The economic impact of open versus endoscope-assisted craniosynostosis surgery

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Open and endoscope-assisted repair are surgical options for sagittal craniosynostosis, with limited research evaluating each technique’s immediate and long-term costs. This study investigates the cost-effectiveness of open and endoscope-assisted repair for single, sagittal suture craniosynostosis.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a retrospective cohort study of patients undergoing single, sagittal suture craniosynostosis repair (open in 17 cases, endoscope-assisted in 16) at less than 1 year of age at Monroe Carell Jr. Children’s Hospital at Vanderbilt (MCJCHV) between August 2015 and August 2017. Follow-up data were collected/analyzed for 1 year after discharge. Surgical and follow-up costs were derived by merging MCJCHV financial data with each patient’s electronic medical record (EMR) and were adjusted for inflation using the healthcare Producer Price Index. Proxy helmet costs were derived from third-party out-of-pocket helmet prices. To account for variable costs and probabilities, overall costs were calculated using TreeAge tree diagram software.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Open repair occurred in older patients (mean age 5.69 vs 2.96 months, p &lt; 0.001) and required more operating room time (median 203 vs 145 minutes, p &lt; 0.001), more ICU days (median 3 vs 1 day, p &lt; 0.001), more hospital days (median 4 vs 1 day, p &lt; 0.001), and more frequently required transfusion (88% vs 6% of cases). Compared to patients who underwent open surgery, patients who underwent endoscopically assisted surgery more often required postoperative orthotic helmets (100% vs 6%), had a similar number of follow-up clinic visits (median 3 vs 3 visits, p = 0.487) and CT scans (median 3 vs 2 scans), and fewer emergency department visits (median 1 vs 3 visits). The TreeAge diagram showed that, overall, open repair was 73% more expensive than endoscope-assisted repair ($31,314.10 vs $18,081.47). Sensitivity analysis identified surgical/hospital costs for open repair (mean $30,475, SEM $547) versus endoscope-assisted repair (mean $13,746, SEM $833) (p &lt; 0.001) as the most important determinants of overall cost. Two-way sensitivity analysis comparing initial surgical/hospital costs confirmed that open repair remains significantly more expensive under even worst-case initial repair scenarios ($3254.81 minimum difference). No major surgical complications or surgical revisions occurred in either cohort.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The results of this study suggest that endoscope-assisted craniosynostosis repair is significantly more cost-effective than open repair, based on markedly lower costs and similar outcomes, and that the difference in initial surgical/hospital costs far outweighs the difference in subsequent costs associated with helmet therapy and outpatient management, although independent replication in a multicenter study is needed for confirmation due to practice and cost variation across institutions. Longer-term results will also be needed to examine whether cost differences are maintained.</jats:p></jats:sec>

Geographic Financial Analysis of Craniosynostosis Surgery in the United States

“…Several studies have established that those undergoing open procedures require longer ICU care. 12,16 This is consistent with findings in this study that ICU length of stay was significantly higher for those undergoing open procedures (P < 0.001) and those with additional risk factors (P < 0.001) (Fig. 1A).…”

“…12 Socioeconomic determinants such as patient proximity to a helmet orthosis center, access to transportation for these appointments, and time away from work for additional clinic visits may affect the decision to undergo open versus endoscopic surgery. 12 Certain states might have government insurance plans that do not completely cover helmet therapy, which could likewise compound disparities in choosing between surgical modalities. 13 The present study noted that significantly more patients undergoing endoscopic procedures had commercial insurance ( P < 0.001), which is reinforced in single-center studies.…”

“…8,9 Racial minorities with craniosynostosis have been demonstrated to have delayed presentations, 10,11 such that some institutions rarely see minority patients present in the appropriate age window to be candidates for endoscopic repair. 12 More timely referral of marginalized patients may decrease cost burden on families and the health system. 12 Socioeconomic determinants such as patient proximity to a helmet orthosis center, access to transportation for these appointments, and time away from work for additional clinic visits may affect the decision to undergo open versus endoscopic surgery.…”

Cost comparison of surgical management of nonsagittal synostosis: traditional open versus endoscope-assisted techniques

“…11,16,24,28,32,35,40,42 With an increased focus on cost-effective healthcare delivery, previous studies have shown a significant decrease in financial burden with endoscopic treatment, most often demonstrated in patients with sagittal synostosis. 1,8,19,23,31,39 Fewer data are available on the charges associated with surgical treatment of nonsagittal synostosis (metopic, coronal, and lambdoid), for which traditional open remodeling procedures are distinct from those for sagittal synostosis. Lambdoid synostosis is the least common of these 4 synostosis types, and there is a corresponding paucity of studies including these rare patients.…”

The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic

“…Whenever evaluating time-trend sales, inflation could play a confounder role in the relationship between exposure (time) and outcomes (sales) ( Bell, Hadi, Khanal, & Paudyal, 2021 ; Liles et al., 2019 ; Moore et al., 2021 ). The Consumer Price Index (CPI) ( Foster & Ferguson, 2012 ) and Producer Price Index (PPI) ( Livingston, 2011 ) are well-recognized inflation measures, which tends to increase over time ( Liles et al., 2019 ; Moore et al., 2021 ). For instance, during the period of the present study (1992–2019), CPI had positive annual increases in all the years except from 2009.…”