Value-based neurosurgery: measuring and reducing the cost of microvascular decompression surgery

Abstract

H ealtH care expenditures in the US continue to rise annually, faster than the national income. In 2010, health spending exceeded 17% of the nation's gross domestic product. 23,29 Numerous elements of national health reform are aimed at cost containment. Importantly, "bending the cost curve" refers most commonly to the government or insurers' payment to providers. However, reducing reimbursements does not decrease the cost of care delivery. The critical issue is how to deliver improved outcomes at the lowest cost and achieve the highest value of care. 41 Although health care providers have put significant effort into the quality and safety of care delivered in the past decade, little attention has been focused on cost measurement and even less on cost containment. This oversight stems from the fact that health systems, departments, and individual physicians misunderstand the costs related to the care they deliver.Early in 2009, the Department of Neurosurgery at our institution, aiming to improve the delivery of neurosurgical care, launched a Clinical Quality Program.2 Numerous improvement processes aimed at optimizing preoperative, intraoperative, and postoperative patient care were implemented by the third quarter of 2009. Previously, we assessed whether the multidisciplinary and multifaceted efforts instituted in 2009 succeeded in improving our delivery of value-based neurosurgery. 2,32 For that initial case study, patients undergoing microvascular decompression (MVD) performed by one neurosurgeon (N.A.M.) was the proposed model given that the surgical technique was standard, anticipated operative risks were relatively predictable, and perioperative care was relatively similar between cases. We documented a favorable impact from Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CaliforniaObject. Care providers have put significant effort into optimizing patient safety and quality of care. Value, defined as meaningful outcomes achieved per dollar spent, is emerging as a promising framework to redesign health care. Scarce data exist regarding cost measurement and containment for episodes of neurosurgical care. The authors assessed how cost measurement and strategic containment could be used to optimize the value of delivered care after the implementation and maturation of quality improvement initiatives.Methods. A retrospective study of consecutive patients undergoing microvascular decompression was performed. Group 1 comprised patients treated prior to the implementation of quality improvement interventions, and Group 2 consisted of those treated after the implementation and maturation of quality improvement processes. A third group, Group 3, represented a contemporary group studied after the implementation of cost containment interventions targeting the three most expensive activities: pre-incision time in the operating room (OR) and total OR time, intraoperative neuromonitoring (IOM), and bed assignment (and overall length of stay [LOS]). The value of care was assessed for all...

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“…This cost is dependent on the actual use of resources involved in the care process and incorporates the proportion of time devoted by each resource as well as the cost of each resource per unit of time . TDABC allows all personnel, equipment, facility, and support costs to be directly attributed to the organization's output of patient care, and it illuminates areas of inefficiency while highlighting opportunities for rational cost reduction …”

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“…[13] A retrospective study involving coordinated implementation of value-based processes across the episode of surgical care of microvascular decompression showed both improved outcome and greater value of the care delivered. [14] Value-based purchasing strategies have also been evaluated by means of peerreviewed and field-based research. [12,15,16] Studies focusing on the understanding of VBHC have not been carried out to the best of our knowledge.…”

Hemifacial Spasm and Neurovascular Compression

“…After one institution implemented enhanced-recovery perioperative protocols and diagnosis-specific clinical pathways in patients undergoing MVD for HFS and trigeminal neuralgia, it reported decreased operating room times, hospital stay length, and a reduction in rates of complications and readmissions [85]. Concurrently, a retrospective study at the same institution reduced surgical care episodes costs by 25% by decreasing duration of operations and simplifying intraoperative monitoring intraoperatively while reducing ICU and total hospital stay length postoperatively [86]. …”