The treatment priorities of a brain tumor patient are quality of life (QOL) and overall survival (OS). High neurosurgical costs could impact public health, even if patients have medical insurance. Comparing costs of different countries helps to better understand weak points and how to improve them.
Documenting costs for neurosurgical care is important for resource allocation, with healthcare sector planning, as well as exploring the benefit of adopting cost-saving interventions, and also helps clinical research aiming at improving patients QOL.
The cost of neurosurgical intervention is the sum of direct and indirect costs. Direct costs can be attributed to a specific service or procedure, while indirect costs are costs that cannot. Identification of patients groups or interventions with higher associated treatment costs may be beneficial in efforts to decrease the overall financial burden. Strategies to reduce cost may require different approaches depending on the procedure type.[13,14] Because of this, we did not compare the costs of microsurgery and endoscopy in this evaluation; each type of procedure has several different particularities. Providing a cheaper but effective treatment not only improves economy but also QOL and OS.
LOS is a useful measure of healthcare quality. In addition to influencing patient care, an increase in LOS is associated with higher healthcare costs.[15,16] Postoperative LOS of 14 or more days has been associated with increased frequency of surgical site infections (SSI) and a rise in healthcare costs of up to 300%. In this series, the mean LOS was 12 days. The smaller LOS was 3 days of an elective procedure. Several patients admitted to the emergency department (ER) were not immediately operated, as was done in elective procedures in which patients were at home and admitted only when properly prepared for surgery. With prolonged LOS, the complication rate increased including infections and thrombosis. This series only evaluated adult patients; for children, analysis characteristics are different.
Due to the need for improving patient outcomes and reducing costs, the concern of developing safe and effective standards in postoperative care emerged, and advances have been achieved.[7,18] In 1994, Engelmann and colleagues introduced the concept of “Fast-Track Surgery” to optimize postoperative recovery. Many neurosurgical centers still adopt an in-patient postoperative care with a mean of 4 days after craniotomy for safety reasons, even in cases with no perioperative complications. As we confirmed in this paper, the hospitalization period is associated with greater costs, especially in ICU (Fig. 7).
Shorter hospital LOS has been associated with decreased complication rates, fewer hospital-acquired infections, and lower costs. Due to concerns for postoperative complications, neurosurgeons could be hesitant to discharge patients on the same day or 1 day after craniotomy. Most severe postoperative sequelae occur within 24 hours after surgery. Observing patients overnight should limit the number of complications developing after discharge. With the evolution of surgical technology, instrumentation, monitoring techniques, and increased proficiency in anesthesia, patients are now receiving improved perioperative care with shorter operative duration and shorter recovery times and times to discharge.
In this study, ICU LOS was considered the second factor responsible for the increased costs. A study revealed that the cost differential between the ICU and neuro-transitional care unit is U$1504 per day. Perhaps some postoperative brain tumor patients could be monitored in a semi-intensive unit and this could decrease costs. Qualification of health professionals for a more dynamic and effective patient approach could be an alternative, and earlier and safer discharge could become more common.[20,21]
This study also revealed that emergency procedures are related to greater hospitalization days, infections, deaths, and total costs. In this scenario, patients did not have proper surgical preparation. Several of them had noncontrolled arterial hypertension, diabetes mellitus, and obesity and were smokers. Rarely brain tumors required surgery in an emergency, usually when they cause hydrocephalus, huge midline shift, or edema. Unfortunately, as we discussed, five billion people do not have access to safe, affordable surgical, and anesthesia care when needed and only get health assistance when they are severely compromised, especially in low-income and lower-middle-income countries. Better patient preparation and fewer emergency procedures are a reasonable option for cost reduction.
Although awake surgery was not statistically significantly associated with smaller costs, this result had bias due to the small number of awake procedures in this series. Several studies described a shorter LOS in patients undergoing awake craniotomies. Some tools have been shown to improve outcomes with decreased complications.[11,23-25] For the selected cases, awake neurosurgery improved functional outcomes with small LOS. The preparation of a multidisciplinary team is required for awake surgery.
In the postoperative period, infections and thromboembolic events are responsible for great morbidity, mortality, and costs. SSI incidence in neurosurgery is low and most readmissions occur within 30 days.[26-28] Broad-spectrum antibiotics are expensive, so careful surgical preparation should be encouraged.[29,30]
Concerning the histological type and costs, meningiomas had a greater cost; however, this association was not significant. For skull base meningiomas, procedures are longer, recovery is slower[31,32], and infection rate was greater than that in nonskull base meningiomas. Among the meningioma group, skull base localization had greater costs. In this series, all patients were submitted for microsurgery; endoscopic procedure costs and complications are different and not considered.
Regarding gliomas, LGG predominates in younger patients with faster recovery and shorter hospitalization, which did not happen to HGG, especially GBM.[33-35] GBM was the most common tumor in this cost evaluation with 22.75% of incidence. It is an aggressive, high-grade brain tumor associated with a significant clinical burden. In most series, nearly half of adult primary malignant brain tumors are GBM. According to the Central Brain Tumor Registry of the United States, the average annual age-adjusted incidence of GBM is 3.2 cases per 100,000 people.
Health economics in GBM is a subject of rising interest, as in many other cancers, but there is only limited knowledge on cost-effectiveness and other economic aspects of different therapies for recurrent GBM. It is important to know the treatment impact of this disease worldwide.
A high proportion of patients with GBM have emergency department visits (32%) and hospitalizations (28%) in the 6 months after diagnosis, indicating the substantial healthcare resource burden associated with GBM. Emergency neurosurgical approaches were required many times as documented in this paper. Mortality rate was greater in emergency patients (92.3%). Only one elective patient died in this series: an elderly female patient with several comorbidities, initial Karnofsky Performance Scale of 40, and a giant olfactory groove meningioma who died of a refractory septic shock due to pneumonia. Adjuvant therapy is not discussed here but is also responsible for more treatment costs.
This study has several limitations. Results of a retrospective cost analysis from a single-center, mixed case index academic practice may not apply to all centers depending on the proportion of cases. This paper did not consider the cost of neurooncological patients who did not undergo neurosurgery.