title: Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage.
abstract: OBJECTIVE The impact of treatment method-surgical clipping or endovascular coiling-on the cost of care for patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. Here, the authors investigated the association between treatment method and long-term Medicare expenditures in elderly patients with aneurysmal SAH. METHODS The authors performed a cohort study of 100% of the Medicare fee-for-service claims data for elderly patients who had undergone treatment for ruptured cerebral aneurysms in the period from 2007 to 2012. To control for measured confounding, the authors used propensity score-adjusted multivariable regression analysis with mixed effects to account for clustering at the hospital referral region (HRR) level. An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding by creating pseudo-randomization on the treatment method. RESULTS During the study period, 3210 patients underwent treatment for ruptured cerebral aneurysms and met the inclusion criteria. Of these patients, 1206 (37.6%) had surgical clipping and 2004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the 1st year after admission for SAH were $113,000 (IQR $77,500-$182,000) for surgical clipping and $103,000 (IQR $72,900-$159,000) for endovascular coiling. When the authors adjusted for unmeasured confounders by using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI $4492-$34,663). CONCLUSIONS In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, surgical clipping was associated with increased 1-year expenditures in comparison with endovascular coiling.
authors.affiliation: Section of Neurosurgery.|The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon.
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Gottlieb
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon.
authors.forename: Yin
authors.initials: Y
authors.lastname: Su
authors.affiliation: Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; and.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lanzino
authors.affiliation: Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, California.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
authors.affiliation: Department of Medicine, Dartmouth-Hitchcock Medical Center.|The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon.|Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
authors.forename: Todd A
authors.initials: TA
authors.lastname: MacKenzie
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000191:economics / Q000453:epidemiology / Q000601:surgery; D015331:Cohort Studies; D057510:Endovascular Procedures / Q000191:economics* / Q000379:methods; D005260:Female; D005102:Health Expenditures; D006801:Humans; D002532:Intracranial Aneurysm / Q000191:economics / Q000453:epidemiology / Q000601:surgery; D008297:Male; D006278:Medicare; D019635:Neurosurgical Procedures / Q000191:economics / Q000379:methods; D013345:Subarachnoid Hemorrhage / Q000191:economics* / Q000453:epidemiology / Q000601:surgery*; D013997:Time Factors; D014481:United States
keywords: COPD = chronic obstructive pulmonary disease; HRR = hospital referral region; ISAT = International Subarachnoid Aneurysm Trial; IV = instrumental variable; Medicare; NIS = Nationwide Inpatient Sample; SAH = subarachnoid hemorrhage; ZIP = Zone Improvement Program; cerebral aneurysms; clipping; coiling; cost; instrumental variable; subarachnoid hemorrhage; vascular disorders