Massachusetts General Hospital Epilepsy and EEG Service
Thursday, February 24, 2011
Cost-Effectiveness of EEG Monitoring
in Acute Brain Injury:
What it is, What it is Not, and How to Measure It.
Kenneth Jordan, MD, FACP, FAAN, FACNS
President, Jordan NeuroScience, Inc
Scope of ICU-CEEG
1.
7,400 Intensive Care Units in USA
2.
$180 billion (30% of acute care costs)
3.
55,000 patients/day in ICUs
4.
Total ICU admissions/year = 5,000,000
5.
10% have ICDN diagnoses at risk for NCS/NCSE.
6.
500,000 potential CEEG patients/year
7.
–
Av. duration of CEEG is 3 days
–
>1.5 mil CEEG days/year to maintain, monitor and read
Market size for CEEG monitors = $52 million
Refs: UCLA Brain Injury Research Center, www.aha.org,www.sccm.org;
Claassen et al Neurology (2004); personal communication from CEO of global EEG
company.
Cost-Effectiveness Analysis
(CEA)
Goal: Identify the most cost-effective
intervention from alternatives that meet
a common health benefit and are
competing for the same resources.
Economic Evaluation of Public Health Preparedness and Response Efforts. CDC, at:
http://www.cdc.gov/owcd/EET/Preface/Fixed/Preface.html
Costs
All intervention’s tangible costs;
excludes intangible costs.
WHAT EFFECTIVENESS IS AND WHAT IT IS NOT
•Effectiveness is a health benefit caused directly or
indirectly by an intervention.
•The health benefit cannot exceed the capabilities of the
intervention.
e.g. The effectiveness of a screening program for prolonged Q-T syndrome
is 1) its accuracy for detecting the condition and 2) its successful public
health deployment.
It is not whether the program saves lives, since that depends on factors
beyond the capability of the screening program (Do pts follow up with the
doctors; are the correct surveillance measures taken, are dangerous drugs
avoided, is timely and correct treatment provided, etc)
•The health benefits of EEG are limited to its detection of
brain wave activity and its deployment methods. They do not
include outcomes from subsequent treatment interventions.
Cost-Effectiveness Ratio
CER=ΔC/ΔE
The numerator is the change in cost due
to the application of an intervention and
the denominator is the change in health
benefit.
Cost-Effectiveness Ratio (CER):
The smaller the CER, the lower the cost
and/or the more effective the intervention:
a4= 27.14, c1= 2.27
CEA of Set-Up Methods for
Emergency EEG and CEEG
Studies:
EEG Technologist Call Back (ETCB)
vs BraiNet® Template (BN)
ETCB Indications
1. Any Study Initiated after 7 PM or before 7 AM
M-F
2. Any Study Initiated on Saturday, Sunday or
work holidays
3. Remove and/or Re-apply CEEG electrodes for
imaging studies or other procedures.
4. Revise, re-apply, repair and/or re-insert
electrodes during CEEG or other ongoing
study
Bradley Kolls, MD, PhD, Dir of Crit. Care Monitoring Duke
University Medical Center
Utilization Over Time by Location*
300
2004
2005
2006
2007
2008
Number of Studies
250
200
150
100
50
ED
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IC
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Total 2008 Emergency EEGs = 450
ETCBs = 320 (71%)
*Pediatric cases not included
Lab Survey Findings
How much do you feel that over-night coverage of the prolonged
monitoring service (call) is a significant contributor to technician
“burnout”?
This service is the largest
contributor
There are many other
factors, this is a modest
contributor
There are many other
factors, this is a minimal
contributor
This service is not a factor in
technician “burnout”
Lab Survey Findings
Do you feel that over-night coverage of the prolonged monitoring
service (call) is a significant contributor to technicians leaving the
Duke Neurodiagnostic lab?
Yes
No
Summary of ECB and CEEG Utilization
Time-Motion Profile
for One ETCB Study
Task
Duration (min)
Page…get ready…leave home
15-30
Drive Time/parking
15-30
To Lab for supplies
15
Set up equipment at bedside
15
Chart review. Enter history
10-20
Measure head:10/20 method
10-20
Apply electrodes
10
Total Set-Up Time
1.5 Hr – 2.3hr
ETCB vs. BraiNet® Costs
Scenario I: 250 ECB/year
ECB $/
Year
BN $/Year
Weekend, holiday and overnight
call back for 3hr/ECB day
$37,950
0.00
On call pay ($50/ECB day)
$12,650
12,650
Supplies**: dispos. electrodes, BN
$16,250
25,000
Total Costs
$66,850
$37,650
Costs*
(includes benefits and paid non-work time)
*ETCB = 6,072 hrs or 253 days/year. 28/hr base wage + benefits,etc, OT=$50/hr.
**Retail: dispos electrodes $65, BN $35+electrodes
ETCB vs. BraiNet® Costs
Scenario 2: 500 ECB/year
ECB $/
Year
BN $/Year
Weekend, holiday and overnight
call back for 6 hr/ECB day
$75,900
0.00
On call pay ($50/ECB day)
$12,650
12,650
Supplies: dispos. electrodes, BN
$32,500
50,000
$121,050
$62,650
Costs
(includes benefits and paid non-work time)
Total Costs
EFFECTIVENESS
Benefits/Equivalence of
BN vs. ETCB
Equivalence Study of BraiNet and Technologist
Applied Electrode Leads*
B. Kolls and K. Dombrowski, Duke University Medical Center
*Sponsored by JNS under DoD Award. JNS provided BN training but was not
otherwise involved in study or data analysis.
Results
• 32 of 36 studies initiated with the BraiNet were
analyzed.
• 6 of the BN studies were done with disks and
26 were done with needles.
• 4 studies were attempted with the BN initially,
but failed due to
–
–
–
–
Improper use of conduction agents on disk electrodes n=1
improper use of fixative agents to needle electrodes n=1
Old leads with capacitance problems n=2
All occurred within the initial weeks of study and did not recur
Both BN and Tech leads had impedances < 5
kOhms at the beginning of the studies with no
significant change over the 8 hours of recording.
Quality Assessment
Four senior EEG readers blinded to the lead
application method reviewed the records.
They were asked to:
1. Guess the lead placement method (BN
Needle, BN Disk, Tech)
2. Rate the quality of the data
3. Report their findings for the segment
Quality Assessment:
Method of Lead Placement
• Reviewers accuracy rate = 33%, equal to
random guesses among the three choices;
ie.
– Reviewers could not detect any differences in
quality of recording among BN SNE, BN
disks, or Tech disks
• When binary choice of BN vs Tech was
offered (random=50%), accuracy rate was
56%, showing no difference in BN vs Tech.
Bias Against EEG Templates
(or Pro-Tech Leads)
60%
Technologist
50%
BraiNet
40%
30%
20%
10%
0%
Poor
P<.001
Adequate
Good
Excellent
Blinded Reviewers Assigned Poorer Quality Recordings to
the BN Method and Higher Quality to the Tech Leads*
Cure for Bias Against EEG Templates
(or Pro-Tech Leads)
50%
Actual Quality Results: No
significant differences
between BN and Tech
Methods
Technologist
BraiNet
40%
30%
20%
10%
50%
0%
Poor
Adequate
Good
Excellent
45%
Technologist
40%
BraiNet
35%
30%
25%
20%
15%
10%
5%
P=0.3810
0%
Poor
Adequate
Good
Excellent
INTERPRETATION OF EEG RECORDINGS
No reported disparities between 8 hours
of BN recordings and subsequent 8 hours
of Tech lead recordings.
Summary of CEA of
BN Method vs. ETCB
1. COST:
• BN saves 45-50% in costs compared to ETCB.
• These savings increase cumulatively, steeply and
almost linearly with increasing emergency requests.
2. EFFECTIVENESS:
• BN is equivalent in quality of recording to ETCB
• BN is 3x faster to set-up EEG compared to ETCB
• BN revealed no interpretation differences from Tech
studies.
CER FOR ETCB vs BN
1. ETCB:
• Average cost for 5 years of incrementing
studies = $186,000
• Relative Speed of set-up = 1.0
• CER = 186/1 = 186
2. BN:
• Average cost for 5 years of incrementing
= $92,000
• Relative Speed of set-up = 3.0
• CER = 92/3 = 31
studies
CONCLUSION
The BN method is six times more
cost effective than ETCB
to Set-Up Emergency EEG and
CEEG Studies
The BN is also the only EEG Set-Up Template
that is:
• FDA cleared for use in all ages: neonates through adults
• Proven for accurate placement and quality of recording
• For every type of ABI, both traumatic and non-traumatic
• Proven effective for acute set-up through continuous EEG
monitoring
• Compatible with CT and MRI imaging
• Plus:
•User electrode choice, including MRI/CT compatible
electrodes
•Electrodes can be placed/replaced by on-site caregivers
•Disposable for infection control
•Compatible with EVD, ICP and Licox monitors
THANK YOU!