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Gillian Shasby

T o T he R eadership : An error occurred during preparation of the article by Shannon et al., “The economic impact of ventriculoperitoneal shunt failure. Clinical article” ( J Neurosurg Pediatr 8: 593–599, December 2011). During the production process, the authors submitted additional information to be included in the Disclosure section of the paper and, unfortunately, we neglected to add the information at that time. We would like to correct that error now. The missing information should have been inserted as the first paragraph of the Disclosure

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Richard P. Menger, David E. Connor Jr., Jai Deep Thakur, Ashish Sonig, Elainea Smith, Bharat Guthikonda and Anil Nanda

per year. 22 The annual cost of treating IIH in the US has been cited as $444 million. 9 A previous study by the senior author (A.N.) noted the overall cost of implanted ventricular shunts to be a $1 billion problem. 19 The delivery of health care in the new marketplace will focus on patient outcomes as well as economic impact. Neurosurgeons will be forced to illustrate that interventions directly help the patient in an economically responsible fashion. Neurosurgeons must remain in the forefront of surgical interventions and must do so in a patient-centered but

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Chevis N. Shannon, Tamara D. Simon, Gavin T. Reed, Frank A. Franklin, Russell S. Kirby, Meredith L. Kilgore and John C. Wellons III

Object

Detailed costs to individuals with hydrocephalus and their families as well as to third-party payers have not been previously described. The purpose of this study was to determine the primary caregiver out-of-pocket expenses and the third-party payer reimbursement rate associated with a shunt failure episode.

Methods

A retrospective study of children born between 2000 and 2005 who underwent initial ventriculoperitoneal (VP) shunt placement and who subsequently experienced a shunt failure requiring surgical intervention within 2 years of their initial shunt placement was conducted. Institutional reimbursement and demographic data from Children's Hospital of Alabama (CHA) were augmented with a caregiver survey of any out-of pocket expenses encountered during the shunt failure episode. Institutional reimbursements and caregiver out-of-pocket expenses were then combined to provide the cost for a shunt failure episode at CHA.

Results

For shunt failures, the median reimbursement total was $5008 (interquartile range [IQR] $2068–$17,984), the median caregiver out-of-pocket expenses was $419 (IQR $251–$1112), and the median total cost was $5411 (IQR $2428–$18,582). Private insurance reimbursed at a median rate of $5074 (IQR $2170–$14,852) compared with public insurance, which reimbursed at a median rate of $4800 (IQR $1876–$19,395). Caregivers with private insurance reported a median $963 (IQR $322–$1741) for out-of-pocket expenses, whereas caregivers with public insurance reported a median $391 (IQR $241–$554) for out-of-pocket expenses (p = 0.017).

Conclusions

This study confirmed that private insurance reimbursed at a higher rate, and that although patients had a shorter length of stay as compared with those with public insurance, their out-of-pocket expenses associated with a shunt failure episode were greater. However, it could not be determined if the significant difference in out-of-pocket expenses between those with private and those with public insurance was due directly to the cost of shunt failure. This model does not take into consideration community resources and services available to those with public insurance. These resources and services could offset the out-of-pocket burden, and therefore should be considered in future cost models.

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M. Sami Walid and Joe Sam Robinson Jr.

Object

Comorbidities in patients undergoing spine surgery may reasonably be factors that increase health care costs. To verify this hypothesis, the authors conducted the following study.

Methods

Major comorbidities and age-adjusted Charlson Comorbidity Index scores were retrospectively analyzed for 816 patients who underwent spine surgery at the authors' institutions between 2005 and 2008, and treatment costs (hospital charges) were assessed with the help of statistical software. The sample was collected by a nonmedical staff (hired at the beginning of 2006). Patients underwent one of the three most common types of spine surgery: lumbar microdiscectomy (20.5%), anterior cervical decompression and fusion (ACDF; 60.3%), or lumbar decompression and fusion (LDF; 19.2%). Patients were nearly equally divided by sex (53% were female and 47% male), and 78% were Caucasian versus 21% who were African American; the rest were of mixed or unidentified race. The average age was 54 years, with an SD of ± 14 years.

Results

There were significant differences in the prevalence of major comorbidities between male and female and between severely obese and nonseverely obese patients. The impact of comorbidities on the cost of spine surgery was more prominent in older patients, and an additive effect from some comorbidities was recorded in various types of spine surgery. For instance, in the ACDF group, female patients with both severe obesity and diabetes mellitus (DM) had significantly higher hospital charges than those with only one or neither of these conditions ($34,943 for both severe obesity and DM vs $25,633 for severe obesity only; $25,826 for DM only; and $25,153 for those with neither condition [p < 0.05]). In the LDF group, female patients with both DM and a history of depression had significantly higher hospital charges than those with only one or neither of these conditions ($65,782 for both DM and depression vs $53,504 for DM only; $55,990 for depression only; and $52,249 for those with neither condition [p < 0.05]). A significant difference was also found in hospital cost ($16,472 [p < 0.01]; 32% increase over baseline) in the LDF group between patients with the lowest and highest scores on the Charlson Index.

Conclusions

Comorbidities additively increase hospital costs for patients who undergo spine surgery, and should be considered in payment arrangements.

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Campbell Liles, Jonathan Dallas, Andrew T. Hale, Stephen Gannon, E. Haley Vance, Christopher M. Bonfield and Chevis N. Shannon

OBJECTIVE

Open and endoscope-assisted repair are surgical options for sagittal craniosynostosis, with limited research evaluating each technique’s immediate and long-term costs. This study investigates the cost-effectiveness of open and endoscope-assisted repair for single, sagittal suture craniosynostosis.

METHODS

The authors performed a retrospective cohort study of patients undergoing single, sagittal suture craniosynostosis repair (open in 17 cases, endoscope-assisted in 16) at less than 1 year of age at Monroe Carell Jr. Children’s Hospital at Vanderbilt (MCJCHV) between August 2015 and August 2017. Follow-up data were collected/analyzed for 1 year after discharge. Surgical and follow-up costs were derived by merging MCJCHV financial data with each patient’s electronic medical record (EMR) and were adjusted for inflation using the healthcare Producer Price Index. Proxy helmet costs were derived from third-party out-of-pocket helmet prices. To account for variable costs and probabilities, overall costs were calculated using TreeAge tree diagram software.

RESULTS

Open repair occurred in older patients (mean age 5.69 vs 2.96 months, p < 0.001) and required more operating room time (median 203 vs 145 minutes, p < 0.001), more ICU days (median 3 vs 1 day, p < 0.001), more hospital days (median 4 vs 1 day, p < 0.001), and more frequently required transfusion (88% vs 6% of cases). Compared to patients who underwent open surgery, patients who underwent endoscopically assisted surgery more often required postoperative orthotic helmets (100% vs 6%), had a similar number of follow-up clinic visits (median 3 vs 3 visits, p = 0.487) and CT scans (median 3 vs 2 scans), and fewer emergency department visits (median 1 vs 3 visits). The TreeAge diagram showed that, overall, open repair was 73% more expensive than endoscope-assisted repair ($31,314.10 vs $18,081.47). Sensitivity analysis identified surgical/hospital costs for open repair (mean $30,475, SEM $547) versus endoscope-assisted repair (mean $13,746, SEM $833) (p < 0.001) as the most important determinants of overall cost. Two-way sensitivity analysis comparing initial surgical/hospital costs confirmed that open repair remains significantly more expensive under even worst-case initial repair scenarios ($3254.81 minimum difference). No major surgical complications or surgical revisions occurred in either cohort.

CONCLUSIONS

The results of this study suggest that endoscope-assisted craniosynostosis repair is significantly more cost-effective than open repair, based on markedly lower costs and similar outcomes, and that the difference in initial surgical/hospital costs far outweighs the difference in subsequent costs associated with helmet therapy and outpatient management, although independent replication in a multicenter study is needed for confirmation due to practice and cost variation across institutions. Longer-term results will also be needed to examine whether cost differences are maintained.

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William E. Gordon, William M. Mangham, L. Madison Michael II and Paul Klimo Jr.

the very least resident education results in indirect costs related to longer OR time. Previous papers have examined the potential economic value of residents in other specialties, but none have appraised neurosurgical residents. 8–12 We undertook this study to provide a quantitative glimpse of the economic impact an on-call junior resident can have over a consecutive 2-year period. Methods Resident On-Call System Institutional review board approval for this study was obtained before data collection. At our institution, a single on-call junior resident (PGY 2, 3

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Brian C. F. Chan, B. Catharine Craven and Julio C. Furlan

Furthermore, the ongoing annual costs after the 1st year of injury were estimated to vary from US$33,500 to US$150,500. 8 Using those costing estimations, the projected lifetime cost for an individual injured at age 25 would span up to US$2.7 million depending on level of injury. 6 Given the substantial economic impact of treating this condition in the short- and long-term, AST should attract greater attention from health care providers, administrators, and health care decision makers working in an economically constrained health care system. In addition to the

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Syed I. Khalid, Ryan Kelly, Rita Wu, Akhil Peta, Adam Carlton and Owoicho Adogwa

incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study . Spine J 14 : 1125 – 1131 , 2014 10.1016/j.spinee.2013.07.474 24126076 34 Villavicencio AT , Pushchak E , Burneikiene S , Thramann JJ : The safety of instrumented outpatient anterior cervical discectomy and fusion . Spine J 7 : 148 – 153 , 2007 17321962 10.1016/j.spinee.2006.04.009 35 Walid MS , Robinson JS Jr : Economic impact of comorbidities in spine surgery . J Neurosurg Spine 14 : 318 – 321 , 2011 10

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Alan Chuong Q. Pham, Christine Fan and Brian K. Owler

6 times that in hospital bed days and total hospital expenditure. Our findings are similar to those of Simon et al., 5 who found that in the US, although hydrocephalus accounts for only 0.6% of all pediatric admissions per annum, it accounts for 1.8% of pediatric hospital days and 3.1% of pediatric hospital charges. This is the first Australian study of the economic costs associated with hydrocephalus. Only a few studies have been conducted in America and Canada about the economic impact of the disease. 4 In 2000, a CSF shunt cost approximately $35,816 (US) to

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Niclas Rudolfson, Michael C. Dewan, Kee B. Park, Mark G. Shrime, John G. Meara and Blake C. Alkire

of neurosurgical disease, as well as the proportion avertable by prevention and treatment, would also be immensely valuable. Conclusions Our study finds that there is a significant economic impact of neurosurgical diseases in LMICs. If cost-utility studies of neurosurgical care in LMICs continue to suggest that it can indeed be cost-effective, previous dogma deeming neurosurgery too complicated and expensive for resource-limited settings would be significantly challenged, especially when accounting for the downstream effects on economic growth as presented in this