Journal of Clinical Neuroscience xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Clinical study

Hospital costs associated with inpatient versus outpatient awake

craniotomy for resection of brain tumors
Farshad Nassiri a, Lawrence Li b, Jetan H. Badhiwala a, Tze Yeng Yeoh b, Laureen D. Hachem a,
Rebecca Moga b, Justin Z. Wang a, Pirjo Manninen b, Mark Bernstein a, Lashmi Venkatraghavan b,⇑
a
Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
b
Department of Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Background: With increasing fiscal restraints on health care systems, procedural cost-effectiveness has
Received 17 June 2018 become an important metric for evaluating surgical procedures. While outpatient craniotomy has been
Accepted 27 October 2018 shown to be safe and effective, the economic implications of this procedure has yet to be examined.
Available online xxxx
Here, we present the first cost analysis comparing inpatient versus outpatient awake craniotomy for
tumor resection/biopsy.
Keywords: Methods: We conducted a retrospective chart review on consecutive patients undergoing awake cran-
Awake craniotomy
iotomy for tumor resection/biopsy at a publicly funded tertiary care center from Sept 2014 to Aug
Brain tumor
Cost analysis
2015. Patient demographics, comorbidities and surgical factors were recorded. Direct and indirect costs
Glioma for each patient visit were calculated based on institutional records.
Healthcare Results: A total of 50 consecutive patients undergoing awake craniotomy for tumor resection were
included in this study (29 outpatients, 21 inpatients). Rates of complications and 30-day readmission
were similar between groups. The total costs associated with inpatient surgery were nearly double that
of outpatient surgery ($10649 versus $5242, P < 0.001). In-patient surgery resulted in a nearly 6-fold
increase in unit/bed costs compared to out-patient surgery ($4142 versus $758, P < 0.001). There were
no differences in the costs incurred from the operating room, laboratory, or anesthesia departments.
Conclusions: Costs associated with outpatient craniotomy are nearly half compared to inpatient cran-
iotomy and this is largely driven by reductions in bed resource utilization and allied health services.
Outpatient neurosurgery for tumor resection is therefore a safe and feasible option for appropriately
selected patients and confers an overall cost reduction.
Ó 2018 Elsevier Ltd. All rights reserved.

1. Introduction are increasingly gaining popularity as safe procedures that may

Neurosurgery has traditionally been considered a resource-
intensive specialty with many patients requiring post-operative
intensive care unit (ICU) stay and prolonged hospital stays. With
advances in the field such as the evolution of surgical technology,
instrumentation and monitoring techniques, and with increased
proficiencies in anesthesia, patients are now receiving improved
perioperative care with shorter operative durations and shorter
recovery times and times to discharge [1,4].
With increasing fiscal restraints on health care systems, proce-
dural cost-effectiveness has become an important metric for eval-
uating surgical procedures. Outpatient or day surgery procedures
⇑ Corresponding author at: Toronto Western Hospital, 399 Bathurst Street,
Toronto, Ontario M5T 2S8, Canada.
E-mail address: lashmi.venkatraghavan@uhn.ca (L. Venkatraghavan).
minimize resource utilization across all surgical subspecialties.
Outpatient craniotomy has been shown to be safe for various neu-
rosurgical indications, including tumor biopsy, tumor resection
and clipping of unruptured aneurysms. The economic implications
of outpatient clipping of unruptured aneurysms have been defined
[5,11], however, cost-analysis of outpatient craniotomy for tumor
resection has not been performed. Therefore, the objective of the
current study was to compare direct and indirect costs associated
with inpatient versus outpatient awake craniotomy for tumor
resection or biopsy at a publically funded tertiary care academic
center.
2. Methods
After approval from the institutional research ethics board, a
retrospective review of electronic patient records was performed

https://doi.org/10.1016/j.jocn.2018.10.110
0967-5868/Ó 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Nassiri F et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.
J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.10.110
2 F. Nassiri et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
for consecutive patients undergoing day surgery craniotomy for
tumor resection or biopsy performed by a single surgeon (M.B) at
a single institution (Toronto Western Hospital, University Health
Network) from September 2014 to August 2015. Given the variabil-
ity of indications for surgery, only awake craniotomy cases with
less than 4 h duration not requiring ICU stay were included for
analysis.
Eligibility for day surgery is determined prospectively by the
senior author in consultation with the patient and the peri-
operative anesthesia service at our institution according to a pre-
defined protocol [7]. The inclusion and exclusion criteria for outpa-
tient craniotomy are detailed in Table 1. Briefly, eligible patients
arrive at the Day Surgery Unit (DSU) at 06:00AM on the day of sur-
gery and undergo a pre-operative MRI head with gadolinium con-
trast used for frameless intra-operative stereotactic navigation.
Intravenous access is gained through peripheral lines, and use of
arterial lines, urinary catheters, and central venous lines are mini-
mized where possible. The scalp is anesthetized using long-acting
local anesthetic agents in combination with epinephrine, and the
patient is also given intravenous sedation for the procedure when
appropriate. No airway manipulation was performed in any of the
patients. Intraoperatively electrophysiological monitoring and cor-
tical mapping are used to map the anatomical distribution of elo-
quent cortex to facilitate maximal safe tumor resection. Post-
operatively, patients are transferred to the Post-Anesthestic Care
Unit (PACU) for 1–2 h and are then transferred to the DSU for an
additional 4–6 h of monitoring. A computed tomography (CT) scan
of the brain is performed 4–6 h post-operatively, as the risk of
post-operative intracerebral hemorrhage is highest within the first
6 h of an operation [9,13]. Patients with unremarkable post-
operative CT scans, good neurological status, and adequately con-
trolled pain and nausea with a caregiver available for overnight
are discharged home with clear instructions for indications to
return to hospital, and post-operative follow-up appointments.
Data collected including patient demographics, comorbidities,
surgical factors (tumor location, duration of surgery, Post-
Anesthestic Care Unit (PACU) stay, total hospital length of stay
(LOS), complications) were recorded for each included patient.
Standardized case-costing analysis was performed using data from
the Ontario Case Costing Initiative.
Primary outcomes included direct and indirect costs associated
with each patient visit. The University Health Network Case Cost-
ing Department is responsible for capturing costs associated with
each patient visit. The total cost for each patient visit is an aggre-
gate of direct and indirect costs. Direct costs were defined as
expenses incurred by the health care system from patient care
departments. This includes direct labour cost, direct supply cost
(including pharmaceuticals), direct patient-supply costs, direct
building and grounds costs, direct equipment costs, and other
direct sundry costs. Indirect costs were defined as expenses
incurred from transient non-patient care departments, such as
financing department, human resources department, and informa-
tion systems department. Costs were further subdivided into either
Table 1
Inclusion and exclusion criteria for outpatient craniotomy.
Inclusion criteria
Supratentorial tumor
Caregiver available overnight
Patient lives close to hospital (within 30 min drive)
Exclusion criteria
Already an inpatient
Cardiorespiratory or airway concerns from anesthesia
Uncontrolled seizures or poor neurological functioning
Duration of surgery expected to be >4 h
Patient preference or psychological unsuitability
Please cite this article in press as: Nassiri F et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.
J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.10.110
fixed costs or variable costs. Fixed costs were defined as expenses
that are set for a given procedural intervention and included fixed
direct labour, fixed direct sundry, fixed direct equipment, building
and grounds and fixed indirect costs. Variable costs included vari-
able direct labour, variable direct supplies (including pharmaceuti-
cals), variable patient-specific supplies and variable indirect costs.
In addition to subdividing costs according to cost type, the break-
down of costs per department were also retrieved for each patient
(Operating Room, Unit/Beds, Lab, Anesthesia, Pharmacy, Allied
Health, Radiology, Food/Nutrition, Other Medical).
Physician fees are separately reimbursed in Ontario by the Min-
istry of Health and therefore were not included as a cost in this
study. Moreover, costs associated with post-discharge care, sup-
plies, follow-up, readmission, and potential loss of income were
not included in this analysis.
Statistical analysis was performed using R (version 3.4.2). Con-
tinuous variables are represented as either means (with standard
deviation) or medians (with range) and were compared using
t-tests, analysis of variance (ANOVA), or Mann-Whitney U tests,
where appropriate. Categorical variables are represented as pro-
portions and compared using Fisher Exact tests or X2 tests, where
appropriate.
3. Results
During the 11-month study period there were 29 and 21
patients undergoing awake craniotomy for tumor resection as out-
patients and inpatients, respectively. Table 2 details the basic
demographic information for each group. The patients in the two
groups were largely similar with respect to baseline demographics,
with the exception that those in the inpatient group were slightly
older (63.4 years versus 55.0 years, P = 0.039) and had more pre-
operative endocrinopathies (42.9% versus 10.3%, P = 0.007). Despite
these differences, the distribution of ASA classes of the patients
were similar, as were the range of pre-operative neurological def-
icits, tumor location and tumor pathology. The indication for sur-
gery in both groups was predominantly for cytoreduction in
addition to tissue diagnosis of an intra-axial tumor (79.3% in out-
patients, 71.4% in inpatients).
The duration of surgery was similar in both groups (149 min in
outpatient surgery, 171 min in-inpatient surgery P = 0.059), how-
ever, patients in the outpatient surgery group had a significantly
longer stay in the Post-Anesthesia Care Unit (PACU) compared to
patients in the in-patient group (152 min versus 117 min,
P < 0.001) (Table 3). After their PACU stay, patients in the outpa-
tient group were transferred to the Day Surgery Unit (DSU) where
they were monitored on average for an additional 303 min prior to
discharge home. Patients in the in-patient group, however, were
not transferred to the DSU after their PACU stay, but rather were
transferred to the hospital ward where they stayed in hospital
for a median of 2 days for further monitoring until discharge. None
of the outpatients required conversion to in-patient hospitaliza-
tion. The rate of complications and 30-day readmission rates were
similar in both groups. In the outpatient group, 4 patients devel-
oped surgical site infection prompting readmission, 3 of whom
were treated with antibiotics and one of whom required operative
management. One patient in the outpatient group was readmitted
for seizure management, and one patient was readmitted for pro-
gressive neurological deterioration. In the inpatient group, 2
patients developed new sensorimotor deficits post-operatively, 1
patient was readmitted with progressive neurological deficits, 1
patient was readmitted for post-operative pain control, and 2
patients were readmitted with systemic illnesses (sepsis and
ketoacidosis) (Table 3).
The total costs associated with inpatient surgery were nearly
double that of outpatient surgery ($10649 versus $5242,
 F. Nassiri et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx 3

Table 2
Baseline demographics and characteristics of patients undergoing inpatient versus outpatient awake craniotomy.

Outpatient (n = 29) Inpatient (n = 21) P-value

Age (years) 55.0 63.4 0.039
Male 21 (72.4%) 15 (71.4%) 0.939
Body Mass Index 25.5 27.4 0.130
American Society of Anesthesiologists (ASA) Score 3 (2–3) 3 (2–4) 0.230
Comorbidities Cardiovascular 8 (27.5%) 8 (38.1%) 0.431
Respiratory 5 (17.2%) 6 (28.6%) 0.340
Endocrine 3 (10.3%) 9 (42.9%) 0.007
Gastrointestinal 10 (34.4%) 7 (33.3%) 0.932
Predominant Tumor location Dominant hemisphere 14 (48.2%) 13 (61.9%) 0.474
Frontal Lobe 16 (55.1%) 11 (52.3%) 0.788
Parietal Lobe 6 (20.7%) 6 (28.6%)
Temporal Lobe 7 (24.1%) 4 (19.0%)
Pre-operative neurological deficit None 9 (31.0%) 2 (9.5%) 0.142
Sensorimotor 14 (48.2%) 13 (61.9%) 0.505
Language 4 (19.0%) 5 (23.8%) 0.5913
Visual impairment 3 (10.3%) 2 (9.5%) 1.00
Cognitive impairment 1 (3.4%) 5 (23.8%) 0.070
Pathology Meningioma 1 (3.4%) 0 (0%) 0.093
Brain metastasis 5 (17.2%) 7 (33.3%)
High grade glioma 19 (65.5%) 11 (52.3%)
Low grade glioma 3 (10.3%) 0 (0%)
Lymphoma 0 (0%) 3 (14.2%)
Other 1 (3.4%) 0 (0%)
Indication for Surgery Resection 23 (79.3%) 15 (71.4%) 0.519
Biopsy only 6 (20.7%) 6 (28.6%)

Table 3
Operative results and complications incurred for patients undergoing inpatient versus outpatient awake craniotomy.

Outpatient (n = 29) Inpatient (n = 21) P-value

Duration Surgery (min) 149 171 0.059
PACU (min) 152 117 <0.001
DSU (min) 303 N/A N/A
Ward (days) N/A 2 (1–8) N/A
Complications 30-day readmission 5 (17.2%) 4 (19.0%) 1.00
New seizure 2 (6.9%) 0 (0%) 0.503
Neurological deficit 0 (0%) 3 (14.2%) 0.067
Venous Thromboembolism 2 (6.9%) 1 (4.8%) 1.00
Surgical Site Infection 4 (13.7%) 0 (0%) 0.129
Systemic 0 (0%) 2 (9.5%) 0.171

Fig. 1. Costs incurred for inpatient versus outpatient awake craniotomy (A) Total costs (B) Direct costs (C) Indirect costs (D) Variable costs (E) Fixed costs.

Please cite this article in press as: Nassiri F et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.
J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.10.110
4 F. Nassiri et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
P < 0.001, Fig. 1A). In order to characterize the increase in costs, the
costs were broken down into direct and indirect costs, and fixed
and variable costs. In-patient surgery resulted in approximate dou-
bling of direct, indirect, fixed, and variable costs (Fig. 1B–E). Costs
were also delineated according to the department that incurred
costs (Fig. 2), and there were no differences in the costs incurred
from the operating room, laboratory, or anesthesia departments
for inpatient versus outpatient awake craniotomy. In-patient sur-
gery resulted in a nearly 6-fold increase in unit/bed costs com-
pared to out-patient surgery ($4142 versus $758, P < 0.001). In-
patient surgery also resulted in increased costs incurred from the
departments of pharmacy, imaging, food and support services that
were minimal in the outpatient surgery group. Costs incurred from
other medical departments contributed the least to the total costs
incurred in in-patients.
4. Discussion
This study is the first to explore the costs associated with inpa-
tient versus outpatient awake craniotomy for tumor resection at a
publically funded tertiary care academic center. Our results
showed that in our cohort of 50 consecutive patients, total costs
associated with inpatient surgery were nearly double the costs
associated with outpatient surgery. The majority of the increase
in costs appears to be incurred from different bed units (PACU,
ward) and allied health services (physiotherapy, occupational ther-
apy, speech language pathologists). Costs associated with medical
care for patients contributed minimally to the increased costs
incurred from in-patient surgery.
With the explosion of technological advancements in surgery
and proficiencies in peri-operative care, day surgery is increasing
in popularity across all surgical subspecialties. In neurosurgery,
day surgery has been commonly used for patients undergoing
spine surgery, and also for those requiring cranial surgery for
Fig. 2. Breakdown of costs as incurred by various hospital departments.
Please cite this article in press as: Nassiri F et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.
J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.10.110
clipping of unruptured intracranial aneurysms and for brain tumor
resection [2,10,14]. Patient selection is key for successful outcome
and complication avoidance, particularly in day surgery. We have
previously shown that our established institutional protocol is
both safe and effective when combined with appropriate patient
education [2,3,5–7,10,14].
Outpatient surgery has numerous advantages. It is known that
the median overall incidence of in-hospital adverse events is
9.2%, and nearly half of these adverse events may be preventable
by avoiding hospital admission [8]. Moreover, there is emerging
data suggesting that avoiding volatile anesthestic agents, as done
during awake craniotomies, may improve survival for patients
with malignancies [15]. In addition to the medical benefits of day
surgery, patients often find their own homes to be a more comfort-
able environment conducive to recovery. This is particularly
important for patients with malignant brain tumors, as their
numerous appointments with health care professionals results in
significant interruptions to their lives. Moreover, as patients
remain outside of the hospital, they are empowered to take control
of their disease and are alleviated from the psychological impact of
their diagnosis. Although patients are often surprised that brain
surgery can be performed on an outpatient basis, their satisfaction
with outpatient surgery is high [9].
In addition to the benefits listed above, outpatient surgery
avoids the costs incurred from in-patient admission and hospital-
ization and may overall be a more cost-effective approach.
Although this is commonly cited as a benefit, very few studies have
performed detailed cost-analyses of outpatient compared to inpa-
tient neurosurgery, and even fewer studies have looked at this in
the context of craniotomy for tumor resection. Silver et al. exam-
ined the costs associated with cervical discectomy and fusion per-
formed a consecutive series of 53 patients at their institution and
found that outpatient surgery resulted in a reduction in hospital
costs of over $90,000 in their cohort [12]. Using estimates of costs
 F. Nassiri et al. / Journal of Clinical Neuroscience xxx (2018) xxx–xxx
associated with unit beds, Bhardwaj et al., suggest that the cost-
savings of outpatient surgery for stereotactic biopsies could range
between $1740 and $2340 [5]. The results of their work, however,
was not based on detailed cost-analysis. Similarly, Purzner et al.
roughly estimated $ 2,313,960 of savings from outpatient cran-
iotomy and biopsy in their cohort of 374 patients based on approx-
imations of costs associated with inpatient bed utilization [10].
To our knowledge, this study is the first to perform an in-depth
cost analysis of in-patient versus outpatient craniotomy for tumor
resection or biopsy. Radovanovic et al. previously performed an in-
depth cost analysis of outpatient craniotomy for microsurgery for
unruptured anterior circulation aneurysms [11]. Similar to our
study, they found that outpatient craniotomy was associated with
total reduction in cost that appeared to be primarily driven by
costs associated with hospital beds, particularly ward beds. They
also found that costs associated with pharmacy and nutrition were
lower in the outpatient surgery group, however, these were largely
inconsequential given their small absolute figures. Interestingly,
they did not find any differences in costs incurred from Allied
Health with outpatient surgery. This is likely due to the fact that
all of their unruptured aneurysm patients were functionally inde-
pendent preoperatively (mRS 0–2), whereas patients with brain
tumors often have neurological deficits due to parenchymal
involvement or mass effect. However, whether the services pro-
vided by allied health professionals must be done as an inpatient,
or whether some of these services can be provided as an outpatient
or perhaps by caregivers, remains to be determined.
This study has several important limitations. First, this study
is a retrospective review of a single surgeon’s practice at a pub-
lically funded tertiary care academic centre, and therefore the
results of this study should be interpreted in context. Moreover,
the small sample size limits the power of this analysis. Our study
did not attempt to evaluate the safety of outpatient craniotomy
in our cohort, although this has been done previously
[2,3,5,10]. Although we attempted to characterize total hospital
costs, our study does not address the out-of-hospital expenses
that may be incurred by patients or the societal costs associated
with illness, disease, and caregiver burden. Our study also does
not address any regional or international variations in operative
and perioperative care, which should be addressed in future
studies on cost savings of day surgery. Lastly, our cost-analysis
is based on institutional segmentation of total hospital costs
which clusters aggregate costs into select departments, for exam-
ple operating room or allied health. More refined case-costing
analysis may be able to provide insight into the exact drivers
of incurred costs for each department.
Please cite this article in press as: Nassiri F et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.
J Clin Neurosci (2018), https://doi.org/10.1016/j.jocn.2018.10.110
5
5. Conclusion
With adherence to strict protocols and with significant efforts in
patient and caregiver education, we have shown that outpatient
neurosurgery for tumor resection is safe and feasible. Outpatient
craniotomy confers many advantages, including overall decreased
costs in a publically funded health care system. We found that
costs associated with outpatient craniotomy are nearly half com-
pared to inpatient craniotomy costs. Increased costs with inpatient
craniotomy appears to be driven by bed resource utilization and
services provided by allied health professionals. Costs incurred
by pharmacy, imaging, food, and other medical departments are
minimal and largely inconsequential.
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