title: Value-based neurosurgery: measuring and reducing the cost of microvascular decompression surgery.
abstract: OBJECTIVE
  Care providers have put significant effort into optimizing patient safety and quality of care. Value, defined as meaningful outcomes achieved per dollar spent, is emerging as a promising framework to redesign health care. Scarce data exist regarding cost measurement and containment for episodes of neurosurgical care. The authors assessed how cost measurement and strategic containment could be used to optimize the value of delivered care after the implementation and maturation of quality improvement initiatives.
  
  
  METHODS
  A retrospective study of consecutive patients undergoing microvascular decompression was performed. Group 1 comprised patients treated prior to the implementation of quality improvement interventions, and Group 2 consisted of those treated after the implementation and maturation of quality improvement processes. A third group, Group 3, represented a contemporary group studied after the implementation of cost containment interventions targeting the three most expensive activities: pre-incision time in the operating room (OR) and total OR time, intraoperative neuromonitoring (IOM), and bed assignment (and overall length of stay [LOS]). The value of care was assessed for all three groups.
  
  
  RESULTS
  Forty-four patients were included in the study. Average preparation time pre-incision decreased from 73 to 65 to 45 minutes in Groups 1, 2, and 3, respectively. The average total OR time and OR cost were 434 minutes and $8513 in Group 1; 348 minutes and $7592 in Group 2; and 407 minutes and $8333 in Group 3. The average cost for IOM, excluding electrode needles, was $1557, $1585, and $1263, respectively, in Groups 1, 2, and 3. Average total cost for bed assignment was $5747, $5198, and $4535, respectively, in Groups 1, 2, and 3. The average total LOS decreased from 3.16 days in Group 1 to 2.14 days in Group 3. Complete relief of or a significant decrease in preoperative symptomatology was achieved in 42 of the 44 patients, respectively. Overall, the average cost of a surgical care episode (index hospitalization + readmission/reoperation) decreased 25% from Group 1 to 3.
  
  
  CONCLUSIONS
  Linking cost-containment and cost-reduction strategies to ongoing outcome improvement measures is an important step toward the optimization of value-based delivery of care.
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California.
authors.forename: Nancy
authors.initials: N
authors.lastname: McLaughlin
authors.forename: Pooja
authors.initials: P
authors.lastname: Upadhyaya
authors.forename: Farzad
authors.initials: F
authors.lastname: Buxey
authors.forename: Neil A
authors.initials: NA
authors.lastname: Martin
mesh_terms: D006801:Humans; D061145:Microvascular Decompression Surgery / Q000191:economics* / Q000379:methods; D009493:Neurosurgery / Q000191:economics*; D019635:Neurosurgical Procedures / Q000191:economics*; D012189:Retrospective Studies
keywords: ABC = activity-based costing; BAEP = brainstem auditory evoked potential; CON = Certificate of Need; HFS = hemifacial spasm; ICU = intensive care unit; IOM = intraoperative neuromonitoring; LOS = length of stay; MVD = microvascular decompression; NIS = Nationwide Inpatient Sample; OR = operating room; RRMC = Ronald Reagan UCLA Medical Center; TDABC = time-driven ABC; TN = trigeminal neuralgia; cost; intraoperative monitoring; microvascular decompression; outcome; readmission; surgical complication; value