Perioperative Costs between Stereotactic Laser Ablation and Craniotomy for Hypothalamic Hamartoma

Perioperative Costs between Stereotactic Laser Ablation and Craniotomy for Hypothalamic Hamartoma

Thank you for the insightful comments and the opportunity for further discussion. We appreciate Drs. Joob and Wiwanitkit for pointing out other factors to consider in health care and policy, such as costs to patients and their families, costs to hospitals and health systems, and costs to society. These are important issues to keep in mind. However, they are beyond the scope of our tightly defined study, where we aimed to examine an institutional case series of hypothalamic hamartomas (HH) treated by stereotactic laser ablation (SLA) compared with those treated by open surgery from a larger national cohort. Individual case selection, clinical judgment, and operator skill are obviously important in all of neurosurgery, and surgery on HH is no exception. Certainly in our institution's experience, our perioperative complication rate with SLA is lower than that reported in open approaches.[1] [2]

As we recognized the strengths and limitations of our dataset, our study was straightforward and focused: we compared inpatient surgical hospitalization costs of SLA and craniotomy. These should not be confused with estimation of economic burden to the family or with indirect costs. Our conclusions were stated with care that SLA may represent an attractive alternative to open craniotomy approaches for HH with refractory epilepsy. The limitations of our study design in the context of stated objectives are clearly delineated, many related to the nature of the national data source, the Kids' Inpatient Database.

While we did not measure or account for indirect costs in our study, instrumentation and training costs may theoretically have been accounted into hospitalization costs from a payer or provider's perspective in rational market models, though we do not suggest this is the case. With respect to quality, the classic equation is quality = outcome/cost. Outcomes in a surgical hospitalization timeframe are more appropriate to measure in perioperative complications and outcomes, rather than long-term outcomes such as seizure control. In any surgery, complication avoidance should assume paramount importance. As we observe a shorter length of stay and lower surgical hospitalization cost in the SLA cohort, it is possible that a lower perioperative complication rate contributes to this more favorable outcome. Of course, larger scale multicenter studies are needed to further quantify, understand, and apply SLA treatment, as we strive together to define and offer ever-improving solutions in the evolving field of epilepsy surgery.

• References

• 1 Wilfong AA, Curry DJ. Hypothalamic hamartomas: optimal approach to clinical evaluation and diagnosis. Epilepsia 2013; 54 (Suppl. 09) 109-114
• 2 Du VX, Gandhi SV, Rekate HL, Mehta AD. Laser interstitial thermal therapy: a first line treatment for seizures due to hypothalamic hamartoma?. Epilepsia 2017; 58 (Suppl. 02) 77-84