Background The comparative effectiveness of the two treatment options (surgical clipping and endovascular coiling) for ruptured cerebral aneurysms has not been studied in real-world practice in the United States. We investigated the association of treatment method for ruptured cerebral aneurysms and outcomes. Methods We performed a retrospective cohort study of elderly patients who underwent treatment for ruptured cerebral aneurysms from 2007 to 2012, using a 100% sample of Medicare fee-for-service claims data. An instrumental variable analysis was used to control for unmeasured confounding and create pseudo-randomization on treatment method. In sensitivity analysis, controlling only for measured confounding, we used propensity score conditioning and inverse probability weighting, with mixed effects to account for clustering at the HRR level. Results During the study period, there were 3,210 patients, who underwent treatment for ruptured cerebral aneurysms, and met the inclusion criteria. Of these, 1,206 (37.6%) had surgical clipping, and 2,004 (62.4%) had endovascular coiling. Instrumental variable analysis demonstrated no difference of coiling in comparison to clipping for 1-year postoperative mortality (OR, 1.04; 95%CI, 0.70-1.54), likelihood of discharge to rehabilitation (OR, 1.07; 95%CI, 0.72-1.58), or 30-day readmission rate (OR, 1.14; 95%CI, 0.70-1.87). Clipping however was associated with 2.7 days longer length of stay (LOS) (95%CI, 0.45-4.99). The same associations were present in propensity score adjusted and inverse probability weighted models. Conclusions In a cohort of Medicare patients, we did not demonstrate a difference in mortality, rate of discharge to rehabilitation, and readmissions between clipping and coiling of ruptured cerebral aneurysms. Clipping was associated with slightly longer LOS.

Background The impact of combined practices on the outcomes of unruptured cerebral aneurysm coiling remains an issue of debate. We investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm coiling. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent endovascular coiling for unruptured cerebral aneurysms from 2007 to 2012. In order to control for confounding we used propensity score conditioning, with mixed effects to account for clustering at the HRR level. Results During the study period, there were 11,716 patients, who underwent endovascular coiling for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 1,186 (10.1%) underwent treatment by hybrid neurosurgeons, and 10,530 (89.9%) by proceduralists who performed only endovascular coiling. Multivariable regression analysis with propensity score adjustment demonstrated lack of association of combined practice with 1-year postoperative mortality (OR, 0.84; 95% CI, 0.58–1.23), discharge to rehabilitation (OR, 1.0; 95% CI, 0.66–1.51), 30-day readmission rate (OR, 1.07; 95% CI, 0.83–1.38) and length of stay (LOS) (adjusted difference, 0.41; 95% CI, −0.26 to 1.09). Higher procedural volume was independently associated with improved outcomes. Conclusions In a cohort of Medicare patients, we did not demonstrate a difference in mortality, discharge to rehabilitation, readmission rate, and LOS between hybrid neurosurgeons, and proceduralists only performing endovascular coiling. Funding Supported by grants from the National Institute on Aging (PO1- AG19783), the National Institutes of Health Common Fund (U01-AG046830), and the National Center for Advancing Translational Sciences (NCATS) of the NIH (Dartmouth Clinical and Translational Science Institute-UL1TR001086). The funders had no role in the design or execution of the study.

Background It is often questioned if one physician can conduct both open and endovascular techniques successfully and safely. We investigated the association of combined open and endovascular expertise with the outcomes of unruptured cerebral aneurysm clipping. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who underwent surgical clipping for unruptured cerebral aneurysms from 2007 to 2012. In order to control for confounding we used propensity score conditioning, and controlled for clustering at the physician level. Results During the study period, there were 3,247 patients, who underwent clipping for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 766 (23.6%) underwent treatment by hybrid neurosurgeons, and 2,481 (76.4%) by proceduralists who performed only clipping. Multivariable regression analysis with propensity score adjustment demonstrated lack of association of combined practice with 1-year postoperative mortality (OR, 0.81; 95% CI, 0.51–1.28), discharge to rehabilitation (OR, 0.95; 95% CI, 0.72–1.25), LOS (adjusted difference 0.85 days; 95% CI, −0.31 to 2.00), or 30-day readmission rate (OR, 1.05; 95% CI, 0.80–1.39). Higher procedural volume was independently associated with improved outcomes. Conclusions In a cohort of Medicare patients with unruptured aneurysms, we did not demonstrate a difference in mortality, discharge to rehabilitation, or readmission rate between hybrid neurosurgeons and surgeons only performing clipping. Funding Supported by grants from the National Institute on Aging (PO1- AG19783), and the National Institutes of Health (NIH) Common Fund (U01-AG046830) and the National Center for Advancing Translational Sciences (NCATS) of the NIH (Dartmouth Clinical and Translational Science Institute-UL1TR001086). The funders had no role in the design or execution of the study.

Background The cost difference between the two treatment options (surgical clipping and endovascular therapy) for unruptured cerebral aneurysms remains an issue of debate. We investigated the association of treatment method for unruptured cerebral aneurysms and Medicare expenditures in elderly patients. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients, who underwent treatment for unruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding, we used multivariable regression analysis with mixed effects to account for clustering at the HRR level. An instrumental variable (regional rates of endovascular treatment) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. Results During the study period, there were 8,705 patients, who underwent treatment for unruptured cerebral aneurysms, and met the inclusion criteria. Of these, 2,585 (29.7%) had surgical clipping, and 6,120 (70.3%) had endovascular treatment. The median total Medicare expenditures in the first year after the admission for the procedure were $46,800 (IQR $31,000 to $74,400) for surgical clipping, and $48,100 (IQR $34,500 to $73,900) for endovascular therapy. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 7-day Medicare expenditures by $3,527 (95% CI, $972 to $5,736) and increased 1-year Medicare expenditures by $15,984 (95% CI, $9,017 to $22,951). Conclusions In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of unruptured cerebral aneurysms was associated with increased 1-year expenditures in comparison to endovascular treatment.

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