Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure

Abstract

OBJECTIVECSF shunts are the most common procedures performed in the pediatric neurosurgical population. Despite attempts in multiple studies, a superior shunt valve has never been shown. Because of this, the authors aim was to examine the impact of shunt valve standardization at their institution to determine if there is a difference in surgical cost, operative time, or short-term postoperative shunt failure.METHODSA retrospective analysis at the authors’ institution was performed for all new CSF diversion shunts, as well as shunt revisions requiring a new valve, or a new valve and at least a new proximal or distal catheter over a 1-year period (January 1, 2016, to December 31, 2016). After a period of transition, neurosurgeons were encouraged to use only one type of fixed-differential-pressure valve and one type of programmable valve when performing shunt surgeries. These patients who underwent “standardized” shunt surgery over a 1-year period (January 1, 2018, to December 31, 2018) were then compared to patients in the prestandardization epoch. All patients were followed for a 12-month period after surgery. Demographic information, surgical cost, operative time, and postoperative shunt failure data were collected in all patients in the study.RESULTSThe authors analyzed 87 shunt surgeries in patients prior to standardization and 94 shunt surgeries in patients after standardization. The rate of violation of the standardized shunt valve policy after implementation was 5.3% (5 of 94 procedures). When comparing the prestandardization group to those who received the standardized valve, operative costs were less ($1821.04 vs $1333.75, p = 0.0034). There was no difference in operative times between groups (78 minutes vs 81 minutes, p = 0.5501). There was no difference in total number of shunt failures between the two groups at 12 months after surgery (p = 0.0859). The rate of postoperative infection was consistent with the literature at 8%.CONCLUSIONSIn accordance with quality improvement principles, the reduction of unexplained clinical variance invariably leads to a decrease in cost and, more importantly, increased value. In this study, the implementation of a standardized shunt valve decreased operative cost. There were no differences in postoperative shunt failures at 12 months after surgery and no differences in length of surgery. Standardizing shunt valves in the treatment of pediatric hydrocephalus seems to be cost-effective and safe.

Letter to the Editor. Standardization of shunt valves: one size does not fit all

“…Unexplained clinical variance may be at the root of our country's high healthcare costs and suboptimal outcomes compared to the rest of the world. 1 It is up to all of us as physicians and surgeons to use our clinical and business acumen to lead change and effect improvement on each side of the "iron triangle" of healthcare-access, quality, and cost. 2…”

“…The design of the study reported by Berns et al 1 limits the strength of any conclusions. Despite a 62.5% increase in the percentage of revisions and a 75% increase in the number of infections in the poststandardization group, the authors report no statistical differences between the groups.…”

“…TO THE EDITOR: We read with great interest the article by Berns et al 1 (Berns J, Priddy B, Belal A, et al Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure. J Neurosurg Pediatr.…”

“…Experience brings wisdom and that conveys value. Articles such as this one by Berns et al 1 may be incorrectly interpreted by hospital administrators who are not equipped to recognize the scientific limitations of a retrospective paper. Flawed studies may be used as "proof" for decisions that prioritize financial considerations above physician or patient concerns.…”

“…3 Physician morale is at a critical low in the United States, a situation that is to some extent attributable to unnecessary practice restrictions. The project reported by Berns et al 1 was met with resistance from other neurosurgeons at the time, and we had significant concerns regarding limiting the resources we allotted for our highly complex hydrocephalus patients. We remain unconvinced that any perceived cost savings from standardization of shunt valves outweighs the benefits of maintaining viable options.…”