Mendhi, Marvesh

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.

Background The neonatal mortality rate in rural Uganda is 38/1000 births as compared to 6/1,000 in the United States. Hypoxic events, also referred to as birth asphyxia, represent 24% of neonatal deaths in Sub-Saharan Africa. Nearly 60% of birth asphyxia worldwide occurs in home-based deliveries with informally trained birth attendants. The World Health Organization has defined two categories of birth attendants in low- and middle-income countries (LMICs): i) midwife skilled birth attendants, who are formally educated; and, ii) traditional birth attendants (TBAs) who usually acquire skills through apprenticeship and have home-based practices in rural areas. Thus, there is an urgent need to provide neonatal resuscitation education and build capacity in rural areas, where access to healthcare is poor and the burden of long-term impairment due to hypoxic brain effects is substantial. Methods We collected data using a focused ethnographic approach to incorporate: i) field-notes; ii) informal interviews while observing five Ugandan midwives providing perinatal care; iii) semi-structured interviews with medical center managers and clinic coordinators; and, iv) a focus group with seven traditional birth attendants in Uganda. This qualitative study used a feminist theoretical stance to show the lived reality of women taking care of other women’s health with limited resources during childbirth and neonatal airway management. Results Our findings showed that the more formally trained midwives exhibited competence in providing neonatal airway management. In contrast, the traditional birth attendants experienced barriers to performing optimal neonatal airway management due to lack of resources, limited knowledge, and cultural practices. The traditional birth attendants identified their learning preferences as demonstration, poem, or song, and by using local spoken language to learn and implement neonatal airway management. Conclusions Findings will contribute to development and dissemination of a culturally tailored educational intervention to enhance TBAs’ understanding of effective neonatal airway management. The joint effort of midwives and traditional birth attendants as a foundation for creating a training intervention with their preferred learning method constitutes a scaled-up team approach to meet the World Health Organization’s Sustainable Development Goal #3 to decrease neonatal mortality. Building on the internationally recognized Helping Babies Breathe model, this integrative initial analysis can be replicated to develop sustainable intervention for other rural areas of low- and middle-income countries.