Clinical and economic consequences of early discharge of patients following supratentorial stereotactic brain biopsy

Abstract

Object. The goal of this study was to determine the clinical and economic consequences of early discharge (< 8 hours) of patients following stereotactic brain biopsy (SBB). Methods. The records of all patients who underwent percutaneous SBB at The Cleveland Clinic Foundation, a tertiary care teaching hospital, during 1994 and 1995 (Group A) were retrospectively reviewed to collect data on the nature and timing of perioperative (< 48 hours) clinical and radiological complications. Biopsies were performed using image-guided stereotaxy either with or without a frame. Based on the results, guidelines for early discharge of patients following SBB were implemented. Information on the nature and timing of perioperative complications was also collected prospectively in all patients who underwent percutaneous SBB from January 1996 through July 1998 (Group B). Hospital financial records for patients who underwent SBB in 1997 and 1998 were also reviewed and assessed for net revenue stratified by discharge status: early discharge (< 8 hours), extended outpatient observation (≥ 8 and < 24 hours), and inpatient hospitalization (≥ 24 hours). In Group A, 130 biopsies were performed. There were five serious complications (3.8%), of which four were transient, and there was one death (0.8%). The death and any sustained deficit occurred in patients in whom a clot had been demonstrated on postoperative CT scans. All complications were detected within 6 hours after surgery. Intraoperative bleeding occurred in 12 patients (9.2%), but was associated with only 40% of cases in which hemorrhage appeared on postoperative CT scans. Guidelines for early discharge (< 8 hours) following SBB were developed and stipulated the absence of the following: 1) intraoperative hemorrhage; 2) new postoperative deficit; and 3) clot on a postoperative CT scan. In Group B, 139 biopsies were performed. There were three serious complications (2.2%), one of which was sustained due to a clot that had been demonstrated on the postoperative CT scan. All complications were detected within 6 hours postsurgery. There were no deaths in this group. Intraoperative bleeding occurred in 11 patients (7.9%), requiring intraoperative craniotomy to control bleeding in one case. Hospital financial records were available for 96 patients, of whom 22 were discharged from the hospital early, 11 were observed for an extended outpatient period, and the remainder were retained for inpatient hospitalization. Average net hospital incomes on technical charges for patients in the inpatient hospitalization, extended outpatient observation, and short-stay (early discharge) groups were $1778, $1175, and $1219, respectively, in 1997, but declined to −$889, −$1339, and $671, respectively, in 1998. The ratios of indirect costs to direct technical costs were 132.5%, 128.7%, and 103.7%, respectively. Conclusions. Early discharge of patients following SBB of supratentorial lesions is safe in the absence of excessive intraoperative bleeding, new postoperative deficit, and clot on a postoperative CT scan. Extended outpatient observation (8–23 hours) is not clinically necessary and may be economically prohibitive in the setting of a teaching hospital.