Skip to main content
PMC home page
The BMJ logoLink to The BMJ
. 1990 Sep 29;301(6753):629–635. doi: 10.1136/bmj.301.6753.629

Steps towards cost-benefit analysis of regional neurosurgical care.

J D Pickard 1, S Bailey 1, H Sanderson 1, M Rees 1, J S Garfield 1
PMCID: PMC1663871  PMID: 2121302

Abstract

OBJECTIVE--To determine the cost of averting death or severe disability by neurosurgical intervention. DESIGN--Retrospective analysis of one year's admissions for neurosurgery; comparison of outcome with expected outcome in the absence of neurosurgical intervention and with the cost of neurosurgery. SETTING--Wessex Neurological Centre. PATIENTS--1026 Patients were admitted to the neurosurgical service in 1984. Of 1185 admissions, 978 case records were available and outcome was known in 919. MAIN OUTCOME MEASURES--Outcome was assessed with the Glasgow outcome scale, modified as necessary, from the case notes, or by letter follow up to the general practitioner. Expected outcomes for each of the 54 diagnoses were derived from both published reports where available and an expert panel of 18 consultant neurosurgeons. The cost of the neurosurgical service for 1983-4 was known from a separate study and the cost per patient was calculated using the length of stay. RESULTS--The cost of neurosurgery in 1983-4 was 1.8 million pounds. In all, 243 deaths or severe disabilities were estimated to have been averted at an average cost of 7325 pounds (range 5000 pounds to 70,000 pounds). The overall cost per quality adjusted life year (QALY) was 350 pounds (range 34 pounds to greater than 400,000 pounds). The cost of long term care for severely disabled survivors is at least 18-fold greater than the cost of neurosurgical intervention to avert such disability. CONCLUSIONS--In Britain neurosurgery is not expensive in comparison with the costs and benefits of other areas of medicine, and the cost per QALY is unexpectedly low except for severe diffuse head injury, malignant brain tumors, and cerebral metastases. The neurosurgical budget should be assessed in the context of managing a patient in hospital and subsequently in the community.

Full text

PDF

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alvord E. C., Jr, Loeser J. D., Bailey W. L., Copass M. K. Subarachnoid hemorrhage due to ruptured aneurysms. A simple method of estimating prognosis. Arch Neurol. 1972 Oct;27(4):273–284. doi: 10.1001/archneur.1972.00490160001001. [DOI] [PubMed] [Google Scholar]
  2. Bartlett J. R., Neil-Dwyer G., Banham J. M., Cruickshank D. G. Evaluating cost-effectiveness of diagnostic equipment: the brain scanner case. Br Med J. 1978 Sep 16;2(6140):815–820. doi: 10.1136/bmj.2.6140.815. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bender M. B., Christoff N. Nonsurgical treatment of subdural hematomas. Arch Neurol. 1974 Aug;31(2):73–79. doi: 10.1001/archneur.1974.00490380021001. [DOI] [PubMed] [Google Scholar]
  4. Charny M. C., Farrow S. C., Roberts C. J. The cost of saving a life through cervical cytology screening: implications for health policy. Health Policy. 1987 Jun;7(3):345–359. doi: 10.1016/0168-8510(87)90075-3. [DOI] [PubMed] [Google Scholar]
  5. Cohadon F. Indications for surgery in the management of gliomas. Adv Tech Stand Neurosurg. 1990;17:189–234. doi: 10.1007/978-3-7091-6925-4_6. [DOI] [PubMed] [Google Scholar]
  6. Geisler W. O., Jousse A. T., Wynne-Jones M., Breithaupt D. Survival in traumatic spinal cord injury. Paraplegia. 1983 Dec;21(6):364–373. doi: 10.1038/sc.1983.60. [DOI] [PubMed] [Google Scholar]
  7. Gjerris F., Schmidt K. Chronic subdural hematoma. Surgery or mannitol treatment. J Neurosurg. 1974 May;40(5):639–642. doi: 10.3171/jns.1974.40.5.0639. [DOI] [PubMed] [Google Scholar]
  8. Graf C. J. Prognosis for patients with nonsurgically-treated aneurysms. Analysis of the Cooperative Study of Intracranial Aneurysms and Subarachnoid hemorrhage. J Neurosurg. 1971 Oct;35(4):438–443. doi: 10.3171/jns.1971.35.4.0438. [DOI] [PubMed] [Google Scholar]
  9. Greenfield S. The state of outcome research: are we on target? N Engl J Med. 1989 Apr 27;320(17):1142–1143. doi: 10.1056/NEJM198904273201710. [DOI] [PubMed] [Google Scholar]
  10. Hawkins T. D., Sims C., Hanka R. Subarachnoid haemorrhage of unknown cause: a long term follow-up. J Neurol Neurosurg Psychiatry. 1989 Feb;52(2):230–235. doi: 10.1136/jnnp.52.2.230. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Jennett B., Bond M. Assessment of outcome after severe brain damage. Lancet. 1975 Mar 1;1(7905):480–484. doi: 10.1016/s0140-6736(75)92830-5. [DOI] [PubMed] [Google Scholar]
  12. Jones J. J., Jeffreys R. V. Relative risk of alternative admission policies for patients with head injuries. Lancet. 1981 Oct 17;2(8251):850–853. doi: 10.1016/s0140-6736(81)91114-4. [DOI] [PubMed] [Google Scholar]
  13. Knox E. G. Evaluation of a proposed breast cancer screening regimen. BMJ. 1988 Sep 10;297(6649):650–654. doi: 10.1136/bmj.297.6649.650. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Koivukangas P., Koivukangas J. Role of quality of life in therapeutic strategies in brain tumors. Health Policy. 1988;10(3):241–257. doi: 10.1016/0168-8510(88)90060-7. [DOI] [PubMed] [Google Scholar]
  15. Mendelow A. D., Campbell D. A., Jeffrey R. R., Miller J. D., Hessett C., Bryden J., Jennett B. Admission after mild head injury: benefits and costs. Br Med J (Clin Res Ed) 1982 Nov 27;285(6354):1530–1532. doi: 10.1136/bmj.285.6354.1530. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Mirimanoff R. O., Dosoretz D. E., Linggood R. M., Ojemann R. G., Martuza R. L. Meningioma: analysis of recurrence and progression following neurosurgical resection. J Neurosurg. 1985 Jan;62(1):18–24. doi: 10.3171/jns.1985.62.1.0018. [DOI] [PubMed] [Google Scholar]
  17. Moffat D. A., Hardy D. G. Early diagnosis and surgical management of acoustic neuroma: is it cost effective? J R Soc Med. 1989 Jun;82(6):329–332. doi: 10.1177/014107688908200606. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Munoz E., Sterman H., Patel P., Chalfin D., Mulloy K., Wise L. Financial risk, hospital cost, and complications and comorbidities (CCs) in non-CC stratified neurosurgical diagnostic related groups (DRGs). Neurosurgery. 1988 May;22(5):955–960. [PubMed] [Google Scholar]
  19. Pickard J. D., Murray G. D., Illingworth R., Shaw M. D., Teasdale G. M., Foy P. M., Humphrey P. R., Lang D. A., Nelson R., Richards P. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ. 1989 Mar 11;298(6674):636–642. doi: 10.1136/bmj.298.6674.636. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Roberts C. J., Farrow S. C., Charny M. C. How much can the NHS afford to spend to save a life or avoid a severe disability? Lancet. 1985 Jan 12;1(8420):89–91. doi: 10.1016/s0140-6736(85)91975-0. [DOI] [PubMed] [Google Scholar]
  21. SIMPSON D. The recurrence of intracranial meningiomas after surgical treatment. J Neurol Neurosurg Psychiatry. 1957 Feb;20(1):22–39. doi: 10.1136/jnnp.20.1.22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Sandercock P. A., Roberts M. A., Blumhardt L. D. A prospective audit of the use and costs of myelography in a regional neuroscience unit. J Neurol Neurosurg Psychiatry. 1989 Sep;52(9):1078–1084. doi: 10.1136/jnnp.52.9.1078. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Shaw M. D., Foy P. M., Conway M., Pickard J. D., Maloney P., Spillane J. A., Chadwick D. W. Dipyridamole and postoperative ischemic deficits in aneurysmal subarachnoid hemorrhage. J Neurosurg. 1985 Nov;63(5):699–703. doi: 10.3171/jns.1985.63.5.0699. [DOI] [PubMed] [Google Scholar]
  24. Silfvenius H. Economic costs of epilepsy--treatment benefits. Acta Neurol Scand Suppl. 1988;117:136–154. doi: 10.1111/j.1600-0404.1988.tb08015.x. [DOI] [PubMed] [Google Scholar]
  25. Smith A. Qualms about QALYs. Lancet. 1987 May 16;1(8542):1134–1136. doi: 10.1016/s0140-6736(87)91685-0. [DOI] [PubMed] [Google Scholar]
  26. Thomson J. L. Experiences at the new magnetic resonance imaging centre at Bristol. Br J Radiol. 1989 Feb;62(734):134–137. doi: 10.1259/0007-1285-62-734-134. [DOI] [PubMed] [Google Scholar]
  27. Vermeer F., Simoons M. L., de Zwaan C., van Es G. A., Verheugt F. W., van der Laarse A., van Hoogenhuyze D. C., Azar A. J., van Dalen F. J., Lubsen J. Cost benefit analysis of early thrombolytic treatment with intracoronary streptokinase. Twelve month follow up report of the randomised multicentre trial conducted by the Interuniversity Cardiology Institute of The Netherlands. Br Heart J. 1988 May;59(5):527–534. doi: 10.1136/hrt.59.5.527. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Walker A. E., Leuchs H. K., Lechtape-Grüter H., Caveness W. F., Kretschman C. Life expectancy of head injured men with and without epilepsy. Arch Neurol. 1971 Feb;24(2):95–100. doi: 10.1001/archneur.1971.00480320023001. [DOI] [PubMed] [Google Scholar]
  29. Williams A. Economics of coronary artery bypass grafting. Br Med J (Clin Res Ed) 1985 Aug 3;291(6491):326–329. doi: 10.1136/bmj.291.6491.326. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Winn H. R., Richardson A. E., Jane J. A. The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol. 1977 Apr;1(4):358–370. doi: 10.1002/ana.410010407. [DOI] [PubMed] [Google Scholar]
  31. Winn H. R., Richardson A. E., O'Brien W., Jane J. A. The long-term prognosis in untreated cerebral aneurysms: II. Late morbidity and mortality. Ann Neurol. 1978 Nov;4(5):418–426. doi: 10.1002/ana.410040506. [DOI] [PubMed] [Google Scholar]
  32. Winyard G. P., McNeilly R. H., Adams C. B. How many beds do we really need--for example, in neurosurgery? Br Med J (Clin Res Ed) 1981 Feb 7;282(6262):498–499. doi: 10.1136/bmj.282.6262.498. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. van den Heever C. M., van der Merwe D. J. Management of depressed skull fractures. Selective conservative management of nonmissile injuries. J Neurosurg. 1989 Aug;71(2):186–190. doi: 10.3171/jns.1989.71.2.0186. [DOI] [PubMed] [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES