Freeman, William D.

ImportanceImplementing multidisciplinary teams for treatment of complex brain tumors needing awake craniotomies is associated with significant costs. To date, there is a paucity of analysis on the cost utility of introducing advanced multidisciplinary standardized teams to enable awake craniotomies.ObjectiveTo assess the cost utility of introducing a standardized program of awake craniotomies.Design, Setting, and ParticipantsA retrospective economic evaluation was conducted at Mayo Clinic Florida. All patients with single, unilateral lesions who underwent elective awake craniotomies between January 2016 and December 2021 were considered eligible for inclusion. The economic perspective of the health care institution and a time horizon of 1 year were considered. Data were analyzed from October 2022 to May 2023.ExposureTreatment with an awake craniotomy before standardization (2016-2018) compared with treatment with awake craniotomy after standardization (2018-2021).Main Outcomes and MeasuresPatient demographics, perioperative, and postoperative outcomes, including length of stay, intensive care (ICU) admission, extent of resection, readmission rates, and 1-year mortality were compared between patients undergoing surgery before and after standardization. Direct medical costs were estimated from Medicare reimbursement rates for all billed procedures. A cost-utility analysis was performed considering differences in direct medical costs and in 1-year mortality within the periods before and after standardization of procedures. Uncertainty was explored in probability sensitivity analysis.ResultsA total of 164 patients (mean [SD] age, 49.9 [15.7] years; 98 [60%] male patients) were included in the study. Of those, 56 underwent surgery before and 108 after implementation of procedure standardization. Procedure standardization was associated with reductions in length of stay from a mean (SD) of 3.34 (1.79) to 2.46 (1.61) days (difference, 0.88 days; 95% CI, 0.33-1.42 days; P = .002), length of stay in ICU from a mean (SD) of 1.32 (0.69) to 0.99 (0.90) nights (difference, 0.33 nights; 95% CI, 0.06-0.60 nights; P = .02), 30-day readmission rate from 14% (8 patients) in the prestandardization cohort to 5% (5 patients) (difference, 9%; 95% CI, 19.6%-0.3%; P = .03), while extent of resection and intraoperative complication rates were similar between both cohorts. The standardized protocol was associated with mean (SD) savings of $7088.80 ($12 389.50) and decreases in 1-year mortality (dominant intervention). This protocol was found to be cost saving in 75.5% of all simulations in probability sensitivity analysis.Conclusions and RelevanceIn this economic evaluation of standardization of awake craniotomy, there was a generalized reduction in length of stay, ICU admission time, and direct medical costs with implementation of an optimized protocol. This was achieved without compromising patient outcomes and with similar extent of resection, complication rates, and reduced readmission rates.

Introduction: The consequences of external cardiovascular compression and cardiac displacement from pectus excavatum (PEx) are debated. The complex geometry of the right (RV) and left ventricle (LV) along with distortion from the extrinsic chest deformity pose significant limitations to reliable assessment of LV and RV volumes and function using transthoracic 2D-echocardiography in this population. Hypothesis: A 3D-echocardiography approach can reliably assess the effects of external cardiac compression and the benefits of surgical correction on RV and LV function in PEx patients. Methods: Adult patients undergoing minimally invasive repair of PEx between Oct-2021 and Feb-2023 were included in this prospective study. Intraoperative transesophageal (TEE) 6 beat full volume video loops incorporating LV and RV were captured and compared before and after surgical correction of the PEx. TomTec Software® was used for offline 3D/4D reconstruction ( Figure 1 shows changes in 3D RV and LV shape pre- and post-surgery). Result: The study included 102 patients (mean age of 32.1 ±11.8 years; Haller index 4.9 ±2.5; 60.8% males). Post PEx repair, there was a significant (p<0.001) increase in the 3D RV volumes, RV ejection fraction (EF), RV stroke volume and RV strain ( Figure 1 ). Additionally, there was a significant improvement in 3D LVEF, 3D LV strain (longitudinal and circumferential), LV twist, and torsion ( Figure 1 ). Conclusion: In this PEx cohort, 3D/4D TEE imaging demonstrated significant increases in RV volumes and in RV and LV systolic function after surgical repair. These findings support the negative cardiovascular consequences of PEx compression and benefits of surgical repair.