Findlay Matthew C, Holdaway Matthew, Gautam Diwas, Bauer Sawyer Z, Gandhoke Gurpreet, Grandhi Ramesh
1Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah.
2University of Nevada, Reno School of Medicine, Reno, Nevada.
J Neurosurg. 2024 Dec 13;142(5):1457-1464. doi: 10.3171/2024.7.JNS24200. Print 2025 May 1.
Cost-minimization approaches for the treatment of patients with chronic subdural hematoma (cSDH) are important given the increasing incidence of this pathology, particularly among 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 their institutional experience, the authors identified thresholds for cost and the cSDH surgical recurrence rate that could influence treatment decisions in patients requiring surgical evacuation for cSDH.
All patients who underwent cSDH evacuation surgery (ES) with concomitant MMAE or ES alone from January 2019 through August 2023 were identified. The authors collected hospital-related costs for the initial admission and any subsequent admissions to address surgical recurrence (rescue surgery [RS]) and conducted cost-minimization analyses. Base-case scenario calculations were supplemented with 1- and 2-way sensitivity analyses to study cost-minimizing variables.
Demographic characteristics, comorbidities, and presenting symptoms did not significantly differ between patients who received ES/MMAE (n = 44) and those who received ES (n = 100). ES/MMAE procedures required a mean ± SD 79.3 ± 34.8 minutes whereas ES alone required 54.3 ± 25.9 minutes (p < 0.01), and patients who underwent ES/MMAE had a greater immediate postoperative hemorrhage volume reduction (-62.5% ± 22.1% vs -54.3% ± 21.3%, p = 0.04). No differences in the rates of 30-day complications, readmissions, or mortality were observed (all p > 0.05), but the ES/MMAE cohort had no reoperations after initial surgery whereas 14% in the ES-alone cohort required RS (p < 0.01). The base-case calculations indicated that ES alone minimizes costs more than ES/MMAE when there is no RS. Two-way sensitivity analyses revealed that, given a 14% probability of RS for the ES-alone group and 0% for the ES/MMAE cohort, ES/MMAE becomes cost-minimizing when the 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.
Although ES/MMAE is more efficacious for the 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, as with a low RS rate and low cost for ES/MMAE or a high RS rate and high cost for ES alone, then ES/MMAE also becomes the cost-minimizing option. These thresholds can be used in combination with institutional costs and RS rates to help guide clinical and economic decision-making.
鉴于慢性硬膜下血肿（cSDH）的发病率不断上升，尤其是在接受抗血小板和抗凝药物治疗的老年患者中，治疗cSDH患者的成本最小化方法至关重要。使用脑膜中动脉栓塞术（MMAE）作为手术清除的辅助手段在降低手术复发率方面已显示出前景；然而，该手术会产生额外费用。作者利用其机构经验，确定了成本阈值以及cSDH手术复发率，这些可能会影响需要进行cSDH手术清除的患者的治疗决策。
确定了2019年1月至2023年8月期间所有接受cSDH清除手术（ES）并同时进行MMAE或仅进行ES的患者。作者收集了首次入院及后续任何因处理手术复发（补救手术[RS]）而入院的医院相关费用，并进行了成本最小化分析。基础病例情景计算辅以单因素和双因素敏感性分析，以研究成本最小化变量。
接受ES/MMAE的患者（n = 44）和接受ES的患者（n = 100）在人口统计学特征、合并症和临床表现方面无显著差异。ES/MMAE手术平均需要79.3±34.8分钟，而仅ES手术需要54.3±25.9分钟（p < 0.01），接受ES/MMAE的患者术后即刻出血量减少幅度更大（-62.5%±22.1%对-54.3%±21.3%，p = 0.04）。在30天并发症、再入院率或死亡率方面未观察到差异（所有p > 0.05），但ES/MMAE组在初次手术后无需再次手术，而仅ES组有14%需要RS（p < 0.01）。基础病例计算表明，在无RS的情况下，仅ES比ES/MMAE更能使成本最小化。双因素敏感性分析显示，考虑到仅ES组RS概率为14%，ES/MMAE组为0%，当ES/MMAE成本保持在21,000美元以下时，ES/MMAE成为成本最小化方案。在相同的失败率和ES/MMAE成本情况下，如果ES成本超过32,000美元，ES/MMAE成为成本最小化方案。
尽管对于需要进行cSDH手术清除的患者，ES/MMAE在预防手术复发方面比仅ES更有效，但仅ES仍是成本最小化选择。然而，在某些特定情况下，如RS率低且ES/MMAE成本低，或RS率高且仅ES成本高时，那么ES/MMAE也会成为成本最小化选择。这些阈值可与机构成本和RS率结合使用，以帮助指导临床和经济决策。
