Costes del tratamiento endovascular frente al quirúrgico en hemorragia subaracnoidea aneurismática

doi:10.1016/j.neucir.2014.04.004

Neurocirugía

Volume 26, Issue 1, January–February 2015, Pages 13-22

https://doi.org/10.1016/j.neucir.2014.04.004 Get rights and content

Resumen

Objetivo

Evaluar los costes derivados del tratamiento quirúrgico y endovascular de una serie consecutiva de 80 pacientes con hemorragia subaracnoidea aneurismática (HSAa).

Material y métodos

Se revisan 80 pacientes ingresados en nuestro centro con HSA aneurismática que recibieron tratamiento endovascular (EV) (n = 57) o quirúrgico (Q) (n = 23) entre enero de 2010 y junio de 2011. Se analizan datos demográficos (edad y sexo), clínicos (Fischer y Hunt-Hess al ingreso) y los resultados (GOS a los 6 meses) de ambas series. Se registra estancia hospitalaria (UCI y planta), coste del tratamiento (número de coils, catéteres, craneotomía…), del seguimiento (arteriografías de control, angio-RMN) y de los retratamientos de cada una de las técnicas. Se calculan los costes según los precios medios estimados de hospitalización, material fungible y procedimientos.

Resultados

No hay grandes diferencias entre ambas series en cuanto a características clínicas (edad, Hunt-Hess y Fischer) ni a los resultados a los 6 meses medidos en la escala GOS. Existen diferencias en cuanto al tiempo de hospitalización tanto en UCI (superior en algo más de 1,4 días en el grupo Q) como en planta (1,7 días más). La hospitalización también se relaciona con la edad, la puntuación de Hunt-Hess y la de Fischer. Los gastos derivados de los materiales de embolización, del seguimiento y de los retratamientos (un 12% de la serie EV) hace que el coste global tratamiento endovascular sea un 4,1% más caro que el quirúrgico (35.835 € versus 34.404 €). El procedimiento endovascular en sí, incluyendo los retratamientos resulta un 110% más caro que el quirúrgico (8.015 € versus 3.817 €).

Conclusiones

Los resultados en cuanto a morbimortalidad obtenidos mediante tratamiento quirúrgico o embolizador no son diferentes. La estabilidad del tratamiento quirúrgico es superior al del endovascular, con mayores tasas de oclusión y menor necesidad de retratamiento. El tratamiento endovascular resulta más caro que el quirúrgico en aneurismas rotos, fundamentalmente debido al precio de los materiales de embolización, a la tasa de retratamientos y al seguimiento que precisan. Estas diferencias podrían ser aún más significativas en el caso de aneurismas no rotos, en los que se presupone un ingreso hospitalario menor, fuente principal del gasto en el tratamiento quirúrgico de esta patología.

Abstract

Objectives

To analyse costs of endovascular versus surgical treatment in 80 patients with aneurysmal subarachnoid haemorrhage (aSAH).

Material and methods

We analysed data on 80 consecutive patients with aSAH between January 2010 and June 2011. Endovascular treatment was used in 57 patients and surgical in 23 patients. Demographic (gender and age) and clinical data (Hunt-Hess and Fisher scales), length of stay (ICU and ward) and results at 6 months (Glasgow outcome scale,[GOS]) were collected. Costs including stay, follow-up, complications and retreatments were calculated.

Results

Age was higher in the endovascular group (statistically significant). There were no differences between the 2 groups in Hunt-Hess and Fisher scales. Results at 6 months were also similar, although slightly better in the surgical group. Length of stay was longer in surgical patients, both in ICU (mean 1.4 days) and ward (1.7 days). Hospitalisation length was also related to age and Hunt-Hess and Fisher scales. Costs from embolisation devices, follow-up and retreatment (12% in this series) made final endovascular treatment 4.1% more expensive than surgical treatment (€35,835 versus €34,404). Endovascular procedure (including retreatments) was 110% more expensive than surgical treatment (€8,015 versus €3,817).

Conclusions

There are no differences between the 2 treatments in terms of morbidity and mortality. Stability of surgical treatment was higher than that of endovascular, with better occlusion and lower retreatment rates. Endovascular treatment is more expensive in ruptured aneurysms, principally due to embolisation device costs, long-term follow-up and retreatments, in retreatments, in spite of shorter hospital stay. In incidental aneurysms, which usually need shorter hospitalisation, differences between the 2 treatments could be even larger.

Section snippets

Introducción

La hemorragia subaracnoidea aneurismática (HSAa) es una causa importante de muerte y discapacidad en pacientes en edades productivas de la vida, siendo su incidencia de 6-12 casos por 100.000 habitantes en países occidentales¹.

Desde la introducción de los coils, el tratamiento endovascular ha ido ganando terreno al quirúrgico de forma exponencial², sobre todo a raíz de la publicación del estudio ISAT en el año 2002³, donde se concluía que el tratamiento endovascular era superior al quirúrgico

Material y métodos

Se revisa una serie consecutiva de 80 pacientes con diagnóstico de HSA aneurismática que ingresan y son tratados en el Hospital Virgen de las Nieves entre enero de 2010 y junio de 2011, con un seguimiento mínimo de un año.

Se recogen datos demográficos (edad, sexo), clínicos (Hunt-Hess al ingreso, tipo de tratamiento, tiempo de ingreso en Unidad de Cuidados Intensivos (UCI) y en planta, Glasgow Outcome Scale (GOS) a los 6 meses) y radiológicos (Fischer, presencia de hemorragia intraventricular,

Resultados

Entre enero de 2010 y junio de 2011 se trataron 80 hemorragias subaracnoideas de causa aneurismática. De este número, la causa de la hemorragia fue resuelta endovascularmente en 57 casos (71%) y el resto mediante cirugía (29%).

Las edades de los pacientes oscilaron entre los 23-83 años con una media de 54,6 años. Hubo un claro predominio femenino, con 58 mujeres, lo que supone un 72,5% de la serie.

Con respecto a la modalidad de tratamiento existen diferencias entre ambas series en cuanto a la

Discusión

El estudio ISAT³ supuso un hito en el manejo de la patología aneurismática intracraneal ya que según los resultados obtenidos de un estudio prospectivo multicéntrico muy amplio (2.143 pacientes) la morbimortalidad del tratamiento quirúrgico versus al endovascular aconsejaba este último como primera opción de tratamiento. Tras su impacto inicial, trabajos posteriores18, 19 han venido a señalar los diferentes sesgos presenta que la serie (selección de cirujanos, selección de los casos,

Conclusiones

Conflicto de intereses

Los autores declaran no tener ningún conflicto de intereses.

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Cited by (4)

Trends in the treatment of cerebral aneurysms: Analysis of a hospital series
2020, Neurologia
Cost of hospitalization for aneurysmal subarachnoid hemorrhage in the United States
2019, Clinical Neurology and Neurosurgery
Citation Excerpt :
The overall cost of healthcare in the United States has increased over time [10–13], which is also reflected in our study; the mean cost of aSAH hospitalization has increased from $68,783 in 2002 to $90,585 in 2014. A number of studies have revealed endovascular coiling to be costlier than surgical clipping [14–18]; however, our study revealed no difference in cost between the 2 procedures. The aforementioned rise in cost could be secondary to increasing resource utilization, including imaging studies, laboratory tests, intensity of care, nursing care and aneurysm treatment procedures.
Recent large-scale studies describing hospitalization cost trends secondary to aneurysmal subarachnoid hemorrhage (aSAH) in the United States are lacking. We sought to discover the impact of aSAH-related factors upon its hospitalization cost.
Patients with a primary diagnosis of aSAH were selected utilizing the National Inpatient Sample. Regression analyses were used to evaluate the impact of aSAH-related factors on hospitalization costs.
From 2002–2014, 22,831 cases of aSAH were identified. The inflation-adjusted mean cost of hospitalization was $82,514 (standard deviation ± $54,983). The proportion of males was lower (31%), but a higher cost of $3385 (± $685; p < .001) remained compared to females. Median length of hospitalization was 16 days (interquartile range 11–23) and each day increase in hospitalization was associated with a cost increase of $3228 (± $19; p < .001). There was no difference in cost between patients undergoing aneurysmal coiling or clipping. When compared to patients < 40 years old, the increase in cost for patients 40–59 years old was $3829 (± $914; p < .001), and $4573 (± $1033; p < .001) for patients 60–79 years old; however, for patients ≥ 80 years old, there was a decrease in cost of $8124 (± $1722; p < .001). Several central nervous system complications were also associated with increased cost.
aSAH is a significant financial burden on the United States healthcare system. We were able to identify many important factors associated with higher costs, and these results may help us understand resource utilization and develop future cost-reduction strategies.
Endovascular trends in the treatment of intracranial aneurysms in a Peruvian reference center
2023, Journal of Neurosciences in Rural Practice
Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil
2019, Hospital Practice

View full text

Investigación ClínicaCostes del tratamiento endovascular frente al quirúrgico en hemorragia subaracnoidea aneurismáticaEndovascular versus surgical treatment in subarachnoid haemorrhage: Cost analysis

Resumen

Objetivo

Material y métodos

Resultados

Conclusiones

Abstract

Objectives

Material and methods

Results

Conclusions

Section snippets

Introducción

Material y métodos

Resultados

Discusión

Conclusiones

Conflicto de intereses

Lancet

Lancet Neurol

Surg Neurol

Incidence of subarachnoid hemorrhage: Role of region, year, and rate of computed tomography: A meta-analysis

Stroke

Recent trends in the treatment of cerebral aneurysms: Analysis of a nationwide inpatient database

J Neurosurg

International subarachnoid aneurysm trial 2009: Endovascular coiling of ruptured intracranial aneurysms has no significant advantage over neurosurgical clipping

Neurosurgery

Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the international subarachnoid aneurysm trial?

J Neurosurg

Hospitalization costs for endovascular and surgical treatment of ruptured aneurysms in the United States are substantially higher than medicare payments

AJNR Am J Neuroradiol

Hospitalization costs for endovascular and surgical treatment of unruptured cerebral aneurysms in the United States are substantially higher than medicare payments

AJNR Am J Neuroradiol

Direct costs of surgical clipping and endovascular coiling of unruptured intracranial aneurysms

Cerebrovasc Dis

The effect of coiling versus clipping of ruptured and unruptured cerebral aneurysms on length of stay, hospital cost, hospital reimbursement, and surgeon reimbursement at the university of florida

Neurosurgery

Length of stay and total hospital charges of clipping versus coiling for ruptured and unruptured adult cerebral aneurysms in the nationwide inpatient sample database 2002 to 2006

Stroke

Analysis of cost related to clinical and angiographic outcomes of aneurysm patients enrolled in the international subarachnoid aneurysm trial in a north american setting

Neurosurgery

Long-term economic impact of coiling versus clipping for unruptured intracranial aneurysms

Neurosurgery

Investigación Clínica
Costes del tratamiento endovascular frente al quirúrgico en hemorragia subaracnoidea aneurismáticaEndovascular versus surgical treatment in subarachnoid haemorrhage: Cost analysis