Awake Versus Asleep Craniotomy for Glioma: A Comparison of Survival and Costs Using Time-Driven Activity-Based Costing

Abstract

BACKGROUND AND OBJECTIVES: Gliomas are among the most common primary brain tumors. Based on proximity to eloquent structures, surgeons may perform an awake craniotomy (AC) or an asleep craniotomy under general anesthesia (GA). To date, no study has used time-driven activity-based costing to compare costs of these procedures. METHODS: We identified all GA (n = 298) and AC (n = 67) performed for glioma resection at our institution from 2017 to 2022. Total costs were determined through interdepartmental collaboration (sterile processing, pharmacy, and plant operations departments) and automated extraction from the electronic medical record. Multivariable generalized linear mixed models were performed to compare costs between AC and GA, accounting for patient and tumor-specific factors. Differences in survival were evaluated using Kaplan-Meier curves and Cox proportional hazards models. RESULTS: The median total cost of surgery was $6600 (IQR: $2875), most of which was driven by the cost of supplies (median: $3178, IQR: $1798) and personnel (median: $3141, IQR: $1155). Although GA patients were older (P = .025), no differences were found in World Health Organization tumor grade distribution (P = .55) or extent of resection (P = .17). After adjusting for confounders, AC was associated with $2175 of additional intraoperative cost (P < .001) compared with GA. Kaplan-Meier analysis demonstrated greater overall survival (OS) for AC compared with GA (log-rank; P = .011), with no significant difference in progression-free survival (PFS) (log-rank; P = .106). However, when adjusting for confounders, multivariable Cox hazards ratios (HRs) revealed no significant differences in OS (HR = 0.84, P = .48) or PFS (HR = 0.9, P = .66) between the 2 modalities. CONCLUSION: Although AC was significantly more expensive than GA, it was not associated with a corresponding improvement in OS or PFS after adjusting for confounders. Continual reassessment of the cost-effectiveness of novel brain tumor approaches will be increasingly important in the era of value-based care.