Introduction: The International Study of Unruptured Intracranial Aneurysms (ISUIA) trial represents the only randomized controlled trial to evaluate clip ligation versus coiling for the treatment of unruptured intracranial aneurysms (UIAs). However, this trial provided evidence for the efficacy of various treatments under ideal conditions. As overall effectiveness is established by nationwide practices, we sought to compare the outcomes and cost associated with coiling and clipping in a nationally selected cohort.
Methods: We utilized the Reuters MarketScan database to examine patients who underwent endovascular or surgical treatment for UIAs between 2000 and 2009, comparing reoperation rates, complications, angiogram use, and healthcare resource use. Propensity score matching techniques were used to match patients who underwent clip ligation to those who had coiling procedures.
Results: We identified 4,504 patients with UIAs treated by surgical (n=1,878) or endovascular treatment (n=2,626), with propensity score matching of 1,338 patients. Reoperation rates were significantly lower in the clipping group compared to the coiling group at 1 year (p<0.0001) and 2 years (p<0.0001) following the procedure. However, postoperative complications (immediate, 30 and 90 days) were significantly higher in those undergoing surgical clipping. Although hospital length of stay and costs were higher in the clipping group for the index procedure, the number of postoperative angiograms and outpatient services used at 1 and 2 years were significantly higher in the coiling group.
Conclusions: Though surgical clipping resulted in lower reoperation rates, it was associated with higher complication rates and initial costs. However, while clipping was more costly than coiling for the index procedure, there was no significant difference in overall costs between the two procedures at 1 and 2 years. This is due to the significantly higher number of follow-up angiograms, outpatient services, and overall outpatient costs in the 1-year and 2 year post-procedure period in those who underwent coiling.
Patient Care: For decades, the standard method to prevent aneurysmal subarachnoid hemorrhage (SAH) has been neurosurgical clipping. Since the introduction of detachable coils to treat aneurysms in the 1990s, endovascular coiling has gained momentum as a primary treatment option for intracranial aneurysms. Many clinical studies have compared outcomes following coiling and clipping of cerebral aneurysms, with some studies suggesting that coiling has lower mortality and morbidity than surgical clipping. This study also demonstrates an increased complication rate in those undergoing clip ligation. However, we also demonstrate significantly lower reoperation rates for those who underwent clipping compared to coiling. Additionally, in the current era of rapidly evolving healthcare reform, economic considerations are important in the cost-benefit evaluation of therapies and can greatly influence reimbursement coverage decisions and policies. We show that although clipping results in higher costs for the index hospitalization, this difference becomes insignificant over the long term as patients who underwent coiling received significantly more follow-up angiograms and other outpatient services, thus increasing healthcare cost. In addition to increased costs, the increased number of angiograms in those who underwent coiling may also place them at a higher risk for postoperative morbidity and mortality. We hope that this study demonstrates clipping to be an efficient treatment modality for the treatment of UIAs and encourage stringent patient selection to reduce the incidence of postoperative complications. Additionally, the significantly higher use of follow-up angiograms in those who undergo coiling should be examined to reduce patient mortality and morbidity, and reduce healthcare expenditure.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of patient selection when deciding the treatment of unruptured intracranial aneurysms, 2) Discuss, in small groups the efficacy, complications, and cost associated with clipping and coiling for unruptured intracranial aneurysms, 3) Identify an effective treatment for unruptured intracranial aneurysms which is also cost-effective.