Chronic subdural hematoma-incidence, complications, and financial impact

Minna Rauhala, Pauli Helén, Heini Huhtala, Paula Heikkilä, Grant L Iverson, Tero Niskakangas, Juha Öhman, Teemu M Luoto, Minna Rauhala, Pauli Helén, Heini Huhtala, Paula Heikkilä, Grant L Iverson, Tero Niskakangas, Juha Öhman, Teemu M Luoto

Abstract

Objective: To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT).

Methods: A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland).

Results: The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia.

Conclusions: Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

Keywords: Causes of death; Chronic subdural hematoma; Excess mortality; Follow-up; Health care costs; Recurrence; Survival.

Conflict of interest statement

Dr. Luoto has received funding from the Government’s Special Financial Transfer tied to academic research in Health Sciences (Finland), the Emil Aaltonen Foundation, and the Finnish Medical Society Duodecim. Dr. Iverson acknowledges unrestricted philanthropic support from the Mooney-Reed Charitable Foundation, Heinz Family Foundation, ImPACT Applications, Inc., and Spaulding Research Institute. He serves as a strategic scientific advisor for BioDirection, Inc. The other authors have nothing to disclose.

Figures

Fig. 1
Fig. 1
Comorbidities and symptoms of patients with chronic subdural hematoma stratified by treatment group
Fig. 2
Fig. 2
Incidence (n/100,000) of chronic subdural hematoma stratified by treatment group in different age groups during the study period between 1990–2015 in Pirkanmaa, Finland
Fig. 3
Fig. 3
Cumulative proportion of recurrences shown as Kaplan–Meier analysis in different age groups (a) and time periods (b). Observations for event-free patients were censored at the time of death
Fig. 4
Fig. 4
Direct costs of chronic subdural hematoma in Tampere University Hospital. Total hospital costs per 5-year time periods, and the number of operatively and non-operatively treated patients (a). A breakdown of mean hospital costs per patient stratified by time groups (b). The analysed CSDH patients living in Pirkanmaa Region accounted approximately half of all the CSDH patients treated in Tampere University Hospital with a catchment population of one million

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