Research is needed to identify overutilization and other areas of wasteful spending, according to a new report.
Costs associated with clipping and coiling for the treatment of aneurysmal subarachnoid hemorrhage (SAH) are increasing at a rate that far outstrips US economic growth, according to a new analysis. Substantial variations in costs by region and hospital provide clues as to where to look for cost-containment strategies.
“With technological advances and publication of large, randomized clinical trials on [aneurysmal] SAH, there is increasing debate over the efficacy of clipping and coiling treatments,” write investigators led by Seungwon Yoon, BS (Barrow Neurological Institute, Phoenix, AZ). “With dynamic changes to the healthcare landscape, however, we lack a longitudinal understanding of the high costs of these therapies.”
In an interview with Neurovascular Exchange, senior author Michael T. Lawton, MD (Barrow Neurological Institute), explained that the hypothesis underlying the study is that “we can control costs better in specialty institutes that focus on one thing and know their business inside and out. You lose that when you get into bigger bureaucratic medical centers that are trying to do too much.”
For their study, published online December 3, 2018, ahead of print in Stroke, Yoon and colleagues identified 23,324 ruptured aneurysm patients from the 2002 to 2013 National Inpatient Sample, which is a 20% stratified random sample of 97% of all US community hospitals. They also collected data on 8,670 surgeries for aneurysmal SAH that took place from 2013 to 2015 from the Vizient Clinical Database, which contains data from over 97% of US academic medical centers and 160 community hospitals.
The investigators used these data to conduct a cross-sectional analysis of the costs of clipping and coiling, including a look at the associations between treatment costs and patient demographics as well as clinical and hospital factors.
Based on data from the National Inpatient Sample, mean inflation-adjusted costs for clipping increased 41.0% (from $66,358 in 2002 to $93,597 in 2013), whereas costs for coiling increased 38.9% ($62,972 to $87,441, respectively). Numbers from the Vizient database, meanwhile, revealed that, from 2013 to 2015, the cost for clipping increased by 11% and the cost for coiling by 5%.
Multivariate analysis showed that age, length of stay, insurance, comorbidities, risk of mortality, and urban teaching hospital status all were associated with higher hospital costs for clipping and coiling (all P < 0.05). Both databases demonstrated that the western United States had the highest health expenditures for aneurysmal SAH (P < 0.05).
Research Into Cost Containment Needed
“Trends in the increased endovascular management of aneurysmal SAH and total hospital expenditures for treatments . . . far exceed national economic growth,” Yoon et al say, noting that the evidence of significant variations in cost between regions and hospitals suggests there are possible avenues for cost containment.
Commenting on the study, Kimon Bekelis, MD, (Dartmouth-Hitchcock Medical Center, Lebanon, NH), pointed out in an email to Neurovascular Exchange that these findings confirm prior work on this topic pioneered by the Dartmouth Institute for Healthcare Policy and Clinical Practice.
“Regional variation needs to be studied at a local level,” he recommended. “A healthy level of variation is expected. However, as we have demonstrated, overutilization can result in wasteful spending and should be the subject of further research in outliers.”
What’s needed is a better understanding of how these outliers are linked to overutilization, Bekelis added. He pointed out, however, that the database used by the authors of this study is derived from patient-level data and therefore not useful for identifying outliers.
To NVX, Lawton described the findings as “a call to arms” and “a symptom of a medical system that does not regulate itself well or simply does not have the tools to control the things that lead to rising costs.”
It’s worth exploring why some hospitals are better at controlling costs than others, he emphasized. “Maybe those places that can control costs and still achieve high outcomes should be our model for the future of American healthcare,” Lawton said. “In the end, we would like to put together an institution that can get you both the best outcome and the lowest cost for the highest value.”
The current study, he added, might spearhead efforts to “find tools and metrics to really read cost on a day-to-day online basis, rather than retrospectively, when you can’t change it.”
Yoon S, Yoon JC, Winkler E, et al. Nationwide analysis of cost variation for treatment of aneurysmal subarachnoid hemorrhage. Stroke. 2018;Epub ahead of print.
Yoon and Bekelis report no relevant conflicts of interest.