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Note: Manuscript very warped.

Note: Title page omits author and title in manuscript. Taken from McGill University Thesis Directory.

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BACKGROUND: The Canadian healthcare system is subject to national standards that may be challenging to meet, given the evolution and integration of technology in healthcare in disciplines like functional neurosurgery, utilizing therapies such as deep brain stimulation (DBS), whereby implanted devices have provided benefit for patients with movement disorders. A comprehensive assessment of the need for this service to match with the delivery of DBS has not been performed. This thesis comprises a series of studies that aim to address this knowledge gap through the quadruple aim of health service research. METHODS: The first study is a systematic review and meta-analysis including economic evaluations comparing DBS for movement disorders with medical management only. The second is a mixed methods survey of Canadian stakeholders for DBS. The final study is a nationwide retrospective cohort study of DBS patients from 2019-2022 to determine factors that may influence access. RESULTS: Through analysis of 14 economic evaluations, DBS appears to be a cost-effective treatment when considered across the remaining lifespan of the patient with positive incremental net benefit for DBS with a mean difference of 40,504.81USD (95% CI 2,422.42; 78,587.19). Additionally, 220 responses from all DBS stakeholder groups revealed that costs associated with travel, waitlists, lack of specific resources, poor understanding of movement disorders and DBS indications, and referral pathways were barriers to accessing DBS. Finally, preliminary results identified 162 DBS patients. Potential factors that may increase access to DBS were indication (Parkinson’s disease), higher socioeconomic status, and race. CONCLUSIONS: While DBS is a cost-effective therapy for patients with movement disorders, the current delivery of this service needs significant improvement. This includes improved education, streamlined referral pathways, and policy change at a governmental level, with further investigation to determine regions of the country where need for DBS far exceeds current access. / Dissertation / Candidate in Philosophy / Movement disorders are progressive, debilitating neurologic conditions that severely impact the quality, speed and fluency of movement as a result of basal ganglia dysfunction. Medical therapies remain the mainstay of treatment, however high quality evidence supports the use of deep brain stimulation (DBS) to relieve these symptoms in well-selected patients. Given the upfront cost of surgery associated with DBS, and the comprehensive evaluations at tertiary care centres (including a multidisciplinary team with neurologists, neurosurgeons, neuropsychologists, psychiatrists, and electrophysiologists), this is a limited resource, particularly in overburdened publicly funded healthcare systems. There have been no previous attempts to comprehensively analyze access to DBS in Canada’s public healthcare system through investigation of need for these services, matched access, and investigation of barriers to access. This thesis comprises 5 chapters that inform this knowledge gap through the quadruple aim of health service research (patient perspective, health care provider perspective, cost, and population level data), aiming for equitable access to care in Canada. Chapter 1 is an introduction providing the rationale for conducting each of the included studies. Chapter 2 reports on an evaluation of cost, titled Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis. Chapter 3 presents an evaluation of healthcare provider and patient perspective, titled Mixed Methods Survey of Stakeholders to Identify Barriers to Accessing Deep Brain Stimulation for Movement Disorders in Canada. Chapter 4 is a retrospective cohort study providing population level data assessing patients who have received DBS in Canada, titled Canadian Access to Deep Brain Stimulation for Movement Disorders: A Nationwide Retrospective Study. Finally, Chapter 5 discusses the conclusion, limitations, and implications of the research presented in this PhD thesis.

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Neurosurgery is an effective method for prolonging life and improving outcomes for patients with brain tumors. However, this option bears the risk of damaging areas of eloquent cortex, areas associated with motor and language tasks that, when lesioned, will result in a functional deficit for the patient. Functional magnetic resonance imaging (fMRI) is a valuable tool in the localization of eloquent cortex for preoperative neurosurgical planning. Through use of this modality of functional neuroimaging, the neurosurgeon can adjust the surgical trajectory to incur the least amount of damage to sites of functional activity. The supplementary motor area (SMA) is one such site of eloquent cortex that must be visualized preoperatively due to the risk of postoperative deficit with lesions in this area. However, due to both the effects of tumor pathology and naturally occurring interindividual variability, the SMA’s location and functional fingerprint can be highly variable. We present a study in which patients with frontal tumor (n=46) underwent task-based fMRI for motor and language network mapping. The patient-specific functional data were normalized and evaluated using ROI analysis to illustrate group-level activation patterns within the SMA during the language and motor tasks. The results illustrate a distinct pattern of activation including a rostro-caudal organization of language and motor activation, overlapping extent cluster volumes throughout the two functional subdivisions of the SMA, the pre-SMA and SMA proper, and discrete activation foci.

Records of all neurosurgical inpatients admitted to Royal North Shore Hospital since 1976 have been prospectively kept in a relational database. Demographic details, diagnoses, operations and complications have been entered continuously since 1982 by the author of this study. Complications are monitored at monthly review meetings attended by medical staff. The recurrence of deep vein thrombosis (DVT) and pulmonary embolism (PE) at these meetings, despite continual improvements in patient care, prompted this study. It aims to use the database to study changes in the incidence of DVT and PE over the previous twenty years; to find what database variables predict these complications; and whether use of mechanical and pharmacological agents has had an impact on DVT and PE rate. Univariate analysis of the incidence of DVT and PE by age, sex, length of stay (LOS), admission month, diagnosis, operation and surgeon over time was run. Any significant variables were then analysed by multivariate logistic regression. The DVT rate was low by world standards, but rose from 0.6% in 1979-83 to 1.2% in 1984-88, then rose exponentially to 3.60% in 1994-98 with a significantly increasing trend over the twenty years (c2 MH =114.20, with IDF, P<0.001). PE rate doubled significantly over the twenty years from 0.6% to 1.2% (c2 MH =17.94 with 1DF, P<0.001). Age, LOS, diagnosis, operation and surgeon were significant predictors of DVT and PE. After adjustment for LOS, time period and age, vascular surgery was found to be the strongest predictor of DVT (OR=2.82, 95% CI: 2.08-3.82, c2 =43.91, P<0.01). Vascular diagnosis was the strongest diagnosis predictor. No effect of sex or month of admission was shown. After adjustment for LOS, time period and age, spinal fusion was the strongest predictor of PE (OR=4.04, 95% CI: 1.81-9.03). Anterior communicating artery aneurysm was the diagnosis most highly associated with PE. The rise in DVT rate may be due to increased complexity of surgical and nursing management, and some screening of patients with the introduction of duplex scanning. The doubling of PE rate is unexplained. The risk of brain or spinal cord haemorrhage makes prophylactic anticoagulation a difficult choice. This study reveals groupings which can be used to determine appropriate prophylaxis. Use of mechanical and pharmaceutical agents is not recorded consistently in the database, but it is known approximately when they were introduced. No impact on the rate of DVT and PE can be demonstrated by these agents. More vigilant and widespread use of mechanical prophylaxis might be just as effective in controlling DVT and PE.