Hospitalization Costs for Endovascular and Surgical Treatment of Ruptured Aneurysms in the United States Are Substantially Higher Than Medicare Payments

Discussion

Overall, we found that costs for treatment of ruptured cerebral aneurysms are substantially higher than the average Medicare payments for all patients regardless of degree of complications and comorbidities. Twenty-three percent of patients undergoing clipping or coiling for ruptured aneurysm in the United States were 65 years of age or older, so Medicare patients represent a significant minority of these cases.

Hoh et al³ reported on the cost of cerebral aneurysm treatment in a study of the NIS for 2002–2006, finding that clipping was associated with significantly longer lengths of stay and significantly higher total hospital charges than coiling for patients with ruptured cerebral aneurysms. We sought to further delineate the reasons for cost differentials in ruptured aneurysms by stratifying patients by age and outcome and by evaluating the trend in cost with time. We found that the charges were not significantly different for clipping and coiling in patients younger than 65 years of age, but clipping was associated with significantly higher costs than coiling in patients 65 years of age or older. Hospitalization costs for both coiling and clipping increased from 2001 to 2008, but the costs for the 2 procedures remained similar to each other during that period (Fig 2). A single center study from the University of Florida found that coiling tended to lead to higher hospital charges than clipping of ruptured aneurysms,⁴ demonstrating that a single center might have costs that deviate from the norms of the NIS data base.

The NIS does not provide itemized cost information, which would allow determination of specific sources of the increase in cost with time. Because the costs of hospitalization are rising in a quite similar pattern, the major contributor may be general inflation of hospital costs rather than expenses specific to the procedures such as device costs. It is possible that hospitals in the United States could succeed in a national effort to reduce overall hospital expenses, which would almost certainly bring down the cost of care for patients with subarachnoid hemorrhage. A report from Pakistan found that from 2004 to 2007, the cost of clipping was $3127, whereas the cost of coiling was higher at $5080, largely due to higher procedure price and cost of consumables.⁵ It is difficult to directly compare costs of hospitalization between different countries because of wide differences in nearly all itemized costs due to fundamental economic differences.

The hospital costs for patients in the NIS treated for ruptured aneurysms was highly dependent on the presence of morbidity or mortality. For patients who had morbidity and mortality, the cost of critical care overwhelmed the differences in periprocedural charges for coiling and clipping. It is not possible to separate complications of the aneurysm treatment from the complications of the initial subarachnoid hemorrhage by using the NIS.

Later charges for follow-up imaging surveillance for aneurysm recurrence are likely to lead to an increase in costs associated with coiling. Also, a higher recurrence rate of coiled aneurysms potentially leading to a need for additional treatment with hospitalization will add further costs to a significant fraction of coiled patients. The International Subarachnoid Aneurysm Trial showed relatively little difference in rerupture rates between coiled and clipped aneurysms,⁶ so differences in hospitalization for subsequent rupture of coiled versus clipped aneurysms are not likely to add to differences in hospital charges. A cost-effectiveness study looking at costs of clipping versus coiling for an entire year, including angiographic follow-up and retreatment, found that the cost of coiling was higher but nonetheless cost-effective.²

Large aneurysms and posterior circulation aneurysms might be associated with higher charges for either clipping, coiling, or both.³ The NIS provides no information on aneurysm size or location, so we cannot evaluate these parameters. Another potential limitation of this study is the occurrence of coding errors, which are present in any large administrative data base.⁷ However, errors in databases of this type are expected to be randomly distributed because recording is done by clerical and coding staff remote from the study questions. Furthermore, random coding errors are probably diluted in such a large sample and thus are not likely to significantly affect overall conclusions. Another limitation is that the hospital charge data are given only as a total, so we are unable to evaluate individual components of those charges. Payments associated with MS-DRG 20, 21, or 22 for patients who did not have a cerebral aneurysm coiled or clipped were not included in this analysis, which would include patients undergoing treatment for brain arteriovenous malformations.