Article Text
Abstract
Object Cost-minimization approaches for treatment of patients with chronic subdural hematoma (cSDH) are important given the increasing incidence of this pathology and the growing population of elderly patients receiving antiplatelet and anticoagulation medications. The use of middle meningeal artery embolization (MMAE) as an adjunct to surgical evacuation has shown promise in reducing surgical recurrence; however, additional costs are involved with this procedure. Using our institutional experience, we identified thresholds for cost and cSDH surgical recurrence rate that could influence treatment decisions in patients requiring surgical evacuation for cSDH.
Methods All patients who underwent cSDH evacuation surgery (ES) with concomitant MMAE (ES/MMAE) or ES alone from January 2019 through August 2023 were identified. We collected hospital-related costs for the initial admission and any subsequent admissions to address surgical recurrences (rescue surgery, RS) and conducted cost-minimization analyses. Base case scenario calculations were supplemented with one- and two-way sensitivity analyses to study cost-minimizing variables.
Results Demographics, comorbidities, and presenting symptoms did not significantly differ between patients receiving ES/MMAE and ES. ES/MMAE procedures required 79.3±34.8 minutes compared with the 54.3±25.9 minutes for ES alone (p<0.01), and patients who underwent ES/MMAE had a more substantial immediate postoperative hemorrhage volume reduction (62.5±22.1% vs. 54.3±21.3%, p=0.04). No differences in 30-day complication rates, readmissions, or mortality were observed (all p>0.05), but no patient in the ES/MMAE group required reoperation after initial surgery whereas 14% in the ES alone cohort (p<0.01) required RS. The base case calculations indicated that ES alone minimizes costs more than ES/MMAE when there is no RS (figure 1). Two-way sensitivity analyses revealed that given a 14% probability of RS for the ES alone group and 0% RS in ES/MMAE, ES/MMAE becomes cost-minimizing when costs for ES/MMAE are kept below $21,000. With these same failure rates and cost of ES/MMAE, if ES costs exceed $32,000, ES/MMAE becomes cost-minimizing.
Conclusion Although ES/MMAE is more efficacious for prevention of surgical recurrence in patients requiring surgical evacuation of cSDH than ES alone, ES alone remains the cost-minimizing option. However, in select situations, including ES/MMAE retaining a 0% RS rate and costing <$21,000; then ES/MMAE becomes cost-minimizing. Likewise, if ES alone RS rates persist at 14%, but ES costs >$32,000, then ES/MMAE also becomes the cost-minimizing option. Using these reported thresholds provided different costs and RS rates can help guide clinical and economic decision-making using individual institutional costs and rates of revision.
Disclosures M. Findlay: None. M. Holdoway: None. D. Gautam: None. S. Bauer: None. G. Gandhoke: None. R. Grandhi: None.