Assessment of costs in open surgery and stereotactic radiosurgery for vestibular schwannomas

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OBJECTIVE

Microsurgical 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.

METHODS

The 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.

RESULTS

The 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.

CONCLUSIONS

This 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.

ABBREVIATIONS ASA = American Society of Anesthesiologists; GKS = Gamma Knife radiosurgery; LOS = length of stay; mRS = modified Rankin Scale; SRS = stereotactic radiosurgery; VDO = Value Driven Outcomes.

Article Information

Correspondence William T. Couldwell: University of Utah, Salt Lake City, UT. neuropub@hsc.utah.edu.

INCLUDE WHEN CITING Published online October 5, 2018; DOI: 10.3171/2018.4.JNS18365.

Disclosures Dr. Jensen is a consultant for Medtronic.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Cost breakdown for vestibular schwannoma treatment. A and B: Pie charts for open surgical (A) and SRS (B) cases demonstrating mean cost breakdown (by percent of total costs) into subcategories (e.g., facility, supplies). C: The average subgroup cost was calculated to allow comparability between open and SRS cases without reporting actual dollar values. These percentages directly correlate with actual average costs for each subgroup and would not necessarily equal 100% as in panels A and B. A significantly higher overall cost was seen on average for open surgical cases (p = 0.05, t-test). D: As in panel C, the mean cost ± SD is shown to demonstrate variability in costs. E: There was a greater variation in costs for open microsurgical resection cases than for SRS cases. Costs remained stable over time for both open resection (β = 0.072, p = 0.47; linear regression) and SRS (β = −0.001, p = 0.99; linear regression). Figure is available in color online only.

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