Massachusetts General Hospital Epilepsy and EEG Service Thursday,

Massachusetts General Hospital Epilepsy and EEG Service Thursday,

Massachusetts General Hospital Epilepsy and EEG Service Thursday, February 24, 2011 Cost-Effectiveness of EEG Monitoring in Acute Brain Injury: What it is, What it is Not, and How to Measure It. Kenneth Jordan, MD, FACP, FAAN, FACNS President, Jordan NeuroScience, Inc Scope of ICU-CEEG 1. 7,400 Intensive Care Units in USA

2. $180 billion (30% of acute care costs) 3. 55,000 patients/day in ICUs 4. Total ICU admissions/year = 5,000,000

5. 10% have ICDN diagnoses at risk for NCS/NCSE. 6. 500,000 potential CEEG patients/year 7. Av. duration of CEEG is 3 days

>1.5 mil CEEG days/year to maintain, monitor and read Market size for CEEG monitors = $52 million Refs: UCLA Brain Injury Research Center, www.aha.org,www.sccm.org; Claassen et al Neurology (2004); personal communication from CEO of global EEG company. Cost-Effectiveness Analysis (CEA)

Goal: Identify the most cost-effective intervention from alternatives that meet a common health benefit and are competing for the same resources. Economic Evaluation of Public Health Preparedness and Response Efforts. CDC, at: http://www.cdc.gov/owcd/EET/Preface/Fixed/Preface.html Costs All interventions tangible costs; excludes intangible costs. WHAT EFFECTIVENESS IS AND WHAT IT IS NOT

Effectiveness is a health benefit caused directly or indirectly by an intervention. The health benefit cannot exceed the capabilities of the intervention. e.g. The effectiveness of a screening program for prolonged Q-T syndrome is 1) its accuracy for detecting the condition and 2) its successful public health deployment. It is not whether the program saves lives, since that depends on factors beyond the capability of the screening program (Do pts follow up with the doctors; are the correct surveillance measures taken, are dangerous drugs avoided, is timely and correct treatment provided, etc) The health benefits of EEG are limited to its detection of

brain wave activity and its deployment methods. They do not include outcomes from subsequent treatment interventions. Cost-Effectiveness Ratio CER=C/E The numerator is the change in cost due to the application of an intervention and the denominator is the change in health benefit. Cost-Effectiveness Ratio (CER): The smaller the CER, the lower the cost

and/or the more effective the intervention: a4= 27.14, c1= 2.27 CEA of Set-Up Methods for Emergency EEG and CEEG Studies: EEG Technologist Call Back (ETCB) vs BraiNet Template (BN) ETCB Indications 1. Any Study Initiated after 7 PM or before 7 AM M-F

2. Any Study Initiated on Saturday, Sunday or work holidays 3. Remove and/or Re-apply CEEG electrodes for imaging studies or other procedures. 4. Revise, re-apply, repair and/or re-insert electrodes during CEEG or other ongoing study Bradley Kolls, MD, PhD, Dir of Crit. Care Monitoring Duke University Medical Center Utilization Over Time by Location* 300

Number of Studies 2004 2005 2006 2007 2008

250 200 150 100 50 0 Total 2008 Emergency EEGs = 450 ETCBs = 320 (71%) *Pediatric cases not included Lab Survey Findings How much do you feel that over-night coverage of the prolonged

monitoring service (call) is a significant contributor to technician burnout? This service is the largest contributor There are many other factors, this is a modest contributor There are many other factors, this is a minimal contributor This service is not a factor in technician burnout

Lab Survey Findings Do you feel that over-night coverage of the prolonged monitoring service (call) is a significant contributor to technicians leaving the Duke Neurodiagnostic lab? Yes No Summary of ECB and CEEG Utilization Time-Motion Profile for One ETCB Study Task

Duration (min) Pageget readyleave home 15-30 Drive Time/parking 15-30 To Lab for supplies

15 Set up equipment at bedside 15 Chart review. Enter history 10-20 Measure head:10/20 method 10-20

Apply electrodes 10 Total Set-Up Time 1.5 Hr 2.3hr ETCB vs. BraiNet Costs Scenario I: 250 ECB/year ECB $/ Year

BN $/Year Weekend, holiday and overnight call back for 3hr/ECB day $37,950 0.00 On call pay ($50/ECB day) $12,650

12,650 Supplies**: dispos. electrodes, BN $16,250 25,000 Total Costs $66,850

$37,650 Costs* (includes benefits and paid non-work time) *ETCB = 6,072 hrs or 253 days/year. 28/hr base wage + benefits,etc, OT=$50/hr. **Retail: dispos electrodes $65, BN $35+electrodes ETCB vs. BraiNet Costs Scenario 2: 500 ECB/year ECB $/ Year

BN $/Year Weekend, holiday and overnight call back for 6 hr/ECB day $75,900 0.00 On call pay ($50/ECB day) $12,650

12,650 Supplies: dispos. electrodes, BN $32,500 50,000 $121,050 $62,650 Costs

(includes benefits and paid non-work time) Total Costs EFFECTIVENESS Benefits/Equivalence of BN vs. ETCB Equivalence Study of BraiNet and Technologist Applied Electrode Leads* B. Kolls and K. Dombrowski, Duke University Medical Center *Sponsored by JNS under DoD Award. JNS provided BN training but was not

otherwise involved in study or data analysis. Results 32 of 36 studies initiated with the BraiNet were analyzed. 6 of the BN studies were done with disks and 26 were done with needles. 4 studies were attempted with the BN initially, but failed due to

Improper use of conduction agents on disk electrodes n=1 improper use of fixative agents to needle electrodes n=1 Old leads with capacitance problems n=2 All occurred within the initial weeks of study and did not recur Both BN and Tech leads had impedances < 5 kOhms at the beginning of the studies with no significant change over the 8 hours of recording. Quality Assessment Four senior EEG readers blinded to the lead application method reviewed the records.

They were asked to: 1. Guess the lead placement method (BN Needle, BN Disk, Tech) 2. Rate the quality of the data 3. Report their findings for the segment Quality Assessment: Method of Lead Placement Reviewers accuracy rate = 33%, equal to random guesses among the three choices; ie. Reviewers could not detect any differences in quality of recording among BN SNE, BN

disks, or Tech disks When binary choice of BN vs Tech was offered (random=50%), accuracy rate was 56%, showing no difference in BN vs Tech. Bias Against EEG Templates (or Pro-Tech Leads) 60% Technologist 50%

BraiNet 40% 30% 20% 10% 0% Poor

P<.001 Adequate Good Excellent Blinded Reviewers Assigned Poorer Quality Recordings to the BN Method and Higher Quality to the Tech Leads* Cure for Bias Against EEG Templates (or Pro-Tech Leads)

50% Actual Quality Results: No significant differences between BN and Tech Methods Technologist BraiNet 40% 30% 20%

10% 0% 50% Poor Adequate Good Excellent

45% Technologist 40% BraiNet 35% 30% 25% 20% 15%

10% 5% P=0.3810 0% Poor Adequate Good Excellent

INTERPRETATION OF EEG RECORDINGS No reported disparities between 8 hours of BN recordings and subsequent 8 hours of Tech lead recordings. Summary of CEA of BN Method vs. ETCB 1. COST: BN saves 45-50% in costs compared to ETCB. These savings increase cumulatively, steeply and almost linearly with increasing emergency requests.

2. EFFECTIVENESS: BN is equivalent in quality of recording to ETCB BN is 3x faster to set-up EEG compared to ETCB BN revealed no interpretation differences from Tech studies. CER FOR ETCB vs BN 1. ETCB: Average cost for 5 years of incrementing studies = $186,000 Relative Speed of set-up = 1.0 CER = 186/1 = 186

2. BN: Average cost for 5 years of incrementing studies = $92,000 Relative Speed of set-up = 3.0 CER = 92/3 = 31 CONCLUSION The BN method is six times more cost effective than ETCB to Set-Up Emergency EEG and CEEG Studies

The BN is also the only EEG Set-Up Template that is: FDA cleared for use in all ages: neonates through adults Proven for accurate placement and quality of recording For every type of ABI, both traumatic and non-traumatic Proven effective for acute set-up through continuous EEG monitoring Compatible with CT and MRI imaging Plus: User electrode choice, including MRI/CT compatible electrodes Electrodes can be placed/replaced by on-site caregivers Disposable for infection control

Compatible with EVD, ICP and Licox monitors THANK YOU!

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