The Cost of Cerebral Spinal Fluid Leaks
After Spinal Surgery in the USA
Presented at the 2009 Annual Meeting of the
Congress of Neurological Surgeons (CNS)
October 24-29, 2009 • New Orleans, LA
Jack Jallo MD, PhD, FACS
Introduction
Frank R Ernst PharmD, MS
The establishment of a watertight closure of the dura mater
following spinal surgery is critical as post operative cerebral
spinal fluid (CSF) leaks may cause medical complications,
increased length of hospital stay, reduced quality of life, and
added costs. Neurosurgeries in the infratentorial and spinal
regions have a greater risk for CSF leaks than procedures in
the supratentorial region likely due to increased hydrostatic
pressure associated with gravity when patients are sitting
upright.(1) Previous research with fibrin glue, as an adjunct
to sutured closure, has found post-operative CSF leak
rates in the spinal region as high as 24%.(1) Our study
assessed the added cost of CSF leaks following spinal surgery
through Premier’s Perspective™ Database (PPD) as little
information is available on the direct medical costs associated
with CSF leaks after spinal surgery.
Michael E Minshall MPH
Thomas Jefferson University, Jefferson Medical
College, Philadelphia, PA, USA (Jallo)
Premier Inc., Charlotte, NC, USA (Ernst)
Covidien, North Haven, CT, USA (Minshall).
COVIDIEN, COVIDIEN with logo, Covidien logo and positive
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The Potential Cost Impact of using a PEG Hydrogel Sealant compared with Fibrin Sealant for Cerebral
The Potential Cost Impact of using a PEG Hydrogel Sealant compared with Fibrin Sealant
Cerebral
Spinal for
Fluid
Leaks after Cranial Surgery
Spinal Fluid Leaks after Cranial Surgery
Clinton J Baird MD; Frank R Ernst PharmD, MS; Michael E Minshall MPH
The Cost of Cerebral Spinal Fluid Leaks After Spinal Surgery in the USA
Clinton J Baird MD; Frank R Ernst PharmD, MS; Michael E Minshall MPH
Oklahoma Spine & Brain Institute, Tulsa, OK, USA (Baird); Premier Inc., Charlotte, NC, USA (Ernst); Covidien, North
Oklahoma Spine & Brain Institute, Tulsa, OK, USA (Baird); Premier Inc., Charlotte, NC, USA (Ernst); Covidien, North
Haven,
CT, USA (Minshall).
Jack
Jallo MD, PhD, FACS; Frank R Ernst PharmD,
MS; Michael
E Minshall
Haven, CT, USA (Minshall).
MPH
Thomas Jefferson University, Jefferson Medical College, Philadelphia, PA, USA (Jallo); Premier Inc., Charlotte, NC, USA (Ernst); Covidien, North Haven, CT, USA (Minshall).
Cost Analysis using a PEG Hydrogel Sealant
Table
1: Demographic
Comparisons:
Patients
Cost
Analysis
using a PEG Hydrogel
Sealant
with
CSF
Leaks
Compared
to
No
CSF
Leaks
Compared
with
Fibrin
Sealant
in
Posterior
Fossa
Compared with Fibrin Sealant in Posterior Fossa
with
CSF
Leaks
Compared
to
No
CSF
Leaks
Cerebrospinal fluid (CSF) leak is a significant causeCerebrospinal
Our spinal surgery
CSF leaks
fluid patient
(CSF) cohort
leak iswithout
a significant
cause
Table 1
Patients without CSF
Patients with CSF
p-Value
Surgery
Surgery
of morbidity following cranial surgery. CSF leaks can
(n=192,409)following
were similar
in age surgery.
(55.3 years)
to our
cohort
of morbidity
cranial
CSF
leaks
can
Leaks (n=192,409)
Leaks (n=8,837)
Demographic
We performed a hypothetical analysis for a hospital
cause secondary
surgical
complications
We performed a hypothetical analysis for a hospital
The establishment
of a watertight
closure
of the duraincluding cause
withsecondary
CSF leaks (n=8,837,
years). However,
there was
surgical55.4
complications
including
that performedComparisons:
100 posterior Patients
fossa procedures Age
using
55.4
55.3
0.422
(Mean,
Years)
meningitis,
encephalitis,
pneumocephalus,
and
mater following spinal surgery is critical as post operative
that performed 100 posterior fossa procedures using
a statistically
significant difference
in CSF leak rates
meningitis,
encephalitis,
pneumocephalus,
andwith a PEG hydrogel sealant on all 100 patients compared
with CSF Leaks
chronic
hematoma
often
leading to added
cerebral spinal
fluidsubdural
(CSF) leaks
may cause
medical
a PEG hydrogel
43.2 sealant on all 100
49.1patients compared
Male (%)
respectsubdural
to genderhematoma
as females were
more
likely totohave
CSF with fibrin sealant on all 100 patients. The expected
chronic
often
leading
added
costs.(1)
A comparative
published
reported
Compared to No
<0.0001
complications,
increased
length of hospital
stay,study
reduced
with
fibrin
sealant
on
all
100
patients.
The expected
leaks than
males (56.8% vs.
43.2%, p<0.0001).
costs.(1)
A comparative
published
study reported
CSF leak rate for posterior fossa surgery was 2%
CSFand
leakadded
ratescosts.
in posterior
fossa procedures
56.8
50.9
Female (%)
quality of life,
Neurosurgeries
in the of 2%
CSF Leaks
CSF leak rate for posterior fossa surgery was 2%
CSF leak rates in posterior fossa procedures of 2% using PEG hydrogel sealant (2/100) and 10% for
using
polyethylene
infratentorial
anda spinal
regions glycol
have a (PEG)
greaterhydrogel
risk for dural
74.8 and 10% for
Caucasian (%)
using PEG71.5
hydrogel sealant (2/100)
fibrin sealant (10/100) based on the comparative
sealant in a 100 patient prospective group, and a using a polyethylene glycol (PEG) hydrogel dural
CSF leaks than
procedures in the supratentorial region
Cost of CSF Leaks in Spinal Surgery from the PPD
study.(2) We then assumed a cost of $16,495 per
fibrin sealant
the comparative
CSF leak rate of 10% using fibrin sealant in a 100 sealant in a 100 patient prospective group, and a
6.5 (10/100) based on7.4
likely due to
increased hydrostatic pressure associated
Table 2 describes the costs by major hospital cost category CSF leak, from the PPD analysis, and $620 per African-American (%)
patient retrospective, cohort group.(2) Our study CSF leak rate of 10% using fibrin sealant in a 100
study.(2) We then assumed a cost of $16,495 per<0.0001
with gravity when patients are sitting upright.(1)
for spinal surgery patients with CSF leaks compared to
treatment for a PEG hydrogel sealant comparedHispanic
with
2.5 the PPD analysis,2.6
(%)
applied the cost of CSF leaks following cranial
CSF leak, from
and $620 per
patient retrospective, cohort group.(2) Our study
Previous research with fibrin glue, as an adjunct to
those who did not have a CSF leak.
$225 per treatment for fibrin sealant applied to all
surgery using the Premier Perspective™ Database
treatment
for
a
PEG
hydrogel
sealant
15.2
19.3 compared with
Other (%)
applied the cost of CSF leaks following cranial
sutured closure, has found post-operative CSF leak
100 procedures for each option. These calculations
Cost of CSF Leaks in Cranial Surgery
(PPD). PPD is the largest clinical and economic
$225 per treatment for fibrin sealant applied to all
rates in the spinal region as high as 24%.(1) Our study
surgery
using
the Premier
Perspective™
are summarized in Table 3.
Table
2 describes
thecost
breakdown
costsDatabase
by
major
database developed for quality and utilization
• We
found
the
average
of spinal in
surgeries
with
100 procedures for each option. These calculations
assessed the added cost of CSF leaks following spinal
Cost3.ofTotal
CSF Costs
Leaksfor
in Cranial
Surgery
(PPD).
PPD to
is be
the
largestfor
clinical
and
economic
Table
100 Posterior
Fossa
hospital
cost
category
cranialat
surgery
patients
+$35,977
benchmarking covering one in every five USA
CSF
leaks
significantly
higher
$25,812
surgery through
Premier’s Perspective™ Database (PPD)
are summarized in Table 3.
Table 2 describes
the Hydrogel
breakdown
in costs by major
Procedures
using a PEG
Sealant
database
developed
for+$22,772
quality
and
utilization
with CSF
leaks
compared
to those
who
did
not have
hospital discharges.
compared
with
$19,333
for
spinal
surgeries
as little information is available on the direct medical
Table 3. Total Costs for 100 Posterior Fossa
Compared
Fibrin Sealant
a CSF leak. covering one in every five USA
hospital with
cost category
for cranial surgery patients
benchmarking
Introduction
Introduction
costs associated with CSF leaks after spinal surgery.
Methods
Table 1: Demographic Comparisons: Patients
Introduction
without CSF leaks (p<0.0001).
Table
2. Cost of CSF Leaks by Major Cost
hospital
discharges.
Category
The
cost differences were largely driven by the following
The PPD was used to establish the costs of CSF
factors:
leaks following cranial surgery using ICD-9 and CPT
Methods
codes for cranial procedures discharged between Q4 • Increased length of hospital stay (6.2 days compared
The PPD was used to establish the costs of CSF
The PPD was
used
toQ3
establish
costs of CSF
2006
and
2008. the
Specifically,
ICD-9 procedure
with 3.5 days, p<0.0001) for spinal surgery patients with
leaks following cranial surgery using ICD-9 and CPT
codesspinal
used surgery
were forusing
CSF ICD-9
repairsand
while
ICD-9
leaks following
CPT
CSF leaks;
for cranial procedures discharged between Q4
diagnosis
codes were
used for
dural tears
codes for spinal
procedures
discharged
between
Q4 and CSFcodes
• Intensive care unit stay (1.2 days compared with 0.4
leaks.
CPT
codes for ICD-9
cranialprocedure
procedures were also 2006 and Q3 2008. Specifically, ICD-9 procedure
2006 and Q3
2008.
Specifically,
days, p<0.0001) for spinal surgery patients with CSF leaks;
included.
We
then
compared
potential hospital costcodes used were for CSF repairs while ICD-9
codes used were for CSF repairs while ICD-9
• Pharmacy costs ($1511+$3,792 compared with
offsets
using
a PEG
hydrogel
diagnosis codes
were
used
for dural
tearssealant
and CSF($620 per diagnosis
codes were used for dural tears and CSF
$853+$4,186, p<0.0001) for spinal surgery patients
treatment,
5
ml
size,
Company
List
Price,
Covidien,
leaks. CPT codes for spinal procedures were also
leaks. CPT codes for cranial procedures were also
with
CSF leaks.
Waltham,
MA) with
fibrinand
sealant
($225 per
Note: Summing the cost categories may not add up to the total
included. PPD
is the largest
clinical
economic
included. We then compared potential hospital cost
cost since each subgroup may have smaller population sizes.
treatment,
ml size,
Company
List Price, Baxter,
Other
Hospital
Information
database developed
for4quality
and
utilization
offsets
a PEG
hydrogel
sealant
per
We using
found the
average
cost of
cranial ($620
surgeries
with
Deerfield,
IL)
assuming
CSF
leak
rates
of
2%
and
benchmarking including one in every five USA
The PPD analysis
also Company
provided other
useful
information
treatment,
5
ml
size,
List
Price,
Covidien,
CSF leaks (n=1,192) to be $49,132+$51,169
10% for posterior fossa procedures only.(2)
hospital discharges. The major direct medical costs
regarding
characteristics
of spinal surgery
patients
in the
Waltham,
MA)with
with
fibrin sealant ($225
per for
compared
$32,637+$38,677
(p<0.0001)
assessed included length of hospital stay, laboratory
USA:
cranial surgeries
without
CSF leaks
The
treatment,
4 ml size,
Company
List (n=16,587).
Price, Baxter,
costs, pharmacy costs, and central hospital supply.
• Spinal
surgery patients
with CSF
leaks
were
more likely
cost
difference
was
largely
driven
by
increased
Deerfield, IL) assuming CSF leak rates of 2% and
Results
tolength
be seenofinhospital
a teaching
compared
withcare
non(3.4hospital
days) and
intensive
10% for posterior fossa procedures only.(2)
Characteristics of Cranial Surgery Patients with and
stays (2.7
days)(53.0%
for cranial
surgery
patients with
teaching
hospitals
vs. 46.3%;
p<0.0001);
without CSF Leaks
CSF
leaks
(both
p<0.0001).
The
PPD
• Spinal surgery patients were more likelyanalysis
to be seen
Table 1 provides basic demographic comparisons of
that allwith
cost300
categories
increased
in a of
Patient Characteristics of Spinal Surgery Patients
inshowed
large hospitals
beds or more
regardless
cranial surgery patients who had CSF leaks
statistically
significant
manner
when
comparing
with and without CSF Leaks
whether they had CSF leaks or not (79.6% vs. 81.1%).
compared to those who did not have a CSF leak. Results
cranial surgery patients with a CSF leak to those
Table 1 provides basic demographic comparisons of
Characteristics of Cranial Surgery Patients with and
without a CSF leak.
spinal surgery patients who had CSF leaks compared to
Methods
Results
those who did not have a CSF leak.
without CSF Leaks
Table 1 provides basic demographic comparisons of
cranial surgery patients who had CSF leaks
Table
2
Costnot
Category
with CSF leaks
compared
to those who did
have
per Patient
a CSF leak.Cost of CSF Leaks by
Table 2. Cost
ofCost
CSFCategory
Leaks by Major Central
Cost Supply
Major
Category
Laboratory
*CSF leak rates reported in posterior fossa procedures.(2)
Conclusions
Procedures
using
Hydrogel
Sealant
Patients
without
CSF
Patients with
CSF a PEG
(n=192,409)
Leaks (n=8,837)
Compared
with Fibrin Leaks
Sealant
p-Value
$9,351 + $16,063
$9,201 + $15,170
0.392
$351 + $892
$205 + 540
<0.0001
Pharmacy
$1,511 + $3,792
$853 + $4,186
<0.0001
Room and Board
$5,857 + $12,983
$2,935 + $6,554
<0.0001
Surgery/OR, Nursing,
Radiology, etc.
$9,384 + $13,086
$6,907 + $7,777
<0.0001
*CSF leak rates reported in posterior fossa procedures.(2)
Use of a PEG hydrogel sealant compared with fibrin
sealant could potentially save $92,460 for a hospital
$25,812 + $35,977
$19,333 + $22,772
<0.0001
TOTALS
that performed 100 posterior fossa procedures
using
Note: Summing the cost categories
may not add up to the total cost since each subgroup may have smaller population sizes.
Conclusions
a PEG hydrogel sealant compared with using fibrin
Use of a PEG hydrogel sealant compared with fibrin
sealant on all 100 procedures. This study
sealant could potentially save $92,460 for a hospital
demonstrates
thethe
economic
advantages
of add
using
Note: Summing
cost categories
may not
upato the total
that performed 100 posterior fossa procedures using
PEG
hydrogel
sealant
in
posterior
fossa
procedures.
cost since each subgroup may have smaller population sizes.
Future
studiesthe
would
be beneficial
confirmsurgeries
these
a PEG hydrogel sealant compared with using fibrin
We found
average
cost oftocranial
with
findings and understand the possible economic
sealant on all 100 procedures. This study
CSF leaks (n=1,192) to be $49,132+$51,169
advantages for other types of cranial surgeries.
Conclusions
demonstrates
economic
advantages
using
compared with
$32,637+$38,677
for system
by the
increased
hospital
(2.7 days) andofICU
staysa (0.8 days).
CSF leaks
after spinal surgery(p<0.0001)
cost our healthcare
an
PEG hydrogel
sealant intargeted
posterior
fossa
procedures.
cranial surgeries
leaks (n=16,587).
The
Interventions
towards
reducing
the incidence of
averagewithout
of $6,479 CSF
incremental
additional dollars
compared
References
Future
studies
would
be
beneficial
to
confirm
these
difference
wasNeurosurgery
largely
driven
increased
CSF leaks after spinal surgery could lower hospital costs
who do not
have by
a CSF
leak. Increased costs
(1)cost
Sawamura
Y etto
al,patients
1999.
44(2):332-337.
findings
and
understand
possible
(2)length
Than KD of
et al,
2008.
Neurosurgery
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1):ONS184hospital
(3.4 after
days)
andsurgery
intensive
care
and
potentially the
improve
patienteconomic
quality of life.
for CSF leaks
spinal
were primarily
driven
ONS189.
advantages for other types of cranial surgeries.
stays (2.7 days) for cranial surgery patients with
CSF leaks (both
p<0.0001).
The
analysis
References:
(1) Sugawara
T et PPD
al, 2005.
Neurosurgery 57 (ONS Suppl 3):ONS290-ONS294.
showed that all cost categories increased in a
References
(1) Sawamura Y et al, 1999. Neurosurgery 44(2):332-337.
statistically significant manner when comparing