Elsevier

World Neurosurgery

Volume 139, July 2020, Pages e88-e97
World Neurosurgery

Original Article
National Trends and Factors Predicting Outcomes Following Laser Interstitial Thermal Therapy for Brain Lesions: Nationwide Inpatient Sample Analysis

https://doi.org/10.1016/j.wneu.2020.03.124Get rights and content

Background

Laser interstitial thermal therapy (LITT) is a stereotactic-guided technique, which is increasingly being performed for brain lesions. The aim of our study was to report the national trends and factors predicting the clinical outcomes following LITT using the Nationwide Inpatient Sample.

Methods

We extracted data from 2011–2016 using ICD-9/10 codes. Patients with a primary procedure of LITT were included. Patient demographics, complications, length of hospital stay, discharge disposition, and index-hospitalization charges were analyzed.

Results

A cohort of 1768 patients was identified from the database. Mean length of hospital stay was 3.2 days, 82% of patients were discharged to home, and in-hospitalization cost was $124,225. Complications and mortality were noted in 12.9% and 2.5% of patients following LITT, respectively. Non-Caucasian patients (estimate ratio [ER] 4.26), those with other insurance (compared with commercial, ER: 5.35), 3 and 4+ comorbidity indexes, patients with higher quartile median household income (second, third, and fourth quartile compared with first quartile), and those who underwent nonelective procedures were likely to have higher complications and less likely to be discharged home. Patients with 4+ comorbidity indexes were likely to have longer length of hospital stay (ER 1.39) and higher complications (ER: 7.95) and were less likely to be discharged home (ER: 0.17) and have higher in-hospitalization cost (ER: 1.21).

Conclusions

LITT is increasingly being performed with low complication rates. Non-Caucasian race, higher comorbidity index, noncommercial insurance, and nonelective procedures were predictors of higher complications and being less likely to be discharged home. In-hospitalization charges were higher in patients with higher comorbidity index and those with noncommercial insurance.

Introduction

Since the introduction of laser interstitial thermal therapy (LITT) in 1983,1 there has been tremendous interest in the utility of this technology for a variety of brain lesions, deep-seated in particular.2, 3, 4, 5, 6 The advent of magnetic resonance thermography further provided an opportunity to monitor the extent of thermal ablation in real time7,8 and therefore opened up the horizons for the widespread use of this technology. This led to U.S. Food and Drug Administration clearance of 2 major LITT devices: Visualase System (Medtronic Inc., Minneapolis, Minnesota, USA) in 2007 and NeuroBlate System (Monteris Medical Corporation, Plymouth, Minnesota, USA) in 2009. In 2013, Sloan et al9 reported the successful application of LITT in phase I clinical trial in patients with deep hemispheric recurrent glioblastoma. Since then, LITT has shown favorable outcomes in patients with a variety of brain lesions (primary or recurrent tumors, radiation necrosis)10, 11, 12, 13, 14, 15, 16 and epilepsy.17, 18, 19, 20 In addition, LITT has been shown to disrupt the blood-brain barrier, which provides an opportunity to deliver chemotherapeutic agents or macromolecules for therapeutic purposes.21,22

Given the minimally invasive nature of this technology, there are several advantages of LITT such as shorter length of hospital stay, lower intraoperative blood loss, and smaller incision compared with traditional open approaches.23,24 Also, LITT is associated with lower rates of major complications compared with open approaches (5.7% vs. 13.8%).23 Cost-effectiveness analysis also showed that LITT offers survival advantage with minimal additional cost, which is well below the current standard for life-years gained.24 Kamath et al14 reported overall complication/readmission rates of 6% each, and mortality was noted in 2.2% of patients following LITT for a variety of brain lesions (n = 120 patients with 133 lesions). Another large series (n = 102 patients and 133 lesions) reported complication rates of 26.5% with complete resolution of symptoms in 64.3% of these patients (9/14 patients), and 2 patients died in this series. The majority of published literature is from single-center studies and therefore reflects the experience of a single surgeon or center with low sample size. Recently, Wu et al25 reported an overall complication rate of 15% (42 complications in 35 patients) in a multicenter series of 234 patients following LITT for mesial temporal lobe epilepsy.

In light of this background, we aimed to query the National Inpatient Sample (NIS) database to identify the practice patterns and outcomes associated with LITT throughout the United States using a large administrative database. We hypothesize that LITT is increasingly being used for a variety of indications with low morbidity and the majority of patients are likely to be discharged home after the procedure.

The objective of our retrospective cohort study was to report the national trends in LITT procedures across the United States using the NIS. We also aimed at evaluating the factors predicting the clinical outcomes following LITT using this database.

Section snippets

Registration, Study Design, and Setting

We used the administrative database NIS for this retrospective case series. NIS is part of the Healthcare Cost and Utilization Project, by the Agency for Healthcare Research and Quality. The NIS is an approximately 20% stratified sample of all inpatient data from U.S. community hospitals, excluding rehabilitation and long-term acute care hospitals. It contains all patients regardless of payer, including individuals covered by Medicare, Medicaid, private insurance, and uninsured. These data

Results

We identified a cohort of 1768 patients who underwent LITT procedure during the study period. LITT is increasing being performed since 2011, with more than half of the cases (58%) being done in 2015 and 2016 (Figure 1).

Discussion

LITT has been increasingly performed for a variety of brain lesions since 2011. LITT was primarily performed as an elective procedure at teaching hospitals in the South and Midwest. Mean LOS was 3.2 days; 82% of patients were discharged to home and in-hospitalization charges were $124,225. Overall, complication rate was 12.9% and mortality was 2.5% after LITT. Cerebrovascular complications were the most common, followed by pulmonary and infection. Non-Caucasian patients, those with 4+

Conclusion

LITT is increasingly being performed for a variety of brain lesions in the United States with a low incidence of complications. Most LITT procedures were performed at large-size teaching hospitals in the South and Midwest. Patient-related (non-Caucasian race, higher comorbidity index, noncommercial insurance) and nonelective LITT procedures were predictors of higher complication rates and less likelihood of being discharged home. In-hospitalization charges were higher in patients with higher

CRediT authorship contribution statement

Mayur Sharma: Conceptualization, Methodology, Investigation, Writing - review & editing. Beatrice Ugiliweneza: Methodology, Formal analysis, Writing - review & editing. Dengzhi Wang: Methodology, Formal analysis, Writing - review & editing. Maxwell Boakye: Writing - review & editing. Norberto Andaluz: Writing - review & editing. Joseph Neimat: Writing - review & editing. Alireza Mohammadi: Writing - review & editing. Gene H. Barnett: Writing - review & editing. Brian J. Williams: Supervision,

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    Conflict of interest statement: Drs. Williams, Mohammadi, and Barnett are consultants for Monteris Medical Company. The rest of the authors have no conflicts of interest or financial disclosures.

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