Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma

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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.

ABBREVIATIONS BAHA = bone-anchored hearing aid; EMR = electronic medical record; LOS = length of stay; PTA = pure tone average; SDS = speech discrimination score; SRS = stereotactic radiosurgery; VS = vestibular schwannoma.

Article Information

Correspondence Douglas Kondziolka: NYU Langone Medical Center, New York, NY. douglas.kondziolka@nyumc.org.

INCLUDE WHEN CITING Published online November 9, 2018; DOI: 10.3171/2018.5.JNS18508.

Disclosures Dr. Kondziolka received support from Brainlab for a non–study-related clinical or research effort that he oversees.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Diagram of data collection methodology. NF2 = neurofibromatosis type 2; OR = operating room.

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    A: Line graphs of follow-up costs for patients who underwent microsurgery (upper panel) and those who received radiosurgery (lower panel). Each line represents an individual patient’s follow-up course. Costs are presented as a percentage of the average index cost for microsurgery. Causes of cost spikes are labeled. B: Accumulation of each month’s average follow-up costs for microsurgery (black line) and radiosurgery (light gray line) with error bars demonstrating the SEM. Graph limited to 32 months because attrition results in patient numbers becoming small (< 20 patients for radiosurgery beyond 32 months), resulting in high uncertainty. ER = emergency room; EVD = external ventricular drain; LD = lumbar drain; VP = ventriculoperitoneal.

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    A: Histograms of the number of patients per total cost (grouped in bins of 20%). Darker gray fill indicates patients who required a secondary intervention, whereas lighter gray fill indicates no secondary intervention. Costs are presented as a percentage of the average index cost for microsurgery. Not pictured for scale purposes: 2 outlier data points in the “Microsurgery” section at 820% and 1280% bins. B: Binned scatterplots with linear regression lines for microsurgery (black) and radiosurgery (light gray). To improve visualization of large data sets, binned scatterplots group the x-axis variable into equal-sized bins and compute the x-axis and y-axis means within each bin (regression calculated from total data set). Costs are presented on the y-axis as a percentage of the average index cost for microsurgery.

References

  • 1

    Arunachalam PSKilby DMeikle DDavison TJohnson IJ: Bone-anchored hearing aid quality of life assessed by Glasgow Benefit Inventory. Laryngoscope 111:126012632001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Banerjee RMoriarty JPFoote RLPollock BE: Comparison of the surgical and follow-up costs associated with microsurgical resection and stereotactic radiosurgery for vestibular schwannoma. J Neurosurg 108:122012242008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Breivik CNNilsen RMMyrseth EPedersen PHVarughese JKChaudhry AA: Conservative management or gamma knife radiosurgery for vestibular schwannoma: tumor growth, symptoms, and quality of life. Neurosurgery 73:48572013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Brook RH: The role of physicians in controlling medical care costs and reducing waste. JAMA 306:6506512011

  • 5

    Dasta JFMcLaughlin TPMody SHPiech CT: Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 33:126612712005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Emanuel EJFuchs VR: Who really pays for health care? The myth of “shared responsibility”. JAMA 299:105710592008

  • 7

    Gait CFrew EJMartin TPJowett SIrving R: Conservative management, surgery and radiosurgery for treatment of vestibular schwannomas: a model-based approach to cost-effectiveness. Clin Otolaryngol 39:22–312014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Golfinos JGHill TCRokosh RChoudhry OShinseki MMansouri A: A matched cohort comparison of clinical outcomes following microsurgical resection or stereotactic radiosurgery for patients with small- and medium-sized vestibular schwannomas. J Neurosurg 125:147214822016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Hoistad DLMelnik GMamikoglu BBattista RO’Connor CAWiet RJ: Update on conservative management of acoustic neuroma. Otol Neurotol 22:6826852001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    International RadioSurgery Association: Radiosurgery Practice Guideline Initiative. Stereotactic Radiosurgery for Patients with Vestibular Schwannomas. Harrisburg, PA: ISRA2006 (http://www.irsa.org/AN%20Guideline.pdf) [Accessed July 17 2018]

    • Search Google Scholar
    • Export Citation
  • 11

    Kahn JMRubenfeld GDRohrbach JFuchs BD: Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care 46:122612332008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Karpinos MTeh BSZeck OCarpenter LSPhan CMai WY: Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery. Int J Radiat Oncol Biol Phys 54:141014212002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kentala EPyykkö I: Clinical picture of vestibular schwannoma. Auris Nasus Larynx 28:15–222001

  • 14

    Kondziolka DMousavi SHKano HFlickinger JCLunsford LD: The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation? Neurosurg Focus 33(3):E82012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Levinsky NG: The doctor’s master. N Engl J Med 311:157315751984

  • 16

    Matthies CSamii M: Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery 40:1–101997

  • 17

    Muennig P: Cost-Effectiveness Analyses in Health: A Practical Approach ed 2. San Francisco: Jossey-Bass2008

  • 18

    Mulrow CDAguilar CEndicott JETuley MRVelez RCharlip WS: Quality-of-life changes and hearing impairment. A randomized trial. Ann Intern Med 113:1881941990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Myrseth EMøller PPedersen PHLund-Johansen M: Vestibular schwannoma: surgery or gamma knife radiosurgery? A prospective, nonrandomized study. Neurosurgery 64:6546632009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Myrseth EMøller PPedersen PHVassbotn FSWentzel-Larsen TLund-Johansen M: Vestibular schwannomas: clinical results and quality of life after microsurgery or gamma knife radiosurgery. Neurosurgery 56:9279352005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Nikolopoulos TPO’Donoghue GM: Acoustic neuroma management: an evidence-based medicine approach. Otol Neurotol 23:5345412002

  • 22

    Peden AH (ed): Comparative Health Information Management. Clifton Park, NY: Cengage Learning2012

  • 23

    Pollock BEDriscoll CLFoote RLLink MJGorman DABauch CD: Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery 59:77852006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Pollock BELunsford LDKondziolka DFlickinger JCBissonette DJKelsey SF: Outcome analysis of acoustic neuroma management: a comparison of microsurgery and stereotactic radiosurgery. Neurosurgery 36:2152291995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Régis JPellet WDelsanti CDufour HRoche PHThomassin JM: Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas. J Neurosurg 97:109111002002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Robinson JC: Decline in hospital utilization and cost inflation under managed care in California. JAMA 276:106010641996

  • 27

    Samii MMatthies C: Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery 40:11–231997

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Semaan MTWick CCKinder KJStuyt JGChota RLMegerian CA: Retrosigmoid versus translabyrinthine approach to acoustic neuroma resection: A comparative cost-effectiveness analysis. Laryngoscope 126 (Suppl 3):S5S122016

    • Search Google Scholar
    • Export Citation
  • 29

    Slattery WH IIIFrancis SHouse KC: Perioperative morbidity of acoustic neuroma surgery. Otol Neurotol 22:8959022001

  • 30

    Sonig AKhan ISWadhwa RThakur JDNanda A: The impact of comorbidities, regional trends, and hospital factors on discharge dispositions and hospital costs after acoustic neuroma microsurgery: a United States nationwide inpatient data sample study (2005–2009). Neurosurg Focus 33(3):E32012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Sulmasy DP: Physicians, cost control, and ethics. Ann Intern Med 116:9209261992

  • 32

    Whitmore RGUrban CChurch ERuckenstein MStein SCLee JY: Decision analysis of treatment options for vestibular schwannoma. J Neurosurg 114:4004132011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Young DW: The folly of using RCCs and RVUs for intermediate product costing. Healthc Financ Manage 61:100-1062007

  • 34

    Zimmerman JE: Intensive care unit length of stay: can it be reduced? Crit Care Med 27:139313941999

  • 35

    Zygourakis CCOh TSun MZBarani IKahn JGParsa AT: Surgery is cost-effective treatment for young patients with vestibular schwannomas: decision tree modeling of surgery, radiation, and observation. Neurosurg Focus 37(5):E82014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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