Thanks to everyone who contributed to a very good journal club last night. Ahsan presented the papers well, but more importantly I think we had a robust, wide-ranging discussion. For those who couldn’t make it, here are some take-aways:
First, we reviewed this paper, published in April, which suggested that hemicraniectomy is both life- and function-saving in patients up to age 80. Prior studies have shown poor functional outcomes in the elderly, and the more recent randomized studies excluded subjects over age 60. Criticisms:
- Although the purpose of the study was to study hemicraniectomy in an older population, they included subjects aged 18-80. There were 47 total subjects, 29 of whom were > 60 years old and only 11 of whom were > 70.
- Favorable outcome was defined as a modified Rankin score (mRS) < 5. This puts those who end up with Rankin 4 as having “favorable” outcome, which is controversial. Using a favorability cutpoint of mRS < 4, which seemed to us to be a better dividing line between favorable and unfavorable, there was no statistically significant difference between surgery and medical therapy.
We paired that article with this systematic review of hemicraniectomy studies, with an emphasis on patient-centered measures of well-being (quality of life, or QoL). Findings:
- Study methodology varied widely (randomized vs. non-randomized, etc.)
- 75% of subjects had non-dominant hemisphere strokes.
- A very large mortality benefit was confirmed; no surprise there.
- A lot of patients ended up with mRS 4.
- Patients reported 67% reduction in the physical aspect of their QoL.
- 56% suffered from depression.
- Despite the above, they only reported 37% reduction in their psychosocial QoL.
- 77% of patients and/or caregivers “expressed satisfaction with life and had no regret for having undergone decompressive hemicraniectomy”.
That’s when things got really interesting. We went around and pretty much everyone agreed that they’d at least want to discuss hemicraniectomy with their older patients, but struggled with how to talk about it without
- Promising something that our neurosurgical colleagues might not be willing to offer
- Suggesting to patients that the procedure should be done or will improve their loved one’s QoL
- Falling into the self-fulfilling prophecy trap
We also talked about whether one could be sued for not offering the intervention. This led to a discussion about levels of evidence, and we agreed that this one paper does not a standard of care make. However, the Wisconsin Supreme Court recently ruled that our state’s informed consent statute requires physicians to inform patients about diagnostic and treatment options that a “reasonable person” would want to know about. So, while it would seem unlikely that a neurologist or neurosurgeon would lose a malpractice claim on the basis of having failed to offer hemicraniectomy to an aged patient, it remains possible that by not even discussing it, one might lose on an informed consent claim. (Disclaimer: I’m not a lawyer and this isn’t legal advice).
Then we moved on to the public health ramifications of these trials. What are the costs of hemicraniectomy and the long-term disability that follows? Should insurance plans be required to cover the procedure for elderly patients? We touched on the fact that in the U.K., there is a governmental entity, the National Institute for Health and Clinical Excellence, that examines medical technologies and makes coverage decisions. If
the death panels Medicare and private insurers decide at some point not to pay because the cost per quality-adjusted life year is too high, should people of means be able to pay for it out of pocket? People were uneasy about that.
Alas, we didn’t solve our nation’s health care financing puzzle last night, but I think it was a worthwhile discussion . . .