Medicare expenditures for elderly patients undergoing surgical clipping or endovascular intervention for subarachnoid hemorrhage

Abstract

Background The impact of treatment method (surgical clipping or endovascular coiling) on the cost of care of patients with aneurysmal subarachnoid hemorrhage (SAH) is debated. We investigated the association of treatment method with long-term Medicare expenditures in elderly patients with aneurysmal SAH. Methods We performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients, who underwent treatment for ruptured cerebral aneurysms from 2007 to 2012. In order to control for measured confounding, we used propensity score adjusted multivariable regression analysis with mixed effects to account for clustering at the 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, there were 3,210 patients, who underwent treatment for ruptured cerebral aneurysms, and met the inclusion criteria. Of these, 1,206 (37.6%) had surgical clipping, and 2,004 (62.4%) had endovascular coiling. The median total Medicare expenditures in the first year after admission for SAH were $113,000 (IQR $77,500 to $182,000) for surgical clipping, and $103,000 (IQR $72,900 to $159,000) for endovascular coiling. When we adjusted for unmeasured confounders, using an instrumental variable analysis, clipping was associated with increased 1-year Medicare expenditures by $19,577 (95% CI, $4,492 to $34,663). Conclusions In a cohort of Medicare patients with aneurysmal SAH, after controlling for unmeasured confounding, we demonstrated that surgical clipping was associated with increased 1-year expenditures in comparison to endovascular coiling.

Geo-Demographic Trends in Nontraumatic Subarachnoid Hemorrhage-Related Mortality Among Older Adults in the United States, 1999-2020

“…Although increasing technological sophistication has led to increased device costs and healthcare expenditures, we are now better equipped to treat patients with ntSAH. 18…”

Perioperative Ischemic Stroke in Unruptured Intracranial Aneurysm Surgical or Endovascular Therapy

“…Third, complete subject analysis was performed with potential for selection bias because of missing exposure, outcome and/or covariate data. Fourth, eligibility criteria and many of the study variables such as treatment selection, ischemic stroke and obesity diagnosis were defined using previously reported ICD-9-CM codes [21], potentially leading to misclassification bias. Fifth, adjusted measures of association may be biased due to unmeasured confounding in the context of an observational design.…”

“…Inclusion criteria were defined as follows: (1) underwent surgical or endovascular treatment for intracranial aneurysms (IAs), with at least one of the following ICD-9-CM procedure codes: . Case definition was based on published literature that examined IA treatment outcomes using national databases [21]. It is worth noting that flow diverters (e.g.…”