Cost-effectiveness of stereotactic vacuum-assisted biopsy for nonpalpable breast lesions.

PURPOSE: To examine the potential cost-savings of stereotactic vacuum-assisted biopsy (SVAB) over open surgical biopsy (OSB) in diagnosis of nonpalpable lesions on mammography and to estimate the cost-saving effect on lesions at different levels of malignant probability. METHODS: This retrospective study was approved by our Institutional Review Board. We retrospectively reviewed 276 (33.8 %) SVAB and 541 (66.2 %) OSB medical records at a medical center. Direct costs included patients' self-paid and national health insurance claim charges. Indirect costs were calculated using sick days, average salary, and age-adjusted employment rate. One-way and two-way sensitivity analyses were conducted. Lesion classification was determined by the assessment categories of Breast Imaging Reporting and Data System (BI-RADS), 4th or 5th editions. RESULTS: SVAB decreased the direct cost by $90.3 (10.1 %) per diagnosis. The indirect cost was decreased by $560.2 (96.0 %). Overall, SVAB saved 43.9 % of resource utilization for each biopsy. Taking the cost of the subsequent malignant surgery into account, from the healthcare providers' perspective, SVAB was cost-effective if a lesion had less than 19 % likelihood of malignancy. From the societal perspective, SVAB reduced productivity loss for all the lesions. Based on the positive predictive value of the BI-RADS categories, SVAB was more suitable for the lesions of category 4A and category 3, resulting in greater savings in both medical and societal resources. CONCLUSIONS: SVAB is a cost-effective diagnostic option for nonpalpable breast lesions. The cost-saving effect is greater for the lesions of category 4A and category 3.

Doing More with Less: A Minimally Invasive, Cost-Conscious Approach to Stereoelectroencephalography.

BACKGROUND: Stereoelectroencephalography (SEEG) is a commonly used technique for mapping the epileptogenic zone before epilepsy surgery. Many SEEG depth electrode implantation techniques involve the use of extensive technological equipment and shaving of the patient's entire head before electrode implantation. Our goal was to evaluate an SEEG depth electrode implantation technique that used readily available cost-effective neurosurgical equipment, was minimally invasive in nature, and required negligible hair shaving. METHODS: Data on demographic characteristics, operative time, hemorrhagic complications, implantation complications, infection, morbidity, and mortality among patients who underwent this procedure were reviewed retrospectively. RESULTS: Between April 2016 and March 2018, 23 patients underwent implantation of 213 depth electrodes with use of this technique. Mean (SD) operative time was 123 (32) minutes (range, 66-181 minutes). A mean (SD) of 9.3 (1.4) electrodes were placed for each patient (range, 8-13 electrodes). Two of the 213 electrodes (0.9%) were associated with postimplantation asymptomatic hemorrhage. One of the 213 electrodes (0.5%) was placed extradurally or incorrectly. None of the 213 electrodes was associated with symptomatic complications. No patients experienced infectious complications at any point in the preoperative, perioperative, or postoperative stages. CONCLUSIONS: This minimally invasive, cost-effective technique for SEEG depth electrode implantation is a safe, efficient method that uses readily available basic neurosurgical equipment. This technique may be useful in neurosurgery centers with more limited resources. This study suggests that leaving the patient's hair largely intact throughout the procedure does not pose an additional infection risk.

Stereoelectroencephalography for Refractory Epileptic Patients Considered for Surgery: Systematic Review, Meta-Analysis, and Economic Evaluation.

BACKGROUND: Stereoelectroencephalography (SEEG) has been shown to be a valuable tool for the anatomoelectroclinical definition of the epileptogenic zone (EZ) in patients with medically refractory epilepsy considered for surgery (RES patients). In Spain, many of those patients are not offered this diagnostic procedure. OBJECTIVE: To evaluate the effectiveness, safety, and cost-effectiveness of SEEG to define the EZ in RES patients compared to no SEEG intervention, ie, remaining with further antiepileptic drugs. METHODS: We undertook a systematic review with meta-analyses on the effectiveness and safety of SEEG. A cost-effectiveness analysis was conducted using a Markov model, which simulates the costs and health outcomes of individuals for a lifetime horizon from the perspective of the Spanish National Health Service. The effectiveness measure was quality-adjusted life years (QALYs). We ran extensive sensitivity analyses, including a probabilistic sensitivity analysis. RESULTS: The EZ was found in 92% of patients who underwent SEEG (95% confidence interval [CI]: 0.87-0.96); 72% were eligible for epilepsy surgery (95% CI: 0.66-0.78) and 33% were free of seizures after surgery (95% CI: 0.27-0.42). Of the patients who underwent surgery, 47% were free of seizures after surgery (95% CI: 0.37-0.58). Complications related to implantation and monitoring of SEEG and the subsequent intervention occurred in 1.3% of patients (95% CI: 0.01-0.02). In the base case analysis, SEEG led to higher QALYs and healthcare costs with an estimated incremental cost-effectiveness ratio of 10 368 EUR per QALY (95% CI: dominant-113 911), making the probability of cost-effectiveness between 75% and 88%. Further sensitivity analyses showed that the results of the study were robust. CONCLUSION: SEEG is a cost-effective technology in RES patients when compared to no SEEG intervention.

A simple, inexpensive method for subcortical stereotactic targeting in nonhuman primates.

BACKGROUND: Many current neuroscience studies in large animal models have focused on recordings from cortical structures. While sufficient for analyzing sensorimotor systems, many processes are modulated by subcortical nuclei. Large animal models, such as nonhuman primates (NHP), provide an optimal model for studying these circuits, but the ability to target subcortical structures has been hampered by lack of a straightforward approach to targeting. NEW METHOD: Here we present a method of subcortical targeting in NHP that uses MRI-compatible titanium screws as fiducials. The in vivo study used a cellular marker for histologic confirmation of accuracy. RESULTS: Histologic results are presented showing a cellular stem cell marker within targeted structures, with mean errors ± standard deviations (SD) of 1.40 ±â€¯1.19 mm in the X-axis and 0.9 ±â€¯0.97 mm in the Z-axis. The Y-axis errors ± SD ranged from 1.5 ±â€¯0.43 to 4.2 ±â€¯1.72 mm. COMPARISON WITH EXISTING METHODS: This method is easy and inexpensive, and requires no fabrication of equipment, keeping in mind the goal of optimizing a technique for implantation or injection into multiple interconnected areas. CONCLUSION: This procedure will enable primate researchers to target deep, subcortical structures more precisely in animals of varying ages and weights.

Length of stay for patients undergoing invasive electrode monitoring with stereoelectroencephalography and subdural grids correlates positively with increased institutional profitability.

OBJECTIVE: Lowering the length of stay (LOS) is thought to potentially decrease hospital costs and is a metric commonly used to manage capacity. Patients with epilepsy undergoing intracranial electrode monitoring may have longer LOS because the time to seizure is difficult to predict or control. This study investigates the effect of economic implications of increased LOS in patients undergoing invasive electrode monitoring for epilepsy. METHODS: We retrospectively collected and analyzed patient data for 76 patients who underwent invasive monitoring with either subdural grid (SDG) implantation or stereoelectroencephalography (SEEG) over 2 years at our institution. Data points collected included invasive electrode type, LOS, profit margin, contribution margins, insurance type, and complication rates. RESULTS: LOS correlated positively with both profit and contribution margins, meaning that as LOS increased, both the profit and contribution margins rose, and there was a low rate of complications in this patient group. This relationship was seen across a variety of insurance providers. SIGNIFICANCE: These data suggest that LOS may not be the best metric to assess invasive monitoring patients (i.e., SEEG or SDG), and increased LOS does not necessarily equate with lower or negative institutional financial gain. Further research into LOS should focus on specific specialties, as each may differ in terms of financial implications.

Building an open-source robotic stereotaxic instrument.

This protocol includes the designs and software necessary to upgrade an existing stereotaxic instrument to a robotic (CNC) stereotaxic instrument for around $1,000 (excluding a drill), using industry standard stepper motors and CNC controlling software. Each axis has variable speed control and may be operated simultaneously or independently. The robot's flexibility and open coding system (g-code) make it capable of performing custom tasks that are not supported by commercial systems. Its applications include, but are not limited to, drilling holes, sharp edge craniotomies, skull thinning, and lowering electrodes or cannula. In order to expedite the writing of g-coding for simple surgeries, we have developed custom scripts that allow individuals to design a surgery with no knowledge of programming. However, for users to get the most out of the motorized stereotax, it would be beneficial to be knowledgeable in mathematical programming and G-Coding (simple programming for CNC machining). The recommended drill speed is greater than 40,000 rpm. The stepper motor resolution is 1.8°/Step, geared to 0.346°/Step. A standard stereotax has a resolution of 2.88 µm/step. The maximum recommended cutting speed is 500 µm/sec. The maximum recommended jogging speed is 3,500 µm/sec. The maximum recommended drill bit size is HP 2.

A low-cost technique to cryo-protect and freeze rodent brains, precisely aligned to stereotaxic coordinates for whole-brain cryosectioning.

A major challenge in the histological sectioning of brain tissue is achieving accurate alignment in the standard coronal, horizontal, or sagittal planes. Correct alignment is desirable for ease of subsequent analysis and is a prerequisite for computational registration and algorithm-based quantification of experimental data. We have developed a simple and low-cost technique for whole-brain cryosectioning of rodent brains that reliably results in a precise alignment of stereotactic coordinates. The system utilises a 3-D printed model of a mouse brain to create a tailored cavity that is used to align and support the brain during freezing. The alignment of the frozen block is achieved in relation to the fixed edge of the mold. The system also allows for two brains to be frozen and sectioned simultaneously. System components, procedural steps, and examples of the end results are presented.

Combining brain diagnosis and therapy in a single strategy: the safety, reliability, and cost implications using same-day versus separate-day stereotactic procedures.

BACKGROUND: A therapeutic radiosurgery procedure usually follows a separate diagnostic stereotactic procedure after days or weeks. OBJECTIVES: To define the clinical reliability, safety, and cost implications of same-day diagnostic stereotactic biopsy and therapeutic radiosurgery. METHODS: During an 8-year interval, 26 patients underwent stereotactic brain biopsy followed by immediate therapeutic stereotactic radiosurgery in a single-day combined procedure. The intraoperative diagnosis was determined using standard histopathological techniques. Diagnostic accuracy, hospital costs, and contribution margins associated with this treatment strategy were compared to those of 26 case-matched patients (controls) who underwent a stereotactic diagnostic procedure followed by a separate-day outpatient SRS procedure within 6 weeks during the same time interval. RESULTS: The intraoperative diagnosis correlated with the final histopathological diagnosis in 96% of the patients. Biopsy-related morbidity did not occur in this series. The mean total costs of same-day patients was significantly lower than the costs of patients who had two-stage procedures (USD 9,077 ± 2,366 vs. 11,284 ± 3,025; p = 0.008). The net contribution to the hospital margin of USD 13,736 was not significantly different between the two management strategies. CONCLUSIONS: The advantages of the same-day approach included a single stereotactic head frame application, reduced total admission time, consecutive histopathological diagnosis and therapy in a single hospital admission, and reduced total hospital costs. For patients who are highly suspected to have a brain tumor for which SRS is likely to be an effective therapeutic strategy, same-day diagnostic stereotactic biopsy followed by therapeutic SRS proved to be a safe, reliable, and cost-effective management strategy.

Efficacy and cost-effectiveness of stereotactic vacuum-assisted core biopsy of nonpalpable breast lesions: analysis of 602 biopsies performed over 5 years.

PURPOSE: The authors sought to evaluate the diagnostic accuracy and cost-effectiveness of vacuum-assisted core biopsy (VACB) in comparison with diagnostic surgical excision for characterisation of nonpalpable breast lesions classified as Breast Imaging Reporting and Data System (BI-RADS) categories R3 and R4. MATERIALS AND METHODS: From January 2004 to December 2008, we conducted 602 stereotactic, 11-gauge, VACB procedures on 243 nonpalpable breast lesions categorised as BI-RADS R3, 346 categorised as BI-RADS R4 and 13 categorised as BI-RADS R5. We calculated the diagnostic accuracy and cost savings of VACB by subtracting the cost of the stereotactic biopsy from that of the diagnostic surgical procedure. RESULTS: A total of 56% of the lesions were benign and required no further assessment. Lesions of uncertain malignant potential (B3) (23.6%) were debated at multidisciplinary meetings, and diagnostic surgical biopsy was recommended for 83.1% of them. All malignant lesions (B4 and B5) underwent surgical excision. VACB had a sensitivity of 94.9%, specificity of 98.3% and diagnostic accuracy of 97.7%. The cost savings per VACB procedure were 464.00 euro; by obviating 335 surgical biopsies, the overall cost savings was 155,440.00 euro over 5 years. CONCLUSIONS: VACB proved to have high diagnostic accuracy for characterising abnormalities at low to intermediate risk of malignancy and obviated surgical excision in about half of the cases, allowing for considerable cost savings.

Impact of stereotactic 11-g vacuum-assisted breast biopsy on cost of diagnosis in Austria.

PURPOSE: To determine the frequency with which stereotactic 11-g vacuum-assisted breast biopsy (11-g SVAB) obviates an open surgical biopsy (OSB), to compare the costs of these two biopsy methods, and to estimate the potential cost savings attributable to 11-g SVAB in the diagnosis of suspicious breast lesions in patients in Austria. MATERIALS AND METHODS: We retrospectively reviewed 318 consecutive breast lesions of BI-RADS categories IV and V (microcalcifications n=166; masses n=152) on which 11-g SVAB and OSB were performed. Cost savings were calculated using nationally allowed flat rates and patient charges. Costs were measured from a hospital and a socioeconomic perspective. Common clinical scenarios and sensitivity analyses assessed the extent of achievable cost savings. RESULTS: 11-g SVAB obviated the need for an OSB in 93 (29%) of 318 women. Overall cost savings per 11-g SVAB over OSB were € 242 per case from a hospital perspective, and € 422 per case from a socioeconomic perspective. The use of 11-g SVAB decreased the cost of diagnosis by 7% from a hospital perspective, and by 10% from a socioeconomic perspective. CONCLUSION: In Austria, annual national savings of over 5 million Euro could be realized with the use of 11-g SVAB for the diagnosis of suspicious breast lesions. Although savings per case are modest, the national health care system realizes significant cost reduction as women benefit from a faster and less invasive approach to diagnosis.

Low-cost phantoms for training of stereotactic vacuum-assisted biopsy of the breast.

To test low-cost phantoms for training in stereotactic breast biopsy, we prepared eggplant with calcium powder; gelatin and turkey breast with coarse salt, peppercorns, and calcium powder, respectively; and short-bread pastry with salt. Three to 12 cores were harvested with an 11-gauge vacuum biopsy unit. Mammography images were taken before and after biopsy and from the biopsy cores. The pastry phantom provided the best simulation of microcalcifications for stereotactic biopsy with realistic cores, long durability, and short preparation time.

A computational model to compare different investment scenarios for mini-stereotactic frame approach to deep brain stimulation surgery.

UNLABELLED: Deep brain stimulation (DBS) alleviates symptoms of many neurological disorders by applying electrical impulses to the brain by means of implanted electrodes, generally put in place using a conventional stereotactic frame. A new image guided disposable mini-stereotactic system has been designed to help shorten and simplify DBS procedures when compared to standard stereotaxy. A small number of studies have been conducted which demonstrate localization accuracies of the system similar to those achievable by the conventional frame. However no data are available to date on the economic impact of this new frame. AIM: The aim of this paper was to develop a computational model to evaluate the investment required to introduce the image guided mini-stereotactic technology for stereotactic DBS neurosurgery. METHODS: A standard DBS patient care pathway was developed and related costs were analyzed. A differential analysis was conducted to capture the impact of introducing the image guided system on the procedure workflow. The analysis was carried out in five Italian neurosurgical centers. RESULTS: A computational model was developed to estimate upfront investments and surgery costs leading to a definition of the best financial option to introduce the new frame. Investments may vary from Euro 1.900 (purchasing of Image Guided [IG] mini-stereotactic frame only) to Euro 158.000.000. Moreover the model demonstrates how the introduction of the IG mini-stereotactic frame doesn't substantially affect the DBS procedure costs.

[Economical body platform for neonatal rats stereotaxic surgery]. / Plataforma economica para cirugia estereotaxica en rata neonata.

INTRODUCTION: Usually, most commercial platforms that adapt to the stereotaxic apparatus in neonatal rats or small animals, to carry out surgery are very expensive. Moreover, the operator must have certain experience in its handling. DEVELOPMENT: The present work presents two platforms, one of them made in acrylic and the other of expanded polystyrene. These adapt perfectly to conventional stereotaxic apparatus, while operator does not require a great entrainment to carry out the surgical procedure. Histological slides of the prefrontal cortex, ventral hippocampus and basolateral amygdala from adult rats (postnatal day 70), staining with cresyl violet are shown. The neonatal lesions were made at postnatal day 7 with ibotenic acid applied in the prefrontal cortex, ventral hippocampus or basolateral amygdala. CONCLUSIONS: The present data suggest that it is possible to carry out lesions or to apply drugs in neonatal rats, by using an acrylic or expanded polystyrene adaptor for the stereotaxic apparatus. These have the advantage of being economic and having a simple design. Also, the type of anesthesia used in neonatal lesion rats, is discussed.

Efficiency of Core Biopsy for BI-RADS-5 Breast Lesions.

Stereotactic biopsy has proven more cost effective for biopsy of lesions associated with moderately suspicious mammograms. Data regarding selection of stereotactic biopsy (CORE) instead of excisional biopsy (EB) as the first diagnostic procedure in patients with nonpalpable breast lesions and highest suspicion breast imaging-reporting and data system (BI-RADS)-5 mammograms are sparse. Records from a regional health system radiology database were screened for mammograms associated with image-guided biopsy. A total of 182 nonpalpable BI-RADS-5 lesions were sampled in 178 patients over 5 years, using CORE or EB. Initial surgical margins, number of surgeries, time from initial procedure to last related surgical procedure, and hospital and professional charges for related admissions were compared using chi-squared, t-test, and Wilcoxon Mann-Whitney tests. A total of 108 CORE and 74 EB were performed as the first diagnostic procedure. Invasive or in situ carcinoma was diagnosed in 156 (86%) of all biopsies, 95 in CORE and 61 in EB groups. Negative margins of the first surgical procedure were more frequent in CORE (n = 70, 74%) versus EB (n = 17, 28%), p < 0.05. Use of CORE was associated with fewer total surgical procedures per lesion (1.29 +/- 0.05 versus 1.8 +/- 0.05, p < 0.05). Time of initial diagnostic procedure to final treatment did not vary significantly according to group (27 +/- 2 days versus 22 +/- 2 days, CORE versus EB). Mean charges including the diagnostic procedure and all subsequent surgeries were not different between CORE and EB groups ($10,500 +/- 300 versus $11,500 +/- 500, p = 0.08). Use of CORE as the first procedure in patients with highly suspicious mammograms is associated with improved pathologic margins and need for fewer surgical procedures than EB, and should be considered the preferred initial diagnostic approach.

Impact of hospital volume on the economic value of computer navigation for total knee replacement.

BACKGROUND: An aim of the use of computer navigation is to reduce rates of revisions of total knee replacements by improving the alignment achieved at the surgery. However, the decision to adopt this technology may be difficult for some centers, especially low-volume centers, where the cost of purchasing this equipment may be high. The purpose of this study was to examine the impact of hospital volume on the cost-effectiveness of this new technology in order to determine its feasibility and the level of evidence that should be sought prior to its adoption. METHODS: A Markov decision model was used to evaluate the impact of hospital volume on the cost-effectiveness of computer-assisted knee arthroplasty in a theoretical cohort of sixty-five-year-old patients with end-stage arthritis of the knee to coincide with the peak incidence of knee arthroplasty in the United States. RESULTS: Computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of the navigation increases, and as the impact on revision rates decreases. Centers at which 250, 150, and twenty-five computer-navigated total knee arthroplasties are performed per year will require a reduction of the annual revision rate of 2%, 2.5%, and 13%, respectively, per year over a twenty-year period for computer navigation to be cost-effective. CONCLUSIONS: Computer navigation is less likely to be a cost-effective investment in health-care improvement in centers with a low volume of joint replacements, where its benefit is most likely to be realized. However, it may be a cost-effective technology for centers with a higher volume of joint replacements, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revision rates with the use of this technology can be realized.

Gene therapy for glioblastoma.

Established treatments such as surgery, radiation, and chemotherapy have only minimally altered the median survival time of patients with glioblastoma multiforme, the most common malignant brain tumor. These failures reflect the highly invasive nature of the disease, as well as the fact that few cells are actively dividing at any given time. As a result, therapies need to act in areas of the brain that are spatially separated from the site of tumor origin and over extended periods of time temporally separated from their introduction. Over the past decade, laboratory studies and early clinical trials have raised the hope that these therapeutic requirements may be fulfilled by gene therapy in which nonreplicating transgene-bearing viruses, oncolytic viruses, or migratory stem cells are used to deliver tumoricidal transgenes. The authors review the principles behind these approaches and their initial results.