TO THE EDITOR: We read with great interest the article by Berns et al.1 (Berns J, Priddy B, Belal A, et al. Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure. J Neurosurg Pediatr. 2021;27[4]:400-405). In particular, we regard "standardization" of shunt valves with great concern. As two of the surgeons whose cases are presented in this article, we have particular insight into this project.
The "shunt design trial" that Berns et al. included in their analysis demonstrated that three valves commonly used at that time had similar failure and infection rates.2 Data such as these are often incorrectly interpreted as indicating that all shunts function in the same way. Hydrocephalus is a protean condition, and thus a "one-size-fits-all" approach does not apply. Brain compliance and siphoning characteristics vary tremendously from one patient to another. Failure to recognize the nuances of hydrocephalus may have devastating downstream effects. Experienced hydrocephalus surgeons often have acquired equipment preferences through knowledge and experience. More importantly, these surgeons are aware of all available options. While it is true that one valve is not superior to all others in all cases, certain features may be clearly superior in a particular patient with a particular condition. Shunt patients require individualized treatment.
The design of the study reported by Berns et al.1 limits the strength of any conclusions. Despite a 62.5% increase in the percentage of revisions and a 75% increase in the number of infections in the poststandardization group, the authors report no statistical differences between the groups. Do the cost savings with valve standardization overcome the cost of the increased reoperation rate? The authors cite "gain-sharing" agreements as a rationale for compliance. Strategies such as this should never guide surgical decisions in pediatric patients. Although many advancements in neurosurgery have come from technology, vendor exclusivity stifles innovation opportunities.
Unfortunately, this article exemplifies a disturbing trend in medicine: trivializing the knowledge and training of physicians. The authors cite "stubbornness" as a barrier to compliance. This statement fits a common strategy to blame, minimize, or denigrate physician experience.
Very little in neurosurgery is supported by the elusive “level 1” evidence. Experience brings wisdom and that conveys value. Articles such as this one by Berns et al.1 may be incorrectly interpreted by hospital administrators who are not equipped to recognize the scientific limitations of a retrospective paper. Flawed studies may be used as "proof" for decisions that prioritize financial considerations above physician or patient concerns. Furthermore, loss of physician autonomy is an oft-cited cause of "burn-out" and job dissatisfaction.3 Physician morale is at a critical low in the United States, a situation that is to some extent attributable to unnecessary practice restrictions. The project reported by Berns et al.1 was met with resistance from other neurosurgeons at the time, and we had significant concerns regarding limiting the resources we allotted for our highly complex hydrocephalus patients. We remain unconvinced that any perceived cost savings from standardization of shunt valves outweighs the benefits of maintaining viable options. We further place more trust in physician judgment over the use of a simplified checklist in treating complex pediatric neurosurgical patients.
Disclosures
The authors report no conflict of interest.
References
- 1↑
Berns J, Priddy B, Belal A, et al. Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure. J Neurosurg Pediatr. 2021;27(4):400–405.
- 2↑
Drake J, Kestle J, Milner R, et al. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery. 1998;43(2):294–303.
- 3↑
West C, Dyrbye L, Shanafelt T. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018;283(6):516–529.
