Introduction: 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.

Patient Care: The cost difference between the two treatment options (surgical clipping and endovascular coiling) for ruptured cerebral aneurysms remains an issue of debate. In a cohort of Medicare patients, after controlling for unmeasured confounding, we demonstrated that surgical clipping of ruptured cerebral aneurysms was associated with increased 1-year expenditures in comparison to endovascular coiling. This analysis provides insight in the economic aspects of the available treatments for aneurysmal SAH. These results are helpful for physicians, policy-makers, and payers when designing and executing new healthcare policies.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) understand the economics of cerebral aneurysm treatment 2) identify how the use of an advanced observational technique can simulate the results of a randomized trial

References: 1. Barker FGn, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC, et al: Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the United States, 1996-2000. Neurosurgery 54:18-28, 2004 2. Barker FGn, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS: In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996-2000: the effect of hospital and surgeon volume. Neurosurgery 52:995-1007, 2003 3. Bekelis K, Goodney RP, Dzebisashvili N, Goodman DC, Bronner KK: Variation in the Care of Surgical Conditions: Cerebral Aneurysms, in Practice TDIfHPaC (ed): A Dartmouth Atlas of Health Care Series. Lebanon, NH, 2014 4. Bekelis K, Gottlieb D, Su Y, O'Malley AJ, Labropoulos N, Goodney P, et al: Surgical clipping versus endovascular coiling for elderly patients presenting with subarachnoid hemorrhage. J Neurointerv Surg 2015 Aug 26 [Epub ahead of print], 2015 5. Bekelis K, Missios S, Coy S, Rahmani R, Singer RJ, MacKenzie TA: Surgical Clipping versus Endovascular Intervention for the Treatment of Subarachnoid Hemorrhage Patients in New York State. PLoS One 10:e0137946, 2015 6. Bekelis K, Missios S, Coy S, Singer RJ, MacKenzie TA: New York State: Comparison of Treatment Outcomes for Unruptured Cerebral Aneurysms Using an Instrumental Variable Analysis. J Am Heart Assoc 4:e002190, 2015 7. Bekelis K, Missios S, Labropoulos N: Cerebral aneurysm coiling: a predictive model of hospitalization cost. J Neurointerv Surg 2014 May 26. [Epub ahead of print], 2014 8. Bekelis K, Missios S, Mackenzie TA, Desai A, Fischer A, Labropoulos N, et al: Predicting inpatient complications from cerebral aneurysm clipping: the Nationwide Inpatient Sample 2005-2009. J Neurosurg Sep 13. [Epub ahead of print], 2013 9. Bekelis K, Missios S, Mackenzie TA, Fischer A, Labropoulos N, Eskey C: A predictive model of outcomes during cerebral aneurysm coiling. J Neurointerv Surg 2013 Jul 4. [Epub ahead of print], 2013 10. Bekelis K, Missios S, MacKenzie TA, Labropoulos N, Roberts DW: A predictive model of hospitalization cost after cerebral aneurysm clipping. J Neurointerv Surg 2015 Jan 12. [Epub ahead of print], 2015