Implementation Costs of Technology-Enhanced Transitional Palliative Care for Rural Caregivers.

OBJECTIVES: Compared to urban family caregivers (FCG), rural FCG experience greater burdens accessing coordinated care for their loved ones during and after hospitalization. The impact of technology-enhanced transitional palliative care (TPC) on caregiver outcomes is currently being evaluated in a randomized control trial. This study evaluates resource use and health system costs of this FCG-focused TPC intervention and potential Medicare reimbursement mechanisms. METHODS: Rural caregivers of hospitalized patients were randomized into an 8-week intervention consisting of video visits conducted by a registered nurse certified in palliative care, supplemented with phone calls and texts (n = 215), or attentional control. Labor costs were estimated for a registered nurse and compared to scenario analyses using a nurse practitioner or social worker wages. Medicare reimbursement scenarios included Transitional Care Management (TCM) and Chronic Care Management (CCM) CPT codes. RESULTS: In the base case, TPC cost was $395 per FCG facilitated by a registered nurse, compared to $337 and $585 if facilitated by a social worker or nurse practitioner, respectively. Mean Medicare reimbursement in the TCM-only scenario was $322 and $260 for high or moderate complexity patients, respectively. Reimbursement in the CCM only scenario was $348 and $274 for complex and non-complex patients, respectively. Reimbursement in the TCM+CCM scenario was $496 and $397, for high/complex and moderate/non-complex patients, respectively. CONCLUSION: TPC is a feasible, low cost and sustainable strategy to enhance FCG support in rural areas. Potential reimbursement mechanisms are available to offset the costs to the health system for providing transitional palliative care to caregivers of patients recently hospitalized.

Cerebral Bypass Using the Descending Branch of the Lateral Circumflex Femoral Artery: A Case Series.

BACKGROUND: When performing extracranial to intracranial (EC-IC) and intracranial to intracranial (IC-IC) bypass, the choice of donor vessel and interposition graft depends on several factors: vessel size and accessibility, desired blood flow augmentation, revascularization site anatomy, and pathology. The descending branch of the lateral circumflex femoral artery (DLCFA) is an attractive conduit for cerebrovascular bypass. OBJECTIVE: To present our institutional experience using DLCFA grafts for cerebral revascularization. METHODS: Retrospective review of perioperative data and outcomes for patients undergoing cerebrovascular bypass surgery using a DLCFA graft from 2016 to 2019. RESULTS: Twenty consecutive patients underwent EC-IC bypass using a DLCFA interposition graft. Bypass indications included 13 (65%) intracranial aneurysms, 4 (20%) medically refractory atherosclerotic large artery occlusions (internal carotid artery or middle cerebral artery), 2 (10%) internal carotid artery dissections, and 1 (5%) patient with moyamoya disease. Most commonly, a donor superior temporal artery was bypassed to a recipient middle cerebral artery (14 of 20; 70%). Two cases demonstrated graft spasm. Graft occlusion occurred in one patient and was asymptomatic. Perioperative bypass surgery-related ischemia occurred in 3 patients: 1 patient with insufficient bypass flow, 1 patient with graft stenosis because of an adventitial band, and 1 patient with focal status epilepticus in the bypassed territory resulting in cortical ischemia. One donor site hematoma occurred. The median (range) modified Rankin scale (mRS) score on follow-up was 1.5 (1-4) at 7.8 (1-27) months, with most patients achieving good functional outcomes (mRS ≤2). CONCLUSION: The DLCFA is a versatile graft for cerebral revascularization surgery, demonstrating good outcomes with minimal graft harvest site morbidity and an acceptable graft patency rate.

Comparative Assessment of Extracranial-to-Intracranial and Intracranial-to-Intracranial In Situ Bypass for Complex Intracranial Aneurysm Treatment Based on Rupture Status: A Case Series.

BACKGROUND: Comparative outcomes of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass for complex aneurysm treatment based on rupture status are not well described in the literature. In this study, we compare outcomes of EC-IC and IC-IC bypass for complex intracranial aneurysm treatment based on rupture status. METHODS: A prospective neurosurgical patient database was retrospectively reviewed. Sixty-three consecutive patients with aneurysm managed with revascularization were identified between July 2014 and December 2018. RESULTS: During the study period, 41 patients with aneurysm underwent EC-IC bypass (65%; 24 [58.5%] ruptured, 17 [41.5%] unruptured) and 22 patients with aneurysm underwent IC-IC bypass (34.9%; 13 [59.1%] ruptured, 9 [40.9%] unruptured). Graft spasm occurred in 4 patients (9.8%) in the EC-IC group (all ruptured aneurysms) and all anastomoses were patent on immediate postoperative imaging. Perioperative mortality occurred in 5 patients who underwent EC-IC bypass (12.2%; 3 ruptured, 2 unruptured) EC-IC and 2 patients who underwent IC-IC bypass (9.1%; both ruptured); (P = 0.709). Bypass-related complications occurred only in patients with ruptured aneurysm (2 [8.3%] in the EC-IC group and 0 [0%] in the IC-IC group; P = 0.285). For unruptured aneurysms, the overall complication rate was lower in IC-IC compared with the EC-IC group (P = 0.006). Modified Rankin Scale scores on discharge were significantly lower in IC-IC compared with EC-IC bypass for unruptured aneurysms (P = 0.008). There was a trend for shorter temporary occlusion and hospitalization times and overall better outcomes with IC-IC compared with EC-IC bypass. CONCLUSIONS: Although often considered riskier than EC-IC bypass, IC-IC in situ bypass showd a favorable technical and safety profile for the treatment of complex, unruptured aneurysms.

Orphaned Middle Cerebral Artery Side-to-Side In Situ Bypass as a Favorable Alternative Approach for Complex Middle Cerebral Artery Aneurysm Treatment: A Case Series.

OBJECTIVE: Middle cerebral artery (MCA) aneurysms have continued to be primarily managed microsurgically. In cases of complex MCA aneurysms, revascularization could facilitate effective aneurysm treatment. The MCA candelabra provides excellent candidates for in situ side-to-side bypass. In the present case series, we have described applications of MCA in situ side-to-side bypass for the management of complex MCA aneurysms, along with a review of the pertinent data. METHODS: A retrospective review of a prospectively maintained neurosurgical patient database was performed to identify all patients treated with MCA side-to-side in situ bypass. Six consecutive patients were identified and included in the present series, representing a single-surgeon experience from February 2016 to November 2018. RESULTS: Of the 6 complex MCA aneurysms, all were unruptured, and one half had been treated via a minipterional approach that also allowed for simultaneous anterior communicating artery aneurysm clipping in 1 case. The median temporary occlusion time for anastomosis was 33 minutes (interquartile range [IQR], 30.3-35 minutes). Bypass patency was confirmed in all cases both intraoperatively and postoperatively. The median hospitalization time was 4.5 days (IQR, 2-8 days). The median follow-up period was 5.5 months (IQR, 2.8-22.3 months). All patients had achieved excellent or good (≤1) modified Rankin scale scores at discharge and during the follow-up period. No mortalities occurred, and no technical, bypass-related, or ischemic morbidities had developed. CONCLUSIONS: Our experience with MCA side-to-side in situ bypass has demonstrated its safety and utility in complex MCA aneurysm management. The favorable anatomy of the MCA branches allows for minimally invasive revascularization and clipping that can potentially reduce the hospitalization time and incidence of perioperative morbidity.