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Abstract winners

CANS Annual Meeting 2020

Simulating Episode-Based Bundled Payments for Cranial Neurosurgical Procedures

Zachary Medress, MD

Background. Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Care Improvement Initiative (BPCI) in order to improve care coordination and cost efficiency. BPCI has been implemented for orthopedic, cardiac, and spine procedures, but has not yet been expanded to cranial neurosurgical
procedures.

Methods. We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment payments for common cranial neurosurgical procedures. Operations were classified into four groups: Craniotomy for unruptured aneurysm, meningioma, malignant glioma, and metastasis. We project 30-, 60-, and 90-day bundle payments for each category, and analyze the contributions of post-discharge payments, medical comorbidities, adjuvant therapies, and discharge status to total bundle payments at each time point.

Results. We identified 15,276 procedures that met our inclusion criteria. We observed significant variability between projected bundle payments despite similar index hospitalization payments between groups. Multivariate analysis showed that medical comorbidities, adjuvant therapies, hospital readmission, and discharge destination significantly affect cranial bundle projections.

Conclusions. For the first time in our knowledge, we report projected costs of 30-, 60-,and 90-day episode-based bundled payments for common elective vascular and tumor cranial operations. Compared to spine and orthopedic procedures, postdischarge costs significantly impact total bundle payments in cranial neurosurgery.

Discrepancy in neurologic outcomes following aneurysmal subarachnoid hemorrhage as a function of socioeconomic class

Ben A. Strickland, MD

We aim to investigate socioeconomic variables contributing to healthcare discrepancies in the ruptured cerebral aneurysm population at our institution. We retrospectively reviewed medical records of the ruptured intracranial aneurysms treated with microsurgical intervention at our tertiary referral University Hospital (UH) and safety net County Hospital (CH) from 2010-2015. 73 UH and 58 CH patients were identified. There was no statistically significant difference in  demographics, Fisher score, GCS, aneurysm characteristics, or complications. UH patients with clinical vasospasm were more likely to receive verapamil infusions (p=0.08), though there was no difference in delayed cerebral ischemia (p= 0.15). The majority of CH cohort were uninsured (19%; UH 0%) or Medicaid (67.2%; UH 35.6%) (p<0.001). Private insurance was more prevalent in UH cohort (49.3%; CH 12.1%) (p<0.0001). UH patients had more dispositions to rehabilitation centers (non-skilled nursing facilities) (UH 82% versus CH 67.3%; p=0.04) despite similar neurologic outcomes at time of discharge. UH had superior neurologic recovery from time of discharge to follow up (p=0.0004). Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified. Reallocation of resources supplementing advanced in-patient acute care technologies and post acute care environments can narrow outcomes gaps.

Robot Assisted Neurosurgery: A Single Center’s Experience with an Emerging Technology

Joseph Falcone, MD

During our most recent year analyzed, 57 robot assisted procedures were performed, of which 45.6% were epilepsy surgery, 40.4% Deep Brain Stimulation (DBS), and 14% lesion biopsy or ablation. Earlier uses also included stem cell implantation. A learning curve was seen on adoption of the robot, with initial significant increase in operative times for DBS (p=0.0007) which lost significance with more experience (p= 0.0845). Given increased operative time and costs of new equipment, we did not find robot assisted surgery to be a cost-saving technology, however we note several other advantages. The robot provided increased accuracy, allowing improved placement of DBS leads and better yield of biopsies. It also allowed increased flexibility of surgical planning and has led to increased research
opportunities.

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