Analysis of Cerebrovascular Aneurysm Treatment Cost: Retrospective Cohort Comparison of Clipping, Coiling, and Flow Diversion

Spencer Twitchell, BS; Hussam Abou-Al-Shaar, MD; Jared Reese, BS; Michael Karsy, MD, PhD, MSc; Ilyas M. Eli, MD; Jian Guan, MD; Philipp Taussky, MD; William T. Couldwell, MD, PhD


Neurosurg Focus. 2018;44(5):e3 

In This Article

Abstract and Introduction


Objective With the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.

Methods The authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient's cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.

Results A total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).

Conclusions Facility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.


The health care system costs and quality of care in the US currently represent a vital issue to the American people. The importance of delivering better care at a lower cost has been the objective for Americans for the past two decades. It is estimated that Americans spend $2.7 trillion a year on health care alone, constituting 18% of the gross domestic product of the country.19 Interestingly, it is estimated that 30% of that cost is wasted on unnecessary and costly services. The importance of this issue increases the demand on providers to limit expenditures and avoid cost-ineffective treatment modalities.

The University of Utah has implemented the Value-Driven Outcomes (VDO) tool to analyze patient costs, evaluate cost drivers, and find ways to reduce cost expenditures while maintaining a high quality of care.[9,11] The features of this system have aided us in evaluating obscured care costs, patients' quality of life, and hidden cost drivers of various neurosurgical procedures.[2,7,14] We previously reported the efficacy of the VDO system in evaluating the impact of various factors on the cost of treatment for patients with pituitary tumors.[7]

The advancement of interventional techniques in the management of intracranial aneurysms and the results of the International Subarachnoid Hemorrhage Trial have convinced many neurosurgeons to switch their management strategy from the surgical to the endovascular route.[15] However, the costs of surgical versus endovascular intervention as well as the cost-effectiveness of these two approaches have been an area of debate since the late 1990s, with various studies showing contradictory results. In addition, the increased use of flow diverter devices for complex aneurysm treatment has affected the cost of care for patients treated for aneurysms. Therefore, the aim of this study was to evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.