < 0.01). Medtronic Neurovascular was the single largest payer to all radiologists combined. CONCLUSION Commercial entities make substantial payments to radiologists, with a significant variation in payments made to the different radiology subspecialties. While the largest number of total payments was made to GGR, the highest median payments were made to neuroradiologists, and significant dispersion in these payments was seen across different geographic regions. The impact of these payments on practice patterns remains to be elucidated.
Collapse
|
30
|
Monsivais D, Morales M, Day A, Kim D, Hoh B, Blackburn S. Cost Analysis of Endovascular Coiling and Surgical Clipping for the Treatment of Ruptured Intracranial Aneurysms. World Neurosurg 2018; 124:S1878-8750(18)32850-X. [PMID: 30579007 DOI: 10.1016/j.wneu.2018.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cost-effectiveness analyses for the treatment of aneurysmal subarachnoid hemorrhage are necessary to determine health policy, treatment guidelines, and screening protocols for cerebral aneurysms. To perform these modeling studies, detailed cost data are necessary and are currently lacking. OBJECTIVE The goal of this study was to determine detailed inpatient cost of aneurysmal subarachnoid hemorrhage. METHODS A retrospective review of our ruptured subarachnoid hemorrhage database was performed to identify consecutive patients between January 2013 and December 2015. Patients were searched by International Classification of Disease 9 diagnosis and procedure codes. Patient demographics and clinical characteristics were acquired. The cost breakdown was compiled into a comprehensive itemized list encompassing all aspects of hospitalization. A mean cost based on resource used per patient was obtained. RESULTS There were 269 patients treated, 209 were coiled and 60 were clipped. Mean age in the clipping group was 49 years and 55 years in the coil group (P = 0.006). Other patient demographics and clinical characteristics were found to be statistically similar for both groups. Total cost per patient for treatment and hospital stay was $74,192 for clipping and $85,553 for coiling (P = 0.06). Cost amplified with increasing Hunt and Hess grade in both clipping and coiling groups. CONCLUSIONS The detailed cost information reported in this article can be used to help establish appropriate, standardized costs nationally by improving transparency. It can also help provide critical information necessary to develop cost-effective treatment algorithms and screening protocols.
Collapse
Affiliation(s)
- Daniel Monsivais
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Miriam Morales
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Arthur Day
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Dong Kim
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Brian Hoh
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| |
Collapse
|
31
|
Horcajadas A, Ortiz I, Jorques AM, Katati MJ. Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales. Neurocirugia (Astur) 2018; 29:267-274. [DOI: 10.1016/j.neucir.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/22/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
|
32
|
Donoho DA, Patel A, Buchanan IA, Chow F, Ding L, Amar AP, Attenello F, Mack WJ. Treatment at Safety-Net Hospitals Is Associated with Delays in Coil Embolization in Patients with Subarachnoid Hemorrhage. World Neurosurg 2018; 120:e434-e439. [PMID: 30205228 DOI: 10.1016/j.wneu.2018.08.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment. METHODS Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days). RESULTS Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals. CONCLUSIONS After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.
Collapse
Affiliation(s)
- Daniel A Donoho
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Arati Patel
- Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ian A Buchanan
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Frances Chow
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Li Ding
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Frank Attenello
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - William J Mack
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| |
Collapse
|
33
|
Chen JH, Huang CY, Lee YC, Wang KW, Liliang PC, Liang CL, Lu K, Chen HJ, Sun YT, Wang HK. Comparative Cost Analysis for the Surgical and Endovascular Treatment of Ruptured Intracranial Aneurysms in Taiwan: A Nationwide Population-Based Cohort Study. World Neurosurg 2018; 116:e485-e490. [PMID: 29758371 DOI: 10.1016/j.wneu.2018.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Using a database that enabled longitudinal follow-up, we assessed the cost, outcome, complications, and readmission rate of ruptured cerebral aneurysms repaired by surgical clipping and endovascular coiling. METHODS This study was a retrospective review of data from a series of patients who underwent surgical clipping or endovascular coiling of ruptured cerebral aneurysms between 1996 and 2013. The medical records and hospital cost data were all examined. RESULTS A total of 7690 and 1380 cases were treated with clipping and coiling, respectively. Patients treated with clipping had more comorbidities and were older. The average total cost for endovascular coiling was $13,974.3, whereas the average total cost for surgical clipping was $16,581.7. Perioperative (30-day) mortality was 10.7% in patients with coiled aneurysms, compared with 12.6% in those with clipped aneurysms (P = 0.045). After 1 year of follow-up, clipping was associated with a significantly longer length of hospital stay (P < 0.001) and significantly higher total hospital costs (P < 0.001). CONCLUSIONS In Taiwan, the total hospital costs for the surgical clipping of cerebral aneurysms were higher than for endovascular coiling, and the surgical results were associated with significant complications. We suggest that the indications for coiling might need to be expanded from the current standards dictated by the guidelines in Taiwan.
Collapse
Affiliation(s)
- Jian-Han Chen
- Department of General Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Yuan Huang
- Neurosurgical Service, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Che Lee
- Department of Nephrology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
| | - Kuo-Wei Wang
- Department of Neurosurgery, Cancer E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
| | - Po-Chou Liliang
- Department of Neurosurgery, Cancer E-Da Hospital, I-Shou University, Kaohsiung, Taiwan; School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
| | - Cheng-Loong Liang
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan; Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Kang Lu
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan; Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Han-Jung Chen
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan; Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yuan-Ting Sun
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Kuang Wang
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan; Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
| |
Collapse
|
34
|
Zhang X, Tang H, Huang Q, Hong B, Xu Y, Liu J. Total Hospital Costs and Length of Stay of Endovascular Coiling Versus Neurosurgical Clipping for Unruptured Intracranial Aneurysms: Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:393-399. [PMID: 29656151 DOI: 10.1016/j.wneu.2018.04.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Comparison of feasibility and safety between endovascular coiling versus neurosurgical clipping for the management of unruptured intracranial aneurysms (UIAs) has been incrementally reported. However, economic comparison has been rarely reported. This meta-analysis aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular versus neurosurgical treatment in UIA. METHODS MEDLINE, the Cochrane database, EMBASE, and Web of Science database were searched for cohort studies describing economic hospital cost or length of stay in patients with UIA. Two authors independently assessed study eligibility and rated quality using the Newcastle Ottawa Scale. Ravmen 5.2 was used to perform forest plot analysis. RESULTS Nine studies describing 24,856 UIAs treated with neurosurgical clipping and 31,309 UIAs treated with endovascular coiling were included. Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling and clipping in UIA patients (standard mean difference [SMD]: -0.33, 95% confidence interval: -0.68 to 0.02, I2 = 99%, P = 0.07). Subgroup analysis showed that THCs of coiling were significantly lower than clipping in the United States but opposite in South Korea. One-year medical costs of coiling were similar in both groups (SMD: -0.04, 95% CI: -0.08 to 0.00, I2 = 0%, P = 0.07). In addition, the length of stay of coiling were significantly shorter than that of clipping (SMD: 0.69, 95% CI: 0.56-0.81, I2 = 95%, P < 0.001). CONCLUSION Generally, no significant difference in THCs and 1-year medical costs between coiling versus clipping in UIAs was observed. However, the length of stay of endovascular coiling was much shorter than neurosurgical clipping and decreased over time.
Collapse
Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
35
|
Zhang X, Li L, Hong B, Xu Y, Liu Y, Huang Q, Liu J. A Systematic Review and Meta-Analysis on Economic Comparison Between Endovascular Coiling Versus Neurosurgical Clipping for Ruptured Intracranial Aneurysms. World Neurosurg 2018; 113:269-275. [PMID: 29476995 DOI: 10.1016/j.wneu.2018.02.078] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Healthcare expenditures and cost reduction have been under critical surveillance in all countries and are critical for policymakers. This review aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular coiling versus neurosurgical clipping in ruptured intracranial aneurysms (RAs). METHODS MEDLINE, the Cochrane database, Embase, and the Web of Science database were searched and evaluated independently by 2 authors according to the Newcastle-Ottawa Scale for cohort studies describing economic hospital cost or length of stay in patients with RAs. RESULTS A total of 8 studies were included, describing 24,219 RAs treated with neurosurgical clipping and 24,962 RAs with endovascular coiling. Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling versus clipping in RAs (standard mean difference [SMD], -0.05; 95% confidence interval [CI], -0.12 to 0.22; I2 = 99%; P = 0.50). Subgroup analysis showed that THCs of clipping and coiling were similar in ruptured aneurysms in the United States. However, in South Korea, the THCs of coiling were significantly higher than clipping. In the long run, 1-year medical costs of endovascular treatment were significantly lower than that of clipping in RAs (SMD, 0.15; 95% CI, 0.05-0.25; I2 = 66%; P = 0.005). In addition, the length of stay of coiled patients was significantly shorter than clipped patients (SMD, 0.29; 95% CI, 0.13-0.45; I2 = 96%; P < 0.001). CONCLUSIONS Medical costs were region-specified. In the United States, total hospital costs and 1-year medical costs were similar in RA patients treated with endovascular coiling and neurosurgical clipping. However, in countries like South Korea and China, coiling was more expensive. The length of stay was much shorter in coiled patients in all countries.
Collapse
Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Li Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
36
|
Abstract
BACKGROUND Guidelines and Class 1 evidence are strong factors that help guide surgeons' decision-making, but dilemmas exist in selecting the best surgical option, usually without the benefit of guidelines or Class 1 evidence. A few studies have discussed the variability of surgical treatment options that are currently available, but no study has examined surgeons' views on the influential factors that encourage them to choose one surgical treatment over another. This study examines the influential factors and the thought process that encourage surgeons to make these decisions in such circumstances. METHODS Semi-structured face-to-face interviews were conducted with 32 senior consultant surgeons, surgical fellows, and senior surgical residents at the University of Toronto teaching hospitals. An e-mail was sent out for volunteers, and interviews were audio-recorded, transcribed verbatim, and subjected to thematic analysis using open and axial coding. RESULTS Broadly speaking there are five groups of factors affecting surgeons' decision-making: medical condition, information, institutional, patient, and surgeon factors. When information factors such as guidelines and Class 1 evidence are lacking, the other four groups of factors-medical condition, institutional, patient, and surgeon factors (the last-mentioned likely being the most powerful)-play a significant role in guiding surgical decision-making. CONCLUSIONS This study is the first qualitative study on surgeons' perspectives on the influential factors that help them choose one surgical treatment option over another for their patients.
Collapse
|
37
|
Hammer A, Steiner A, Kerry G, Ranaie G, Baer I, Hammer CM, Kunze S, Steiner HH. Treatment of ruptured intracranial aneurysms yesterday and now. PLoS One 2017; 12:e0172837. [PMID: 28257502 PMCID: PMC5336199 DOI: 10.1371/journal.pone.0172837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 02/10/2017] [Indexed: 12/03/2022] Open
Abstract
Objective This prospective study is designed to detect changes in the treatment of ruptured intracranial aneurysms over a period of 17 years. Methods We compared 361 treated cases of aneurysm occlusion after subarachnoid hemorrhage from 1997 to 2003 with 281 cases from 2006 to 2014. Specialists of neuroradiology and vascular neurosurgery decided over the modality assignment. We established a prospective data acquisition in both groups to detect significant differences within a follow-up time of one year. With this setting we evaluated the treatment methods over time and compared endovascular with microsurgical treatment. Results When compared to the earlier group, microsurgical treatment was less frequently chosen in the more recent collective because of neck-configuration. Endovascular treatment was chosen more frequently over time (31.9% versus 48.8%). Occurrence of initial symptomatic ischemic stroke was significantly lower in the clipping group compared to the endovascular group and remained stable over time. The number of reinterventions due to refilled treated aneurysms significantly decreased in the endovascular group at one-year follow-up, but the significantly better occlusion- and reintervention-rate of the microsurgical group persisted. The rebleeding rate in the endovascular group at one year follow-up decreased from 6.1% to 2.2% and showed no statistically significant difference to the microsurgical group, anymore (endovascular 2.2% versus microsurgical 0.0%, p = 0.11). Conclusion Microsurgical clipping still has some advantages, however endovascular treatment is improving rapidly.
Collapse
Affiliation(s)
- Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
- * E-mail:
| | - Anahi Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Ghassan Kerry
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Gholamreza Ranaie
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Ingrid Baer
- Institute of Radiology and Neuroradiology, Klinikum Nuremberg, Nuremberg, Bavaria, Germany
| | - Christian M. Hammer
- Department of Anatomy 2, University of Erlangen-Nuremberg, Universitätsstraße 19, Erlangen, Bavaria, Germany
| | - Stefan Kunze
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Baden-Wuerttemberg, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| |
Collapse
|
38
|
Bekelis K, Gottlieb D, Su Y, Lanzino G, Lawton MT, MacKenzie TA. Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage. J Neurosurg 2017; 126:805-810. [PMID: 27203138 PMCID: PMC5549790 DOI: 10.3171/2016.2.jns152994] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The impact of treatment method-surgical clipping or endovascular coiling-on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score-adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.
Collapse
Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Dan Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | | | - Michael T. Lawton
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
39
|
Bekelis K, Gottlieb DJ, Su Y, O’Malley AJ, Labropoulos N, Goodney P, Lawton MT, MacKenzie TA. Comparison of clipping and coiling in elderly patients with unruptured cerebral aneurysms. J Neurosurg 2017; 126:811-818. [PMID: 27203150 PMCID: PMC5116411 DOI: 10.3171/2016.1.jns152028] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The comparative effectiveness of the 2 treatment options-surgical clipping and endovascular coiling-for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68-2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66-1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85-10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90-4.71). The same associations were present in propensity score-adjusted and inverse probability-weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS.
Collapse
Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon
| | - Daniel J. Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
| | - Nicos Labropoulos
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon
- Department of Biomedical Data Science, Hanover, New Hampshire
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
- Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon
| |
Collapse
|
40
|
Bekelis K, Gottlieb D, Su Y, Labropoulos N, Bovis G, Lawton MT, MacKenzie TA. Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for unruptured cerebral aneurysms. J Neurointerv Surg 2017; 9:324-328. [PMID: 27013232 PMCID: PMC5035560 DOI: 10.1136/neurintsurg-2016-012313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association between treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients. METHODS We performed a cohort study of 100% Medicare fee-for-service claims data for elderly patients who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding we used multivariable regression analysis with mixed effects to account for clustering at the Hospital Referral Region (HRR) level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period 8705 patients underwent treatment for unruptured cerebral aneurysms and met the inclusion criteria. Of these, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46 800 (IQR $31 000-$74 400) for surgical clipping and $48 100 (IQR $34 500-$73 900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3527 (95% CI $972 to $5736) and increased 1-year Medicare expenditures by $15 984 (95% CI $9017 to $22 951). CONCLUSIONS In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures compared with endovascular treatment.
Collapse
Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Dan Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Yin Su
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Nicos Labropoulos
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY
| | - George Bovis
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, CA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| |
Collapse
|
41
|
Ridwan S, Urbach H, Greschus S, von Hagen J, Esche J, Boström A. Health Care Costs of Spontaneous Aneurysmal Subarachnoid Hemorrhage for Rehabilitation, Home Care, and In-Hospital Treatment for the First Year. World Neurosurg 2017; 97:495-500. [DOI: 10.1016/j.wneu.2016.09.123] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/25/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
|
42
|
Chang HW, Shin SH, Suh SH, Kim BS, Rho MH. Cost-Effectiveness Analysis of Endovascular Coiling versus Neurosurgical Clipping for Intracranial Aneurysms in Republic of Korea. Neurointervention 2016; 11:86-91. [PMID: 27621944 PMCID: PMC5018553 DOI: 10.5469/neuroint.2016.11.2.86] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/10/2016] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The International Subarachnoid Aneurysm Trial (ISAT) revealed that in ruptured intracranial aneurysms (RA), endovascular coiling (EC) yields better clinical outcomes than neurosurgical clipping (NC) at 1 year. In unruptured aneurysms (UIA), EC is being increasingly used as an alternative to NC due to patients' preference. There is a lot of difference in treatment cost (EC vs. NC) between countries. There is one recently published study dealing with the comparative cost analysis only in UIAs in South Korea. But it is a hospital-based study. So, the authors performed a nation-wide cost effective comparison in our country. MATERIALS AND METHODS This study was a retrospective analysis of healthcare big data open systems in Health Insurance Review & Assessment Service (HIRA). Hospital cost data of the recent 5 years (from January 2010 to December 2014) were analyzed according to patients' age and sex and the presence of subarachnoid hemorrhage. RESULTS When comparing the total hospital costs for NC of a UIA (n=13,756) and EC of a UIA (n=17,666), NC [mean±standard deviation (SD): ₩7,987,179±3,855,029] resulted in significantly lower total hospital costs than EC [₩10,201,645±5,001,626, p<0.0001], although a shorter hospital stay with EC of a UIA [8.6 ±7.4 days] vs. NC [15.0 ±8.3 days, p<0.0001]. When comparing the total hospital costs for NC of a RA (n=7,293) and EC of a RA (n=6,954), NC [₩13,914,993±6,247,914] resulted in significantly lower total hospital costs than EC [₩16,702,446±7,841,141, p<0.0001], although shorter hospital stays for EC of a RA [19.8 ±11.4] vs. NC [23.0 ±10.3, p<0.0001]. CONCLUSION The total hospital costs for the NC of both UIAs and RAs were found to be lower than those for EC in South Korea.
Collapse
Affiliation(s)
- Hyuk Won Chang
- Department of Radiology, Keimyung University, School of Medicine & Dongsan Medical Center, Daegu, Korea
| | - Shang Hun Shin
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Myung Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea
| |
Collapse
|
43
|
Zanaty M, Daou B, Chalouhi N, Starke RM, Samaniego E, Derdeyn C, Jabbour P, Hasan D. Same-Day Discharge After Treatment with the Pipeline Embolization Device Using Monitored Anesthesia Care. World Neurosurg 2016; 96:31-35. [PMID: 27565476 DOI: 10.1016/j.wneu.2016.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The Pipeline Embolization Device (PED) has been used and shown to be safe under monitored anesthesia care (MAC). We present the results of the first study, to our knowledge, assessing the safety and feasibility of same-day discharge in patients undergoing treatment with the PED, using MAC. METHODS A total of 130 patients with 143 cerebral aneurysms (CAs) were identified. Patients were treated under MAC with the PED. All of the patients were counseled preoperatively about the elective nature of the procedure and the same-day discharge. RESULTS The mean age of the participants was 60.7 ± 12.12 years. Men constituted 27.69% (36/130) of the population. The number of procedures was 138. All of our patients elected to return home the same day, whereas only 6.15% (8/130) of them changed their mind in the postoperative setting and elected to stay overnight out of convenience (late discharge, patient preference, or living alone at home). Overall discharge home on the same day occurred after 90.6% of procedures (125/138) and in 91.53% (119/130) of the patients. All same-day discharges took place within 4-6 hours after the procedures. The rate of major complications was 0.75% (1/134). The mortality rate was 0%. CONCLUSIONS PED treatment under MAC is feasible and safe. This has brought forth an era of outpatient treatment of CAs where patients are discharged home 6 hours after the procedure.
Collapse
Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Edgar Samaniego
- Department of Neurology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Department of Radiology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA.
| |
Collapse
|
44
|
Abstract
Background Surgical clipping or endovascular coiling are the main procedures used in the treatment of cerebral aneurysms, with a preference for endovascular coiling. In Morocco, the number of patients needing endovascular coiling is growing, but many of them do not have access to this technique. The aim of this study was to determine the main parameters associated with variations in the total cost of this procedure in order to establish the amount (lump sum) that may be reimbursed by health insurance funds. Methods One hundred and seventeen patients with 124 aneurysms were admitted for treatment of one or more intracranial aneurysms between January 2010 and December 2015. The overall cost of hospitalization was assessed by using the micro-costing technique. The calculation was based on the tariffs of medical procedures as defined by the Ministry of Health in Morocco. A regression analysis was used to define the correlation between the overall cost and the various parameters. Results Univariate linear regression showed that the total cost was influenced by overall duration of hospitalization, ICU duration of hospitalization and size of aneurysm. On the other hand, univariate linear regression showed that the total cost was not influenced by sex, localization of aneurysm, and size of the aneurysm’s neck. However, multivariate linear regression showed that the total cost was influenced by one type of insurance health, overall duration of hospitalization, ICU duration of hospitalization, size of the aneurysm, and size of the aneurysm’s neck. Conclusion Setting a rate for reimbursement of patients who have had coiling treatment for a cerebral aneurysm should take into account the results of our study in order to limit the costs borne by patients. The parameters that influence the overall cost must be reimbursed in each case while the parameters that do not influence treatment costs could be included in a lump sum.
Collapse
|
45
|
Liu H, Park D, Hwang SM, Lee GY, Lim OK, Kim M, Lee DH, Park W, Koo HW, Yang K, Suh DC. Outpatient Day-care Neuroangiography and Neurointervention of Unruptured Intracranial Aneurysms. Neurointervention 2016; 11:37-41. [PMID: 26958411 PMCID: PMC4781915 DOI: 10.5469/neuroint.2016.11.1.37] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 02/26/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose Day-care management of unruptured intracranial aneurysms can shorten hospital stay, reduce medical cost and improve outcome. We present the process, outcome and duration of hospital stay for the management of unruptured intracranial aneurysms via a neurointervention clinic in a single center during the past four years. Materials and Methods We analyzed 403 patients who were referred to Neurointervention Clinic at Asan Medical Center for aneurysm evaluation between January 1, 2011 and December 31, 2014. There were 141 (41%) diagnostic catheter angiographies, 202 (59%) neurointerventional procedures and 2 (0.6%) neurointerventional procedures followed by operation. We analyzed the process, outcome of angiography or neurointervention, and duration of hospital stay. Results There was no aneurysm in 58 patients who were reported as having an aneurysm in MRA or CTA (14 %). Among 345 patients with aneurysm, there were 283 patients with a single aneurysm (82%) and 62 patients with multiple aneurysms (n=62, 18%). Aneurysm coiling was performed in 202 patients (59%), surgical clipping in 14 patients (4%), coiling followed by clipping in 2 patients (0.6%) and no intervention was required in 127 patients (37%). The hospital stay for diagnostic angiography was less than 6 hours and the mean duration of hospital stay was 2.1 days for neurointervention. There were 4 procedure-related adverse events (2%) including 3 minor and 1 major ischemic strokes. Conclusion Our study revealed that day-care management of unruptured intracranial aneurysms could be performed without an additional risk. It could enable rapid patient flow, shorten hospital stay and thus reduce hospital costs.
Collapse
Affiliation(s)
- Hairi Liu
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea.; Department of Interventional Radiology, Taizhou People's Hospital, Taizhou, Jiangsu Province 225300, P. R. China
| | - Danbi Park
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sun Moon Hwang
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ga Young Lee
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ok Kyun Lim
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Minjae Kim
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Deok Hee Lee
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Wonhyoung Park
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hae-Won Koo
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kuhyun Yang
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Chul Suh
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
46
|
Zweifel C, Sacho RH, Tymianski R, Radovanovic I, Tymianski M. Safety, efficacy, and cost of surgery for patients with unruptured aneurysms deemed unsuitable for endovascular therapy. Acta Neurochir (Wien) 2015; 157:2061-70; discussion 2070. [PMID: 26496925 DOI: 10.1007/s00701-015-2606-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Open surgery is a frequent option given to patients with unruptured intracranial aneurysms (UIAs) unsuitable for endovascular repair. Since the risk of rupture of UIAs is generally low, we determined whether the risks and costs of surgery in this patient subset are warranted. METHODS The safety, efficacy, and costs of minimally invasive surgery by minicraniotomy were evaluated in 102 consecutive patients with anterior circulation UIAs deemed unsuitable for endovascular repair by an interdisciplinary conference of surgeons and neurointerventionalists. Data from 107 UIA patients treated by endovascular means in the same period were used as the standard. RESULTS Surgical patients comprised a different subset of aneurysms, with more MCA and fewer paraophthalmic aneurysms (54 vs. 6, p < 0.0001 and 4 vs. 60, p < 0.0001, for minicraniotomy and endovascular, respectively). However, surgery incurred shorter anesthesia time (197.7 vs. 149.3 min, p < 0.0001), higher rates of complete aneurysm obliteration (94.57 vs. 66.67 %, p < 0.0001), and lower overall hospital costs ($8,287 CAD vs. $17,732 CAD, p < 0.0001) than the endovascular cohort. There were no treatment-related surgical deaths, but one patient had an mRS of 3 after 6 months due to temporal lobe epilepsy and memory problems. This compared favorably with the endovascular cohort in which two patients died due to treatment (mRS = 6) and one suffered a severe stroke (mRS = 5 at 6 months). CONCLUSIONS For patients counseled to undergo treatment but have UIAs unsuitable for endovascular repair, surgery is safe, effective, and cost-efficient.
Collapse
Affiliation(s)
- Christian Zweifel
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Raphael Hillel Sacho
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Rachel Tymianski
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael Tymianski
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, 4W-435, 399 Bathurst Street, M5T 2S8, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
47
|
Zakhari N, Lum C, Quateen A, Iancu D, Lesiuk H. Next day discharge after elective intracranial aneurysm coiling: is it safe? J Neurointerv Surg 2015; 8:983-6. [DOI: 10.1136/neurintsurg-2015-011953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/20/2015] [Indexed: 11/03/2022]
Abstract
BackgroundThere is a paucity of literature on early discharge after elective aneurysm treatment. We hypothesize that patient discharge on the next day is not associated with an increase in post-discharge adverse events.MethodsWe retrospectively reviewed elective coiling procedures between 2009 and 2013. The primary outcome measure was 30-day adverse events (emergency department visits, readmission or prolonged admission >30 days, and death). We evaluated the association between early and standard discharge for the primary outcome using the Fisher exact test. We also assessed the association of the primary outcome with other patient and technical variables as well as findings on pre-discharge diffusion weighted imaging.ResultsWe included 97 patients. Median length of hospital stay (LOS) was 2.52 days, and in 26 patients (26.8%) LOS was <2 days. There was no significant difference in post-discharge adverse outcome rates between early and standard discharge groups (19.2% vs 18.3%; p=1.000). The primary outcome was significantly associated with the use of flow diverters (p=0.0287) and change in modified Rankin Scale category at discharge (p=0.0329). No significant association was noted between the outcome and the other variables including the presence of diffusion restriction pre-discharge (p>0.05).ConclusionsPatient discharge the next day after elective intracranial aneurysm coiling is not associated with an increase in 30-day adverse outcomes. A prospective study investigating early discharge in elective treatment is warranted.Trial numberOHSN-REB #20130786-01H.
Collapse
|
48
|
Alshafai N, Falenchuk O, Cusimano MD. International differences in the management of intracranial aneurysms: implications for the education of the next generation of neurosurgeons. Acta Neurochir (Wien) 2015; 157:1467-75. [PMID: 26231628 DOI: 10.1007/s00701-015-2494-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/23/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The publication of the International Subarachnoid Aneurysm Trial rapidly changed the management of patients with subarachnoid hemorrhage. The present and perceived future trends of aneurysm management have significant implications for patients and how we educate future cerebrovascular specialists. OBJECTIVE To determine present perceived competencies of final-year neurosurgical residents who have just finished their residencies and to relate those to what practitioners from a variety of continents expect of these persons. The goal is to provide a basis for further discussion regarding the design of further educational programs in neurosurgery. METHODS A 55-item questionnaire with 33 questions related to competencies and expectations of competency from final-year residents who have just finished residency was completed by 229 neurosurgeons and neuro-radiologists (81 % response rate) of mixed seniority from 45 countries. We used bivariate and descriptive analyses to determine future trends and geographic differences in cerebral aneurysm management as well as the educational implications on the future. RESULTS More North Americans than those from the rest of the world are of the opinion that graduating residents are presently competent to perform basic cerebrovascular procedures like evacuation of a hematoma and clipping a simple 7-mm middle cerebral artery aneurysm. Extremely few graduating neurosurgical residents anywhere are presently capable of performing endovascular techniques for even the most basic of aneurysms. Most of those surveyed also believe that endovascular and open surgical management of aneurysms should be a part of residency training for all residents (70.4 and 88.7 %, respectively). CONCLUSIONS Our findings have implications for the design of neurosurgical curricula for residents as well as for certification examinations and procedures. Specialty and educational organizations and those responsible for the education of future clinicians who will care for patients with cerebrovascular problems should adjust educational objectives and implement curricula and learning experiences that will ensure that cerebrovascular specialists are capable of providing the best care possible to the patient with an aneurysm, whether that be open surgery or endovascular management. These findings mean that organizations around the world will need to make these adjustments to the education of future specialists.
Collapse
Affiliation(s)
- Nabeel Alshafai
- Division of Neurosurgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, Canada, M5B 1W8
| | | | | |
Collapse
|
49
|
Deshaies EM, Villwock MR, Singla A, Toshkezi G, Padalino DJ. Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms. J Vis Exp 2015:e51661. [PMID: 26325337 DOI: 10.3791/51661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.
Collapse
Affiliation(s)
- Eric M Deshaies
- Neurovascular and Stroke Center, Crouse Neuroscience Institute; Department of Biology, Syracuse University;
| | - Mark R Villwock
- Neurovascular and Stroke Center, Crouse Neuroscience Institute
| | - Amit Singla
- Department of Neurosurgery, University of Florida
| | | | | |
Collapse
|
50
|
Bekelis K, Missios S, Coy S, Singer RJ, MacKenzie TA. New York State: Comparison of Treatment Outcomes for Unruptured Cerebral Aneurysms Using an Instrumental Variable Analysis. J Am Heart Assoc 2015; 4:JAHA.115.002190. [PMID: 26169534 PMCID: PMC4608094 DOI: 10.1161/jaha.115.002190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background There is wide regional variation in the predominant treatment for unruptured cerebral aneurysms. We investigated the association of elective surgical clipping and endovascular coiling with mortality, readmission rate, length of stay, and discharge to rehabilitation. Methods and Results We performed a cohort study involving patients with unruptured cerebral aneurysms, who underwent surgical clipping or endovascular coiling from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System database. An instrumental variable analysis was used to investigate the association of treatment technique with outcomes. Of the 4643 patients undergoing treatment, 3190 (68.7%) underwent coiling, and 1453 (31.3%) underwent clipping. Using an instrumental variable analysis, we did not identify a difference in inpatient mortality (marginal effect, 0.13; 95% CI, −0.30, 0.57), or the rate of 30-day readmission (marginal effect, −1.84; 95% CI −4.06, −0.37) between the 2 treatment techniques for patients with unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to rehabilitation (marginal effect, 2.31; 95% CI 0.21, 4.41), and longer length of stay (β, 2.01; 95% CI 0.85, 3.04). In sensitivity analysis, mixed-effect regression, and propensity score, adjusted regression models demonstrated identical results. Conclusions Using a comprehensive all-payer cohort of patients in New York State with unruptured cerebral aneurysms, we did not identify an association of treatment method with mortality or 30-day readmission. Clipping was associated with a higher rate of discharge to rehabilitation and longer length of stay.
Collapse
Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA (S.M.)
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, NH (S.C.)
| | - Robert J Singer
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (K.B., R.J.S.)
| | - Todd A MacKenzie
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.A.M.K.) The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.M.K.)
| |
Collapse
|