October 7, 2014 13:20 — 4 Comments
Too Much Practice Variation in Treating Brain Aneurysms?
According to a recent report, there is considerable regional variation in the U.S. in the treatment of ruptured and unruptured cerebral aneurysms. The report suggests that some of this variation is not warranted and implies that patients need more information to be able to make reasonable choices. For example, the rates of endovascular coiling for unruptured aneurysms among Medicare beneficiaries ranged from a low of 35.0 percent in Modesto, Calif., to a high of 98.6 percent in Tacoma, Wash. For ruptured aneurysms, similar variation in the rate of coiling was seen — ranging from 36.3 percent in Atlandta, Ga., to 98.8 percent in Fort Lauderdale, Fla., according to the Dartmouth Atlas of Health Care report. “There’s obviously a question, why is that happening? I don’t think there’s a clear answer. But these variations can’t be attributed just to patient choice,” said Kimon Bekelis, MD, of Dartmouth-Hitchcock Medical Center. Patients are faced with complex decisions revolving around whether treatment is needed and what approach should be taken, particularly as they age and develop other illnesses, the researchers noted. The Nation Neurosurgery Quality and Outcomes Databse (N2QOD) has recently launched a module that will include factors such as neurological status, durability of coiling and the use of new endovascular devices to allow accurate risk-adjustment for head-to-head comparison of coiling and clipping, the report noted. To read more about this report, click here.
Uniformity of treatment for cerebral aneurysm is probably not a realistic nor desirable goal for such an inherently variable and complex disease. Factors like aneurysm architecture and navigation anatomy are only the beginning. Medical comorbidities and aftermath of the disease process itself, as in the case of subarachnoid hemorrhage, require intimate knowledge of the condition and complex decision making designed to protect the patient not only from aneurysm rupture, but from the predictable aftermath of intracranial pressure elevation, vasospasm, hydrocephalus, etc. A young patient with a ruptured aneurysm that appears easily amenable to coil embolization, for example, benefits substantially instead from a craniectomy and expansion duraplasty, which prepares him for predictable brain swelling and vasospasm. If all of these options are not available to the surgeon, the focus of care may erroneously become simply eliminating the aneurysm, which is NOT the primary objective. Instead, protection of the brain is always primary for the neurosurgeon. Eliminating the aneurysm is incidental to this first responsibility. Because these decisions are highly complex, it is also incorrect to give patients and families any responsibility in making them. Instead, recommendations are made based on a risk-benefit analysis shared and discussed openly with them. It has been my experience that families and patients respond well to reasoning and a transparent, even-handed decision making process. It has also been my experience that they (correctly) feel ill-equipped to make such a decision, often are overwhelmed by the circumstances of the illness, and are relieved to have a sturdy recommendation from their doctor, instead. Despite their complexity, these decisions are rarely difficult for the clinician familiar with neurocritical care and all aspects of the disease, which extends well beyond the relatively simple and early elimination of the aneurysm. Nowhere is the experience, clinical acumen and depth of the neurosurgeon more evident or absolutely necessary than in the asessment and treatment of cerebral aneurysm. Treatment variability is an expected and desirable result if treatment decisions are being made by seasoned clinicians, and not by patients or radiologists in isolation.
Report this comment
IN MY COUNTRY, NICARAGUA ALL ANEURYSMS, EXCEPT THOSE VERY COMPLEX OR COMATOSE PATIENTS, ARE CLIPPED. WE DON’T HAVE ENOUGH EXPERIENCE ON ENDOVASCULAR TREATMENT. THIS ARTICLE GIVES US THE VARIABILITY IN TREATMENT OPTIONS AND DIFFERENT POINTS OF VIEW OF THIS PATHOLOGY.
Report this comment
I have watched for 20 years how a lot of the research that hits national media from my alma mater Dartmouth is always about one thing- regional variations in treatment. And after 30 years of practicing neurosurgery I have one response- so what? The finding hints that something is wrong in one place or another. It is fundamentally a cheap shot. With no answers- no real questions that are interesting- just an anomaly. And fundamentally it is also boring to listen to this type of research that implies there is only one safe and effective way to do anything. That perspective suffers from the kind of intellectual hubris I gladly left behind when I graduated.
Report this comment
Agree. Uniformity of treatment is not the objective, especially for cerebrovascular disease.
Report this comment