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Acker SN, Prendergast C, Inge TH, Pickett-Nairne K, Perez-Jolles M, Blakely M, Gosain A, Peterson P. Lack of Association of Pediatric Surgical Patient Outcomes With Increased Disposable Operating Room Supply Costs. J Pediatr Surg 2024:S0022-3468(24)00200-8. [PMID: 38616467 DOI: 10.1016/j.jpedsurg.2024.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations. METHODS Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs. RESULTS 1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23). CONCLUSION Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA.
| | - Connor Prendergast
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Thomas H Inge
- Division of Pediatric Surgery, Lurie Children's Hospital, Northwestern University School of Medicine, Chicago, IL, USA
| | - Kaci Pickett-Nairne
- Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Martin Blakely
- Division of General and Thoracic Pediatric Surgery, University of Texas at Houston, USA
| | - Ankush Gosain
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Pamela Peterson
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
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Acker SN, Kaar JL, Prendergast C, Inge TH, Diaz-Miron J, Peterson PN. Variation in cost of disposable operating room supplies at a children's hospital. J Pediatr Surg 2023; 58:518-523. [PMID: 35973858 DOI: 10.1016/j.jpedsurg.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/13/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Operating room (OR) costs account for 40% of hospital costs. Disposable supplies make up a portion of OR costs and are the only cost that is under control of the surgeon. There are little data to explain how surgeons select surgical supplies and what factors predict supply selection. Our goal with the current work was to assess variation in cost of disposable OR supplies at the surgeon level, hypothesizing high variability would be observed. STUDY DESIGN Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For each procedure, the average disposable OR costs for each surgeon were tabulated and compared to the median supply cost for a given procedure at the group level. RESULTS For each procedure, the variation ranged from 149% (gastrostomy tube placement) to 758% (tonsillectomy and adenoidectomy). The median supply cost for an individual surgeon was not always above or below the median supply cost for that procedure for the group. No relationship was observed between whether the supply cost was above or below the median for a given case and a surgeon's case volume, years in practice, or operative length. There was also no relationship between surgeon volume and median cost, surgery length, and years of experience. CONCLUSION These data demonstrate variation in the cost of disposable OR supplies at the individual surgeon level at a single institution. This variation is not explained by case volume, years in practice, or operative length.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States.
| | - Jill L Kaar
- Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States; Section of Endocrinology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Connor Prendergast
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Thomas H Inge
- Division of Pediatric Surgery, Lurie Children's Hospital, Northwestern University School of Medicine, Chicago, IL, United States
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States; Reseach Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States
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Surgical Cost Awareness Program Study: Impact of a Novel, Real-Time, Cost Awareness Intervention on Operating Room Expenses in Thoracoscopic Lobectomy. J Am Coll Surg 2022; 235:914-924. [PMID: 36377904 DOI: 10.1097/xcs.0000000000000359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For surgical patients, operating room expenses are significant drivers of overall hospitalization costs. Surgical teams often lack awareness of the costs associated with disposable surgical supplies, which may lead to unnecessary expenditures. The aim of this study is to evaluate whether a Surgical Cost Awareness Program would reduce operating room costs. STUDY DESIGN A prototype software displays the types and costs of disposable instruments used in real-time during surgery and generates insight-driven operative cost reports, which are automatically sent to the surgeons. A prospective pre-post controlled trial of thoracoscopic lobectomy procedures performed by 7 surgeons at a single academic center was conducted. Control and intervention groups consisted of consecutive cases from February 2nd through June 23, 2021, and from June 28th through December 22, 2021, respectively. The primary outcome was mean per case surgical disposables cost. RESULTS Three hundred twenty-two lobectomies were evaluated throughout the study period (control: n = 164; intervention: n = 158). Baseline characteristics were comparable between groups. Mean disposables cost per case was $3,320.73 ± $814.83 in the control group compared with $2,567.64 ± $594.59 in the intervention group, representing a mean cost reduction of $753.08 (95% CI, $622.29 to $883.87; p < 0.001). All surgeons experienced a reduction in disposable costs after the intervention. Intraoperative and postoperative outcomes did not differ between the cohorts. CONCLUSIONS Providing real-time educational feedback to surgical teams significantly reduced costs associated with disposable surgical equipment without compromising perioperative outcomes for lobectomy. Integrating the novel AssistIQ software across other procedural settings may generate further data insights with the potential for significant cost savings on a larger scale.
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Christou CD, Athanasiadou EC, Tooulias AI, Tzamalis A, Tsoulfas G. The process of estimating the cost of surgery: Providing a practical framework for surgeons. Int J Health Plann Manage 2022; 37:1926-1940. [PMID: 35191067 DOI: 10.1002/hpm.3431] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/25/2021] [Accepted: 01/21/2022] [Indexed: 02/05/2023] Open
Abstract
Over the last decades, health care costs have been increasing at an alarming, exponential rate which is considered unsustainable. Surgical care utilizes one-third of health care costs. Estimating, evaluating, and understanding the cost of surgery is a vital step towards cost management and reduction. Current cost estimation studies and cost-effectiveness studies have vast disparities in their methodology, with published costs of Operating Room varying from as low as $7 and as high as $113 per minute. Costs in surgery are distinguished as direct and indirect. Allocation of direct costs involves identification, measurement, and valuation processes. Allocation of indirect costs involves the allocation of capital and overhead costs and of indirect department costs. Annualised capital costs and overhead hospital costs are then allocated to surgery by either the cost-centre allocation or the activity-based allocation frameworks. Indirect department costs are allocated to a specific surgery by weighted service allocation or hourly rate allocation or inpatient day allocation, or marginal markup allocation. The growing societal, financial and political pressure for cost reduction has brought cost analysis to the forefront of healthcare discussions. Thus, we believe that almost every single surgeon will eventually enter the field of healthcare economics by necessity. This review aims to provide surgeons with a practical framework for engaging in cost estimation studies.
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Affiliation(s)
- Chrysanthos D Christou
- Organ Transplant Unit, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni C Athanasiadou
- Surgical Oncology Department, Theageneio Anticancer Hospital of Thessaloniki, Thessaloniki, Greece
| | - Andreas I Tooulias
- First General Surgery Department, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Argyrios Tzamalis
- Second Department of Ophthalmology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsoulfas
- Organ Transplant Unit, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Macielak RJ, Thao V, Borah BJ, Moriarty JP, Marinelli JP, Van Gompel JJ, Carlson ML. Lifetime Cost and Quality-Adjusted Life-Years Across Management Options for Small- and Medium-Sized Sporadic Vestibular Schwannoma. Otol Neurotol 2021; 42:e1369-e1375. [PMID: 34282100 DOI: 10.1097/mao.0000000000003266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the growing emphasis on healthcare costs, limited data address this aspect of care within the vestibular schwannoma (VS) literature. We sought to determine which strategy confers the lowest lifetime cost and greatest quality-adjusted life-years (QALYs) for patients with small- to medium-sized sporadic VS tumors. STUDY DESIGN A Markov model was created to determine the most cost-effective management algorithm. Tumor characteristics, magnetic resonance imaging surveillance schedule, treatment outcomes, and health-related quality of life values were derived from previously published data. Cost estimates were based on CMS Fee Schedule reimbursement rates. SETTING Economic Evaluation Service within the Kern Center for the Science of Healthcare Delivery. PATIENTS Patients diagnosed with small- to medium-sized sporadic VS. INTERVENTIONS Upfront microsurgery following diagnosis, upfront radiosurgery following diagnosis, observation with microsurgery reserved for observed tumor growth, and observation with radiosurgery reserved for observed tumor growth. RESULTS Across patient ages at time of diagnosis ranging from 18 to 70 years, observation with subsequent radiosurgery used for tumor growth was the most cost-effective management algorithm while upfront microsurgery was the least. When presented with a hypothetical 50-year-old patient, the strategy with the lowest lifetime cost and highest QALYs was observation with subsequent radiosurgery reserved for tumor growth ($32,161, 14.11 QALY), followed by observation with microsurgery reserved for tumor growth ($34,503, 13.94 QALY), upfront radiosurgery ($43,456, 14.02 QALY), and lastly, upfront microsurgery ($47,252, 13.60 QALY). Sensitivity analyses varying mortality rates, estimated costs, health-related quality of life, and progression to nonserviceable hearing demonstrated consistent ranking among treatments. CONCLUSIONS When considering initial management of small- and medium-sized sporadic VSs, neither lifetime cost nor QALYs support upfront microsurgery or radiosurgery, even for younger patients. Initial observation with serial imaging, reserving radiosurgery or microsurgery for patients exhibiting tumor growth, confers the greatest potential for optimized lifetime healthcare cost and QALY outcomes.
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Affiliation(s)
| | - Viengneesee Thao
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - Bijan J Borah
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - James P Moriarty
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Jamie J Van Gompel
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Cost-effectiveness analysis of treatment for Koos 2 and 3 vestibular schwannomas: Wait & scan or radiosurgery. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hear me out: rethinking internal auditory meatus magnetic resonance imaging in primary care. A cohort evaluation. The Journal of Laryngology & Otology 2021; 136:37-44. [PMID: 34412715 DOI: 10.1017/s0022215121002243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Imaging detects acoustic neuroma, a rare pathology associated with asymmetric sensorineural hearing loss and tinnitus, that is mostly managed conservatively. Scanning indication is debatable, without evaluation in primary care, despite the high burden of audiovestibular symptoms and commissioning of general practitioner imaging.
Method
Cohort evaluation of two years' internal auditory meatus magnetic resonance imaging in primary care.
Results
Of 200 scans requested by 77 general practitioners, only 33 per cent conformed to guideline indications. Most were referred to specialists, regardless of result. Only 10.5 per cent were appropriately imaged to rule out neuroma without specialist referral. One neuroma was detected (diagnostic yield 0.5 per cent) in a patient already referred. Incidental findings were shown in 44.5 per cent, triggering low-value cascades in 18 per cent. Whilst fewer than 1 in a 1000 imaged patients may improve through surgery, 1 in 5 can suffer negative imaging cascades.
Conclusion
Considering the bi-directional relationship between distress and audio-vestibular symptoms, anxiety-provoking imaging overuse should be minimised. In low-prevalence primary care, retrocochlear imaging could be limited to those with asymmetric sensorineural hearing loss. Alternatively, assessment and imaging could be shifted to audiologist-led settings, with a wider therapeutic offer, likely more beneficial and cost-effective than conventional surgical pathways.
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Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning. Otol Neurotol 2021; 42:e584-e592. [PMID: 33443974 DOI: 10.1097/mao.0000000000003042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Patients who underwent vestibular schwannoma resection between 2008 and 2019. INTERVENTIONS Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing. MAIN OUTCOME MEASURES LOS was evaluated as the number of days from surgery to discharge. RESULTS Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59). CONCLUSIONS Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.
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Abstract
OBJECTIVE To determine the current epidemiology and management trends for patients with vestibular schwannomas (VS). STUDY DESIGN Retrospective cohort study. SETTING The Surveillance, Epidemiology, and End Results (SEER) tumor registry. PATIENTS The SEER database was queried to identify patients diagnosed with VS from 1973 to 2015. Demographics, patient and tumor characteristics, and treatment methods were analyzed. RESULTS A total of 14,507 patients with VS were identified. The mean age at diagnosis was 55 ± 14.9 years. Age-adjusted incidence from 2006 to 2015 was 1.4 per 100,000 per year and remained relatively stable. Incidence across age varied with sex, as younger women and older men had increased incidences comparatively. A higher percentage of patients underwent surgery alone (43%), followed by observation (32%), radiation alone (23%), and combined radiation and surgery (2%). Age 65 and older was associated with observation (odds ratio [OR] 1.417; p = 0.029) whereas age 20 to 39 and 40 to 49 were associated with surgery (OR 2.013 and 1.935; p < 0.001). Older age was associated with radiation. Larger tumor size was associated with surgery and combined treatment. African American patients and American Indian or Alaskan Native patients were more likely to undergo observation than surgery. CONCLUSIONS The overall incidence of VS is 1.4 per 100,000 per year and has remained relatively stable. There is a trend toward more conservative management with observation, which may be secondary to earlier diagnosis given widespread use of magnetic resonance imaging. Further studies are necessary to investigate differences in disease patterns and disparities in management.
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Dietz N, Sharma M, Ugiliweneza B, Wang D, Boakye M, Williams B, Andaluz N. Health Care Utilization in Patients Undergoing Repeat Stereotactic Radiosurgery for Vestibular Schwannoma with 5-Year Follow-up: A National Database Analysis. J Neurol Surg B Skull Base 2020; 83:19-27. [DOI: 10.1055/s-0040-1716672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 08/03/2020] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Stereotactic radiosurgery (SRS) has been used as an alternative to microsurgery in patients with small vestibular schwannoma (VS). We compare health care utilization metrics in patients undergoing repeat-SRS (re-SRS) and no repeat SRS (nr-SRS) at long-term follow-up.
Materials and Methods We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had diagnosis of VS and treatment with SRS with at least 5 years of continuous enrollment after the procedure. Outcomes were hospital admissions, outpatient services, and medication refills.
Results Of 1,047 patients, 5.1% (n = 53) had repeat SRS. Majority of re-SRS (74%, n = 39) were done within 2 years of index procedure and 51% were within 1-year of initial procedure. Patients who required re-SRS incurred higher hospital readmission rate, outpatient services, and had higher payments compared with those who did not require re-SRS at 6 months, 1 year, and 2 years following the initial procedures. Re-SRS received 3.0- and 3.1-times higher payments at 1 and 2 years compared with nr-SRS cohort. At 5 years following SRS, median combined payments for re-SRS cohort was $105286 (interquartile range [IQR] $70999, $156569) compared with $44172 (IQR $22956, $84840) for nr-SRS cohort.
Conclusion More than half of the re-SRS procedures were noted within first year of initial SRS for VS. Overall payments at 5 years for repeat SRS was more than double that for nr-SRS. Repeat SRS was also associated with more re-admissions and outpatient services at annual follow-up time points.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Brian Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Norberto Andaluz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
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Ren Y, Sethi RKV, Stankovic KM. National Trends in Surgical Resection of Vestibular Schwannomas. Otolaryngol Head Neck Surg 2020; 163:1244-1249. [PMID: 32571146 DOI: 10.1177/0194599820932148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To characterize the national trend for surgical resection of vestibular schwannoma (VS) and to assess changes in demographics, length of stay (LOS), discharge patterns, and hospital charges. STUDY DESIGN Population-based inpatient registry analysis. SETTING National Inpatient Sample and SEER database (Surveillance, Epidemiology, and End Results). PATIENTS AND METHODS Retrospective review of the US National Inpatient Sample and the SEER database from 2001 to 2014 of all patients who underwent resection of VS. RESULTS A total of 24,380 VS resections were performed. While the annual incidence of VS remained stable at 1.38 per 100,000, surgical volume declined by 36.1%, from 2807 in 2001 to 1795 in 2014 (R2 = 0.58). Total hospital charges more than doubled, from $52,475 in 2001 to $115,164 in 2014 ($4478 per year, R2 = 0.96). While most procedures were performed at large-sized hospitals, this decreased from 89% in 2002 to 75.8% in 2014. Average LOS remained stable at 5.2 days during the study period. The number of discharges to a nursing facility increased from 113 (5.5%) in 2002 to 245 (13.6%) in 2014 (P = .0002). CONCLUSION VS resection has evolved in the United States. While the incidence remained stable, surgical volume decreased by 36%, and hospital charges more than doubled. More cases are being performed at smaller hospitals. Although LOS did not vary significantly, there is an increase in nonroutine discharges. These data may guide future research in resource utilization in neurotology.
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Affiliation(s)
- Yin Ren
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine, University of California-San Diego, San Diego, California, USA
| | - Rosh K V Sethi
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Konstantina M Stankovic
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
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Offodile AC, Sen AP, Holtsmith S, Escalante J, Park A, Terrell J, Bassett R, Perrier ND. Harnessing Behavioral Economics Principles to Promote Better Surgeon Accountability for Operating Room Cost: A Prospective Study. J Am Coll Surg 2020; 230:585-593. [PMID: 31954814 DOI: 10.1016/j.jamcollsurg.2019.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Operating room (OR) cost accounts for a significant portion of inpatient spending, but most surgeons are unaware of the costs of OR implants and supplies. We leveraged behavioral economics principles and a cost transparency tool to have an impact on discretionary OR spending (disposable supplies). STUDY DESIGN We performed a single-institution, prospective study, from January to December 2018, across 3 departments: urology, thoracic, and endocrine. Two self-selected procedures per department were subjected to intraoperative supply cost (ISC) feedback via a custom dashboard and monthly email reports. Behavioral economics principles like choice overload, social ranking, and threshold effects were leveraged during study design. The primary outcome of percentage change in the department-level mean ISC, as determined via an interrupted time-series mixed effects model, was compared between the intervention year (2018) and "pre-baseline" (2016) and "baseline" (2017) years. RESULTS A total of 2,853 procedures and 26 surgeons comprised our analytical sample. Costs decreased in 5 of the 6 procedures in 2018. On average, there was a significant monthly decrease in costs of approximately 0.5% over the study period (p = 0.0004). Post-intervention, there was a nonsignificant additional decrease of 0.6% in monthly cost (p = 0.0648). Overall cost significantly decreased by 20% due to the intervention (p < 0.0001). Similar results were noted on sensitivity analysis. There were no significant changes in the incidence of postoperative complication due to our intervention. CONCLUSIONS Deployment of a cost feedback tool using behavioral economics principles resulted in a significant decrease in OR spending without negatively affecting complication rate.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX; Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, TX; Baker Institute for Public Policy, Rice University, Houston, TX
| | - Aditi P Sen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shelby Holtsmith
- Department of EHR Analytics and Reporting, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jon Escalante
- Department of EHR Analytics and Reporting, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anne Park
- Office of Performance Improvement, University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Terrell
- Office of Performance Improvement, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roland Bassett
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nancy D Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Correlation-Based Ensemble Feature Selection Using Bioinspired Algorithms and Classification Using Backpropagation Neural Network. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2019; 2019:7398307. [PMID: 31662787 PMCID: PMC6778924 DOI: 10.1155/2019/7398307] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/02/2019] [Accepted: 08/16/2019] [Indexed: 11/17/2022]
Abstract
A framework for clinical diagnosis which uses bioinspired algorithms for feature selection and gradient descendant backpropagation neural network for classification has been designed and implemented. The clinical data are subjected to data preprocessing, feature selection, and classification. Hot deck imputation has been used for handling missing values and min-max normalization is used for data transformation. Wrapper approach that employs bioinspired algorithms, namely, Differential Evolution, Lion Optimization, and Glowworm Swarm Optimization with accuracy of AdaBoostSVM classifier as fitness function has been used for feature selection. Each bioinspired algorithm selects a subset of features yielding three feature subsets. Correlation-based ensemble feature selection is performed to select the optimal features from the three feature subsets. The optimal features selected through correlation-based ensemble feature selection are used to train a gradient descendant backpropagation neural network. Ten-fold cross-validation technique has been used to train and test the performance of the classifier. Hepatitis dataset and Wisconsin Diagnostic Breast Cancer (WDBC) dataset from University of California Irvine (UCI) Machine Learning repository have been used to evaluate the classification accuracy. An accuracy of 98.47% is obtained for Wisconsin Diagnostic Breast Cancer dataset, and 95.51% is obtained for Hepatitis dataset. The proposed framework can be tailored to develop clinical decision-making systems for any health disorders to assist physicians in clinical diagnosis.
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Abou-Al-Shaar H, Azab MA, Karsy M, Guan J, Alzhrani G, Gozal YM, Jensen RL, Couldwell WT. Assessment of costs in open surgery and stereotactic radiosurgery for vestibular schwannomas. J Neurosurg 2019; 131:561-568. [DOI: 10.3171/2018.4.jns18365] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/09/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMicrosurgical resection and radiosurgery remain the most widely used interventions in the treatment of vestibular schwannomas. There is a growing demand for cost-effectiveness analyses to evaluate these two treatment modalities and delineate the factors that drive their total costs. Here, the authors evaluated specific cost drivers for microsurgical and radiosurgical management of vestibular schwannoma by using the Value Driven Outcomes system available at the University of Utah.METHODSThe authors retrospectively reviewed all cases involving microsurgical and radiosurgical treatment of vestibular schwannomas at their institution between November 2011 and September 2017. Patient and tumor characteristics, subcategory costs, and potential cost drivers were analyzed.RESULTSThe authors identified 163 vestibular schwannoma cases, including 116 managed microsurgically and 47 addressed with stereotactic radiosurgery (SRS). There were significant differences between the two groups in age, tumor size, and preoperative Koos grade (p < 0.05), suggesting that indications for treatment were markedly different. Length of stay (LOS) and length of follow-up were also significantly different. Facility costs were the most significant contributor to both microsurgical and SRS groups (58.3% and 99.4%, respectively); however, physician professional fees were not specifically analyzed. As expected, microsurgical treatment resulted in an average 4-fold greater overall cost of treatment than for SRS cases (p < 0.05), and there was a greater variation in costs for open cases as well. Costs remained stable over time for both open resection and SRS. Multivariable analysis showed that LOS (β = 0.7, p = 0.0001), discharge disposition (β = 0.2, p = 0.004), nonserviceable hearing (β = 0.1, p = 0.02), and complications (β = 0.2, p = 0.005) affected cost for open surgery, whereas no specifically examined factor could be identified as driving costs for SRS.CONCLUSIONSThis analysis identified the fact that facility utilization constitutes the majority of total costs for both microsurgery and SRS treatment modalities of vestibular schwannomas. LOS, discharge disposition, nonserviceable hearing, and complications contributed significantly to the total costs for the microsurgical group, whereas none of the factors could be identified as driving total costs for the SRS group. This information may be used to establish policies and protocols to reduce facility costs, with the goal of decreasing the total costs without jeopardizing patient care.
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Hojjat H, Svider PF, Hong R, Folbe AJ, Eloy JA, Shkoukani MA. In Response to To Image or Not to Image? A Cost-effectiveness Analysis of MRI for Patients With Asymmetric Sensorineural Hearing Loss. Laryngoscope 2018; 129:E50. [PMID: 30485449 DOI: 10.1002/lary.27146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/25/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Houmehr Hojjat
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Robert Hong
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan.,Michigan Ear Institute, Farmington Hills, Michigan
| | - Adam J Folbe
- Department of Otolaryngology, William Beaumont Hospital, Royal Oak, Michigan
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey Department of Neurological Surgery, Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Mahdi A Shkoukani
- Department of Otolaryngology, Head and Neck Surgery, Cleveland Clinic-Abu Dhabi, Abu Dhabi, United Arab Emirates
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Schnurman Z, Golfinos JG, Epstein D, Friedmann DR, Roland JT, Kondziolka D. Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma. J Neurosurg 2018; 131:1395-1404. [PMID: 30497146 DOI: 10.3171/2018.5.jns18508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given rising scrutiny of healthcare expenditures, understanding intervention costs is increasingly important. This study aimed to compare and characterize costs for vestibular schwannoma (VS) management with microsurgery and radiosurgery to inform practice decisions and appraise cost reduction strategies. METHODS In conjunction with medical records, internal hospital financial data were used to evaluate costs. Total cost was divided into index costs (costs from arrival through discharge for initial intervention) and follow-up costs (through 36 months) for 317 patients with unilateral VSs undergoing initial management between June 2011 and December 2015. A retrospective matched cohort based on tumor size with 176 patients (88 undergoing each intervention) was created to objectively compare costs between microsurgery and radiosurgery. The full sample of 203 patients treated with resection and 114 patients who underwent radiosurgery was used to evaluate a broad range of outcomes and identify cost contributors within each intervention group. RESULTS Within the matched cohort, average index costs were significantly higher for microsurgery (100% by definition, because costs are presented as a percentage of the average index cost for the matched microsurgery group; 95% CI 93-107) compared to radiosurgery (38%, 95% CI 38-39). Microsurgery had higher average follow-up costs (1.6% per month, 95% CI 0.8%-2.4%) compared to radiosurgery (0.5% per month, 95% CI 0.4%-0.7%), largely due to costs incurred in the initial months after resection. A major contributor to total cost and cost variability for both resection and radiosurgery was the need for additional interventions in the follow-up period, which were necessary due to complications or persistent functional deficits. Although tumor size was not associated with increased total costs for radiosurgery, linear regression analysis demonstrated that, for patients who underwent microsurgery, each centimeter increase in tumor maximum diameter resulted in an estimated increase in total cost of 50.2% of the average index cost of microsurgery (95% CI 34.6%-65.7%) (p < 0.001, R2 = 0.17). There were no cost differences associated with the proportion of inpatient days in the ICU or with specific surgical approach for patients who underwent resection. CONCLUSIONS This study is the largest assessment to date based on internal cost data comparing VS management with microsurgery and radiosurgery. Both index and follow-up costs are significantly higher when tumors were managed with resection compared to radiosurgery. Larger tumors were associated with increased resection costs, highlighting the incremental costs associated with observation as the initial management.
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Affiliation(s)
| | | | | | - David R Friedmann
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York
| | - J Thomas Roland
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York
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Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery? Acta Neurochir (Wien) 2018; 160:2263-2275. [PMID: 30229403 DOI: 10.1007/s00701-018-3674-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Currently, there is no consensus in the initial management of small vestibular schwannomas (VSs). They are routinely watched and/or referred for radiosurgical treatment, although surgical removal is also an option. We hereby evaluate clinical outcomes of patients who have undergone surgical removal of smaller symptomatic VSs. METHODS Patients with vestibular schwannomas (grade T1-T3b according to Hannover classification) were reviewed. Patients with symptomatic tumors who underwent surgery were evaluated. Their preoperative hearing status was based on the guideline of the committee on hearing and equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) foundation. Their postoperative facial nerve function, hearing status, vestibular symptoms, and degree of tumor resection were assessed. RESULTS Thirty patients were selected for surgery via a retrosigmoid approach based on their age, symptoms, and their own decision-making after discussion of management options. Most patients presented with hearing loss. Seventeen patients had useful hearing preoperatively. Among them, 10 patients (59%) preserved useful hearing (class A or B) postoperatively. MRI at 1-year follow-up confirmed complete resection in 26/29 patients. Also, 29 patients (97%) had HB grade I-II, and 1 patient had HB III at 1-year follow-up. Except for 1 patient with CSF leak, 1 patient with delayed facial nerve palsy, and 2 patients with asymptomatic sigmoid sinus occlusion, there were no other new morbidities. CONCLUSION Although both observation and radiosurgery are valid options in the management of smaller size vestibular schwannomas, surgical treatment seems to offer a high rate of facial nerve preservation, a reasonable rate of hearing sparing, and a high total resection rate. Clinicians should consider surgical treatment as a valid option in the initial management of symptomatic small vestibular schwannomas in younger patients.
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Ryu WHA, Yang MMH, Muram S, Jacobs WB, Casha S, Riva-Cambrin J. Systematic review of health economic studies in cranial neurosurgery. Neurosurg Focus 2018; 44:E2. [PMID: 29712519 DOI: 10.3171/2018.2.focus17792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE As the cost of health care continues to increase, there is a growing emphasis on evaluating the relative economic value of treatment options to guide resource allocation. The objective of this systematic review was to evaluate the current evidence regarding the cost-effectiveness of cranial neurosurgery procedures. METHODS The authors performed a systematic review of the literature using PubMed, EMBASE, and the Cochrane Library, focusing on themes of economic evaluation and cranial neurosurgery following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Included studies were publications of cost-effectiveness analysis or cost-utility analysis between 1995 and 2017 in which health utility outcomes in life years (LYs), quality-adjusted life years (QALYs), or disability-adjusted life years (DALYs) were used. Three independent reviewers conducted the study appraisal, data abstraction, and quality assessment, with differences resolved by consensus discussion. RESULTS In total, 3485 citations were reviewed, with 53 studies meeting the inclusion criteria. Of those, 34 studies were published in the last 5 years. The most common subspecialty focus was cerebrovascular (32%), followed by neurooncology (26%) and functional neurosurgery (24%). Twenty-eight (53%) studies, using a willingness to pay threshold of US$50,000 per QALY or LY, found a specific surgical treatment to be cost-effective. In addition, there were 11 (21%) studies that found a specific surgical option to be economically dominant (both cost saving and having superior outcome), including endovascular thrombectomy for acute ischemic stroke, epilepsy surgery for drug-refractory epilepsy, and endoscopic pituitary tumor resection. CONCLUSIONS There is an increasing number of cost-effectiveness studies in cranial neurosurgery, especially within the last 5 years. Although there are numerous procedures, such as endovascular thrombectomy for acute ischemic stroke, that have been conclusively proven to be cost-effective, there remain promising interventions in current practice that have yet to meet cost-effectiveness thresholds.
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Affiliation(s)
- Won Hyung A Ryu
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Michael M H Yang
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Sandeep Muram
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - W Bradley Jacobs
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Steven Casha
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
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Tveiten ØV, Carlson ML, Goplen F, Myrseth E, Driscoll CLW, Mahesparan R, Link MJ, Lund-Johansen M. Patient- versus physician-reported facial disability in vestibular schwannoma: an international cross-sectional study. J Neurosurg 2017; 127:1015-1024. [DOI: 10.3171/2016.8.jns16707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVEPatient-reported outcomes are increasingly used in studies of vestibular schwannoma (VS); however, few studies have examined self-evaluated facial nerve function and its relation to physician-reported outcomes. The primary objective of this study was to compare patient self-evaluations of facial disability with physician-evaluated facial nerve status and with self-evaluations of a healthy control group. The second objective was to provide insight into the controversial subject of the optimal initial management of small- and medium-sized VSs; consequently, the authors compared patient-reported facial nerve disability following treatment via observation (OBS), Gamma Knife surgery (GKS), or microsurgery (MS). Lastly, the authors sought to identify risk factors for facial nerve dysfunction following treatment for small- and medium-sized VSs.METHODSAll patients with a VS 3 cm or smaller that was singly treated with OBS, GKS, or MS at either of 2 independent treatment centers between 1998 and 2008 were retrospectively identified. Longitudinal facial nerve measures and clinical data, including facial nerve evaluation according to the House-Brackmann (HB) grading system, were extracted from existing VS databases. Supplementing the objective data were Facial Disability Index (FDI) scores, which were obtained via survey of patients a mean of 7.7 years after initial treatment.RESULTSThe response rate among the 682 eligible patients was 79%; thus, data from a total of 539 patients were analyzed. One hundred forty-eight patients had been managed by OBS, 247 with GKS, and 144 with MS. Patients who underwent microsurgery had larger tumors and were younger than those who underwent OBS or GKS. Overall, facial nerve outcomes were satisfactory following treatment, with more than 90% of patients having HB Grade I function at the last clinical follow-up. Treatment was the major risk factor for facial nerve dysfunction. Almost one-fifth of the patients treated with MS had an objective decline in facial nerve function, whereas only 2% in the GKS group and 0% in the OBS cohort had a decline. The physical subscale of the FDI in the VS patients was highly associated with HB grade; however, the social/well-being subscale of the FDI was not. Thus, any social disability caused by facial palsy was not detectable by use of this questionnaire.CONCLUSIONSThe majority of patients with small- and medium-sized VSs attain excellent long-term facial nerve function and low facial nerve disability regardless of treatment modality. Tumor size and microsurgical treatment are risk factors for facial nerve dysfunction and self-reported disability. The FDI questionnaire is sensitive to the physical but not the social impairment associated with facial dysfunction.
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Affiliation(s)
- Øystein Vesterli Tveiten
- Departments of 1Neurosurgery and
- 3Department of Clinical Medicine, University of Bergen, Norway; and
| | - Matthew L. Carlson
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Departments of 4Neurologic Surgery and
| | | | | | - Colin L. W. Driscoll
- Departments of 4Neurologic Surgery and
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | | | - Michael J. Link
- Departments of 4Neurologic Surgery and
- 5Otolaryngology–Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Morten Lund-Johansen
- Departments of 1Neurosurgery and
- 3Department of Clinical Medicine, University of Bergen, Norway; and
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Caulley L, Sawada M, Hinther K, Ko YTI, Crowther JA, Kontorinis G. Geographic distribution of vestibular schwannomas in West Scotland between 2000-2015. PLoS One 2017; 12:e0175489. [PMID: 28493872 PMCID: PMC5426599 DOI: 10.1371/journal.pone.0175489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/27/2017] [Indexed: 12/21/2022] Open
Abstract
Background Although the natural history of vestibular schwannomas (VS) has been previously studied, few studies have investigated associated epidemiological factors, primarily because of the lack of large available cohorts. Objective The objective of this study was to perform a multi-scale geographical analysis of the period prevalence of VS in West Scotland from 2000 to 2015. Methods Adults diagnosed with sporadic VS were identified through the National Health Services of West Scotland database and geocoded to the unit postcode. To assess whether the cohort of VS cases could be pooled into a period prevalence measure, the locations of VS cases were analyzed by sex using Cross-L and Difference-K functions. VS period prevalence was examined at two aggregate spatial scales: the postcode district and a coarser scale of NHS Health Boards. The spatial structure of period prevalence within each level of spatial aggregation was measured using univariate global and local Moran’s I. Bivariate local Moran’s I was used to examine the between-scale variability in period prevalence from the postcode district level to the NHS Health Boards levels. Prior to spatial autocorrelation analyses, the period prevalence at the postcode district was tested for stratified spatial heterogeneity within the NHS Health Boards using Wang’s q-Statistic. Results A total of 512 sporadic VS were identified in a population of over 3.1 million. Between 2000 and 2015, VS period prevalence was highest within the NHS Health Boards of Greater Glasgow and Clyde, Ayrshire and Arran and the Western Isles. However, at the NHS scale, period prevalence exhibited no spatial autocorrelation globally or locally. At the district scale, Highland exhibited the most unusual local spatial autocorrelation. Bivariate local Moran’s I results indicated general stability of period prevalence across the postcode district to Health Boards scales. However, locally, some postcode districts in Greater Glasgow and Clyde, Ayrshire and Arran exhibited unusually low district to zone spatial autocorrelation in period prevalence, as did the southern parts of the Western Isles. Some unusually high period prevalence values between the postcode district to Health Board scale were found in Tayside, Forth Valley and Dumfries and Galloway. Conclusion Geographic variability in VS in West Scotland was identified in this patient population, showing that there are areas, even remote, with unusually high or low period prevalence. This can be partially attributed to links between primary and tertiary care. Potential genetic or environmental risk factors that may contribute to geographic variation in this disease within Scotland are also a possibility but require further investigation.
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Affiliation(s)
- Lisa Caulley
- Department of Otolaryngology – Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael Sawada
- Laboratory for Applied Geomatics and GIS Science (LAGGISS), Department of Geography, Environment and Geomatics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kelsey Hinther
- Undergraduate Medicine Program, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ya-tung Iris Ko
- Department of Otolaryngology – Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - John A. Crowther
- Department of Otolaryngology – Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Georgios Kontorinis
- Department of Otolaryngology – Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- * E-mail:
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Kim DH, Morales M, Tai R, Hergenroeder G, Shah C, O'Leary J, Harrison N, Edquilang G, Paisley E, Allen-McBride E, Murphy A, Smith J, Gormley W, Spielman A. Quality Programs in Neurosurgery: The Memorial Hermann/University of Texas Experience. Neurosurgery 2017; 80:S65-S74. [PMID: 28375495 DOI: 10.1093/neuros/nyw158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Indexed: 11/14/2022] Open
Abstract
The importance of outcome measures is steadily increasing due to the rise of "pay for performance" and the advent of population health. In 2007, a quality initiative was started due to poor performance on rankings such as the University Health Consortium (UHC) report card. Inherent to all such efforts are common challenges: how to engage the providers; how to gather and ensure the accuracy of the data; how to attribute results to individuals; how to ensure permanent improvements. After analysis, a strategy was developed that included an initial focus on 3 metrics (mortality, infection rates, and complications), leadership from practicing neurosurgeons, protocol development and adherence, and subspecialization. In addition, it was decided that the metrics would initially apply to attending physicians only, but that the entire team would need to be involved. Once the fundamental elements were established, the process could be extended to other measures and providers. To support this effort, special information system tools were developed and a support team formed. As the program matured, measured outcomes improved and more metrics were added (to a current total of 48). For example, UHC mortality ratios (observed over expected) decreased by 75%. Infection rates decreased 80%. The program now involves all trainee physicians, advanced practice providers, nurses, and other staff. This paper describes the design, implementation, and results of this effort, and provides a practical guide that may be useful to other groups undertaking similar initiatives.
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Affiliation(s)
- Dong H Kim
- Department of Neurosurgery, The Uni-versity of Texas Medical School at Hous-ton, Houston, Texas
| | | | - Rahil Tai
- Memorial Hermann Healthcare System, Houston, Texas
| | - Georgene Hergenroeder
- Department of Neurosurgery, The Uni-versity of Texas Medical School at Hous-ton, Houston, Texas
| | - Chirag Shah
- Memorial Hermann Healthcare System, Houston, Texas
| | - Joanna O'Leary
- Department of Neurosurgery, The Uni-versity of Texas Medical School at Hous-ton, Houston, Texas
| | | | | | | | | | | | - Justin Smith
- Clear Path Solutions, Jamaica Plain, Massachusetts
| | - William Gormley
- Department of Neuro-surgery, Harvard Medical School, Cam-bridge, Massachusetts
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23
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Kim DH. “The Coming Changes in Neurosurgical Practice”: A Supplement to Neurosurgery. Neurosurgery 2017; 80:S1-S3. [DOI: 10.1093/neuros/nyw145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/13/2016] [Indexed: 11/14/2022] Open
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Nellis JC, Sharon JD, Pross SE, Ishii LE, Ishii M, Dey JK, Francis HW. Multifactor Influences of Shared Decision-Making in Acoustic Neuroma Treatment. Otol Neurotol 2017; 38:392-399. [PMID: 27930442 PMCID: PMC5303176 DOI: 10.1097/mao.0000000000001292] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify factors associated with treatment modality selection in acoustic neuromas. STUDY DESIGN Prospective observational study. SETTING Tertiary care neurotology clinic. PATIENTS Data were prospectively collected from patients initially presenting to a tertiary care neurotology clinic between 2013 and 2016. Patients who did not have magnetic resonance imaging (MRI), demographic, psychometric, or audiometric data were excluded from analysis. INTERVENTION Demographic information, clinical symptoms, tumor characteristics, and psychometric data were collected to determine factors associated with undergoing acoustic neuroma surgical resection using univariate and multiple logistic regression analysis. MAIN OUTCOME MEASURE The decision to pursue acoustic neuroma surgical resection versus active surveillance. RESULTS A total of 216 patients with acoustic neuroma (mean age 55 years, 58% women) were included. Ninety eight patients (45.4%) pursued surgical resection, 118 patients (54.6%) pursued active surveillance. Surgical treatment was significantly associated with patient age less than 65, higher grade tumors, growing tumors, larger volume tumors, lower word discrimination scores, Class D hearing, headache, and vertigo as presenting symptoms, higher number of total symptoms, and higher headache severity scores (p < 0.05). There was no significant association between surgical intervention and preoperative quality of life, depression, and self-esteem scores. On multiple logistic regression analysis, the likelihood of undergoing surgical resection significantly decreased for patients older than age 65 (odds ratio [OR] 0.19; 0.05-0.69) and increased in patients with medium (OR 4.34; 1.36-13.81), moderately large (OR 33.47; 5.72-195.83), large grade tumors (OR 56.63; 4.02-518.93), tumor growth present (OR 4.51; 1.66-12.28), Class D hearing (OR 3.96; 1.29-12.16), and higher headache severity scores (OR 1.03; 95% confidence interval [CI] 1.01-1.05). The likelihood of undergoing surgical resection was completely predictive for giant grade tumors and not significant for small grade tumors and Class B or C hearing. CONCLUSIONS Non-elderly acoustic neuroma patients with larger tumors, growing tumors, significant hearing loss, and worse headaches are more likely to pursue surgical resection rather than active surveillance. Psychological factors such as quality of life, depression, and self-esteem do not seem to influence decision-making in this patient population.
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Affiliation(s)
- Jason C Nellis
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland
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Wu H, Zhang L, Han D, Mao Y, Yang J, Wang Z, Jia W, Zhong P, Jia H. Summary and consensus in 7th International Conference on acoustic neuroma: An update for the management of sporadic acoustic neuromas. World J Otorhinolaryngol Head Neck Surg 2016; 2:234-239. [PMID: 29204572 PMCID: PMC5698531 DOI: 10.1016/j.wjorl.2016.10.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 11/26/2022] Open
Abstract
Sporadic vestibular schwannoma (acoustic neuroma) is a benign tumor arising from cochleovestibular nerve. Nowadays, various specialties and medical centers are treating this disease, and the multidisciplinary collaboration is the trend. In an effort to promote a uniform standard for reporting clinical results, even for treatment indications, the mainly controversies were posed and discussed during the 7th International Conference on acoustic neuroma, and the agreement was summarized by the Committee of this conference. The main symptoms grading and tumor stage should note its name of classification for making them comparable. The goal of the modern managements for vestibular schwannoma is to improve the quality of life with lower mortality, lower morbidity and better neurological function preservation. The experience of surgical team and their preference might be a major factor for the outcome. Because of lacking of long-term follow-up large data after radiotherapy, and with the development of microsurgery, radiotherapy is now less recommended except for recurrent cases or elderly patients.
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Affiliation(s)
- Hao Wu
- Department of Otolaryngology Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China.,Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital Shanghai University School of Medicine, Shanghai 200092, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Liwei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medial University, Beijing 100050, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Dongyi Han
- Department of Otolaryngology Head and Neck Surgery, People's Liberation Army General Hospital, Beijing 100853, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Jun Yang
- Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital Shanghai University School of Medicine, Shanghai 200092, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Zhaoyan Wang
- Department of Otolaryngology Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China.,Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital Shanghai University School of Medicine, Shanghai 200092, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Wang Jia
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medial University, Beijing 100050, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China.,Committee of 7th International Conference on Acoustic Neuroma, Shanghai, China
| | - Huan Jia
- Department of Otolaryngology Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, China.,Department of Otolaryngology Head and Neck Surgery, Xinhua Hospital Shanghai University School of Medicine, Shanghai 200092, China
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Birk H, Zygourakis CC, Kliot M. Developing an algorithm for cost-effective, clinically judicious management of peripheral nerve tumors. Surg Neurol Int 2016; 7:80. [PMID: 27625890 PMCID: PMC5009575 DOI: 10.4103/2152-7806.189299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/20/2016] [Indexed: 11/06/2022] Open
Abstract
Peripheral nerve tumors such as neurofibromas and schwannomas have become increasingly identified secondary to improved imaging modalities including magnetic resonance neurogram and ultrasound. Given that a majority of these peripheral nerve tumors are benign lesions, it becomes important to determine appropriate management of such asymptomatic masses. We propose a normal cost-effective management paradigm for asymptomatic peripheral nerve neurofibromas and schwannomas that has been paired with economic analyses. Specifically, our management paradigm identifies patients who would benefit from surgery for asymptomatic peripheral nerve tumors, while providing cost-effective recommendations regarding clinical exams and serial imaging for such patients.
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Affiliation(s)
- Harjus Birk
- School of Medicine, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Corinna C Zygourakis
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michel Kliot
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
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Zygourakis CC, Valencia V, Boscardin C, Nayak RU, Moriates C, Gonzales R, Theodosopoulos P, Lawton MT. Predictors of Variation in Neurosurgical Supply Costs and Outcomes Across 4904 Surgeries at a Single Institution. World Neurosurg 2016; 96:177-183. [PMID: 27613498 DOI: 10.1016/j.wneu.2016.08.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/27/2016] [Accepted: 08/30/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is high variability in neurosurgical costs, and surgical supplies constitute a significant portion of cost. Anecdotally, surgeons use different supplies for various reasons, but there is little understanding of how supply choices affect outcomes. Our goal is to evaluate the effect of patient, procedural, and provider factors on supply cost and to determine if supply cost is associated with patient outcomes. METHODS We obtained patient information (age, gender, payor, case mix index [CMI], body mass index, admission source), procedural data (procedure type, length, date), provider information (name, case volume), and total surgical supply cost for all inpatient neurosurgical procedures from 2013 to 2014 at our institution (n = 4904). We created mixed-effect models to examine the effect of each factor on surgical supply cost, 30-day readmission, and 30-day mortality. RESULTS There was significant variation in surgical supply cost between and within procedure types. Older age, female gender, higher CMI, routine/elective admission, longer procedure, and larger surgeon volume were associated with higher surgical supply costs (P < 0.05). Routine/elective admission and higher surgeon volume were associated with lower readmission rates (odds ratio, 0.707, 0.998; P < 0.01). Only patient factors of older age, male gender, private insurance, higher CMI, and emergency admission were associated with higher mortality (odds ratio, 1.029, 1.700, 1.692, 1.080, 2.809). There was no association between surgical supply cost and readmission or mortality (P = 0.307, 0.548). CONCLUSIONS A combination of patient, procedural, and provider factors underlie the significant variation in neurosurgical supply costs at our institution. Surgical supply costs are not correlated with 30-day readmission or mortality.
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Affiliation(s)
- Corinna C Zygourakis
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA.
| | - Victoria Valencia
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Christy Boscardin
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rahul U Nayak
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA
| | - Christopher Moriates
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
| | - Ralph Gonzales
- Center for Healthcare Value, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Continuous Process Improvement Department, UCSF Health, San Francisco, California, USA
| | - Philip Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Cost analysis of vestibular schwannoma screening with contrast-enhanced magnetic resonance imaging in patients with asymmetrical hearing loss. The Journal of Laryngology & Otology 2015; 130:21-4. [PMID: 26365591 DOI: 10.1017/s0022215115002431] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Vestibular schwannomas are a rare cause of asymmetrical hearing loss, and routine screening with magnetic resonance imaging can be costly. This paper reports results on vestibular schwannoma screening at our institution and compares the cost of screening to a utility of hearing benefit. METHOD All screening examinations with magnetic resonance imaging performed for asymmetrical hearing loss between 2006 and 2011 were retrospectively reviewed. The cost per new vestibular schwannoma diagnosis was calculated. The cost per patient for those who benefitted from intervention was estimated based on rates of hearing preservation reported in the literature. RESULTS Forty-five (4.3 per cent) of 1050 screening examinations with magnetic resonance imaging performed for asymmetrical hearing loss were positive for vestibular schwannoma, and the cost per new diagnosis was $11,436. The estimated screening cost per patient for those who benefitted from surgery or radiation was $147,030, while US federal compensation for unilateral hearing loss was $44,888. CONCLUSION Although we achieved a lower screening cost per new diagnosis than reported in the current literature, there remains disparity between the screening cost per benefitted patient and the 'benefit' of hearing.
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