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Recapitulating the Bayesian framework for neurosurgical outpatient care and a cost-benefit analysis of telemedicine for socioeconomically disadvantaged patients in the Philippines during the pandemic

Kevin Paul Ferraris, Jared Paul Golidtum, Brian Karlo W. Zuñiga, Maria Cristina G. Bautista, Jose Carlos Alcazaren, Kenny Seng, and Joseph Erroll Navarro

During these extraordinary times, enhancing the telemedicine system is recommended to optimize the care of patients. Methods The aim of this study was to assess the responsiveness of a current telemedicine setup during the COVID-19 pandemic by using the following methods: 1) a utility and expenditure survey of patient telemedicine users, 2) a cost-benefit analysis (CBA) from the perspective of the patient, and 3) a case illustration of a Bayesian approach application unique to the teleconsultation scenario. This study was approved by the medical center institutional

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Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma

Presented at the 2013 Joint Spine Section Meeting 

Saniya S. Godil, Scott L. Parker, Kevin R. O'Neill, Clinton J. Devin, and Matthew J. McGirt

the primary outcome evaluated. Presence of SSI was determined by visual wound inspection and contrast-enhanced MRI, which was used in all cases in which superficial or deep SSI was suspected. All infections were treated with IV antibiotics for a period of 6–8 weeks and/or operative intervention as deemed necessary. Any complications related to application of the vancomycin were also recorded. Cost-Benefit Analysis Hospital accounting and billing records were reviewed to determine total infection-related medical cost (cost of reoperation/wound debridement

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Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis

Clinical article

Lester Lee, Nicolas K. K. King, Dinesh Kumar, Yew Poh Ng, Jai Rao, Huiyu Ng, Kah Keow Lee, Ernest Wang, and Ivan Ng

nonprogrammable shunt is more suitable for the management of hydrocephalus after aneurysmal SAH in patients who often have a secondary form of NPH. We sought to determine if programmable or nonprogrammable shunts had lower revision rates and if the adjustments made to the shunt settings in the programmable valves resulted in better clinical outcomes in our patients. We also carried out a cost-benefit analysis to determine if the use of programmable shunts was more expensive overall than the use of nonprogrammable shunts for the estimated length of hospital stay in this group of

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Functional benefits and cost/benefit analysis of continuous intrathecal baclofen infusion for the management of severe spasticity

Fiona C. Sampson, Andrew Hayward, Gillian Evans, Richard Morton, and Beverly Collett

general population, which may differ from those of the treatment group. Nevertheless, the EQ-5D is one of the few existing multiattribute scales that has a single index score based on preference weights, and it can thus be used to estimate cost/benefit values. It has the advantage of being simple to use and assesses a manageable number of health states. The results of this cost/benefit analysis can thus be considered as indicative of the scale of benefit that may be expected, according to the best available estimates in the absence of primary research data. 9, 27 In

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Evidence-based surveillance protocol for vestibular schwannomas: a long-term analysis of tumor growth using conditional probability

Daniele Borsetto, Mantegh Sethi, Katherine Clarkson, Rupert Obholzer, Nicholas Thomas, Eleni Maratos, Sinan A. Barazi, Asfand Baig Mirza, Mohamed Okasha, Giovanni Danesi, Alessandro Pusateri, Rachele Bivona, Gian Gaetano Ferri, Janan El Alouani, Andrea Castellucci, Scott Rutherford, Simon Lloyd, Bilal Anwar, Jerry Polesel, Juliette Buttimore, Nicola Gamazo, Richard Mannion, James R. Tysome, Manhoar Bance, Patrick Axon, and Neil Donnelly

useful in a dynamic evaluation of growth risk over time. In this methodology, the probability of VS growth ( G ) at a time ( t ) is calculated by taking into consideration how long the patient’s VS has not grown ( N ) before t . Thus, the aim of the present study was to make use of more accurate and clinically useful conditional probability estimates to derive long-term growth risks that can be used to guide clinician decisions on surveillance timelines and endpoints. We propose a new evidence-based protocol for VS surveillance and perform a cost-benefit analysis

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Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies

Jeff Ehresman, Zach Pennington, Andrew Schilling, Ravi Medikonda, Sakibul Huq, Kevin R. Merkel, A. Karim Ahmed, Ethan Cottrill, Daniel Lubelski, Erick M. Westbroek, Salia Farrokh, Steven M. Frank, and Daniel M. Sciubba

OBJECTIVE

Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients.

METHODS

The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1–4 levels) and long-length (5–8 levels) spinal constructs.

RESULTS

Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007).

CONCLUSIONS

TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.

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Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery

Michael M. Safaee, Cecilia L. Dalle Ore, Corinna C. Zygourakis, Vedat Deviren, and Christopher P. Ames

correction, and increased cost. 9 , 37 BMP has been shown to reduce the incidence of pseudarthrosis after spinal fusion surgery, but is also associated with significant cost. 5 , 7 , 12 , 34 , 36 In this study, we review our experience with the use of BMP for prevention of pseudarthrosis-related revision surgery and conduct a cost-benefit analysis for BMP. Rates of pseudarthrosis after surgical correction for ASD range from 10% to 24%. 9 , 21–24 , 34 , 45 Previously described risk factors include increased sagittal imbalance, increasing construct length, and increasing

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Cost-effectiveness analysis of mechanical thrombectomy in acute ischemic stroke

Clinical article

Chirag G. Patil, Elisa F. Long, and Maarten G. Lansberg

Object

Mechanical thrombectomy is increasingly being used for the treatment of large-vessel ischemic stroke in patients who arrive outside of the 3-hour tissue plasminogen activator time window. In this study, the authors evaluated the cost and effectiveness of mechanical thrombectomy compared with standard medical therapy in patients who are ineligible to receive tissue plasminogen activator.

Methods

Clinical outcomes of an open-label study of mechanical thrombectomy were compared with a hypothetical control group with a lower recanalization rate (18 vs 60%) and a lower rate of symptomatic intracranial hemorrhage (0.6 vs 7.8%) than the active treatment group. A Markov cost-effectiveness model was built to compare the health benefits and costs associated with mechanical thrombectomy compared with standard medical therapy. All probabilities, quality-of-life factors, and costs were estimated from the published literature. Univariate sensitivity analyses were performed to assess how variations in model parameters affect health and economic outcomes.

Results

Treatment of acute ischemic stroke with mechanical thrombectomy increased survival time by 0.54 quality-adjusted life years (QALYs), compared with standard medical therapy (2.37 vs 1.83 QALYs), at an increased cost of $6600. This yielded an incremental cost-effectiveness ratio (ICER) of $12,120 per QALY gained, a value generally considered cost-effective. Sensitivity analysis showed that mechanical thrombectomy remained cost-effective (ICER < $50,000 per QALY gained) for all model inputs varied over a reasonable range, except for age at stroke treatment. For patients older than 82 years of age, the treatment was only borderline cost-effective (ICER of $50,000–100,000 per QALY gained).

Conclusions

The treatment of large-vessel ischemic stroke with mechanical thrombectomy appears to be costeffective. These results require validation when data from a randomized, controlled trial of mechanical thrombectomy become available.

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Neurosurgical complications after apparently minor head injury

Assessment of risk in a series of 610 patients

Ralph G. Dacey Jr., Wayne M. Alves, Rebecca W. Rimel, H. Richard Winn, and John A. Jane

✓ A small number of patients with an apparently minor head injury will develop a life-threatening intracranial hematoma that must be rapidly detected and removed. To assess the risk of a significant intracranial neurosurgical complication after apparently minor head injury, the authors collected data prospectively on 610 patients who had sustained a transient posttraumatic loss of consciousness or other neurological function and who had a Glasgow Coma Scale (GCS) score of 13, 14, or 15 in the emergency room. Skull x-ray films were obtained in 583 patients, 66 of whom (10.8% of the study population) had cranial fractures. Eighteen of the 610 patients (3.0%) required a neurosurgical procedure. Three acute subdural hematomas, one epidural hematoma, and one traumatic intracerebral hematoma required craniotomy. Of the 66 patients who had skull fracture, 7.6% required a craniotomy for intracranial hematoma. Thirteen (19.7%) of the 66 patients with skull fracture required an operative procedure as compared to five (1.0%) of the 517 patients without skull fracture. Two patients with a normal GCS score of 15 and normal skull x-ray films subsequently underwent operative treatment.

The cost of three alternative management schemes for these patients was estimated. A 50% reduction in cost of management could be effected by the use of computerized tomography (CT) scans (or possibly skull x-ray films) in determining which of the patients who are alert at the time of presentation should be admitted for observation. Several other conclusions can be drawn from this study. First, an initial GCS score between 13 and 15 does not necessarily indicate that a patient has sustained a trivial head injury, since 3% of such patients will require an operative procedure despite an initially normal level of alertness. Second, an abnormal skull x-ray film increases by a factor of 20 the probability that a patient will need neurosurgical treatment. Third, it is very unusual for patients who have a GCS score of 15 and a normal skull x-ray film to have a significant neurosurgical complication. Fourth, the alternative management schemes that depend on selective use of skull films and CT scans may significantly reduce the cost of caring for patients with minor head injury.

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Cost—benefit value of microscopic examination of intervertebral discs

Dana M. Grzybicki, Edward J. Callaghan, and Stephen S. Raab

whether to perform microscopic pathological examinations depends on the trade-off between the value of information gained by the examination and the cost of the examination. The application of cost—benefit analysis to anatomical pathology is relatively recent. Using cost—benefit analysis, Netser, et al., 4 showed that the microscopic pathological examination of “routine” tonsil and adenoid specimens was not cost beneficial. Routine tonsil and adenoid specimens are similar to most intervertebral disc specimens, because both specimen types are removed primarily for