Cost%Effectiveness-Analysis-of-Cholesteatoma-...
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CostEffectiveness Analysis of Cholesteatoma Management: MRI Surveillance Versus Planned Second Stage Procedures Kathryn Noonan, MD 1 Clifford Eskey, MD, PhD 1 Daniel Morrison, MD 2 James Saunders, MD 1 1 Dartmouth Hitchcock Medical Center, 2 AtlantiCare New Jersey Dartmouth Hitchcock To compare the costeffectiveness of magnetic resonance imaging (MRI) surveillance in the assessment of postoperative cholesteatomas versus planned second stage procedures. Objective Introduction • Costeffectiveness analysis was performed for three postoperative management strategies: 1) Surgical initial cholesteatoma resection followed by staged secondlook procedure with OCR 2) Imaging – initial cholesteatoma resection with concurrent OCR followed by postop DWI at 6 and 18 months 3) Hybrid – initial cholesteatoma resection and staged secondlook with OCR followed by DWI if residual disease at that surgery • Average current hospital charges at a tertiary care center were used for cost data. • Effectiveness estimates and event probabilities used in the decision algorithm were based on published data. • A Markov analysis was performed to further study the progression through treatment and effectiveness variations between the strategies. • Sensitivity analysis was preformed to incorporate the variability among probabilities reported in the literature. Postoperative management of cholesteatoma has historically been challenging due to high recurrence rates and difficulty with accurate detection of residual disease on physical examination. CT imaging frequently results in false positives due to problematic differentiation between scar tissue, postoperative changes, infection, or residual disease. Traditionally, surgical resection and hearing reconstruction is performed as a staged procedure 6 to 18 months after the original surgery. A delayed surgical approach enables accurate detection of postoperative cholesteatomas by direct visualization and the promotion of healthier middle ear mucosa for optimal hearing outcomes. This staged approach however can be expensive, inefficient, and time consuming for patients. New advances in imaging technology now enables the detection of residual disease with high sensitivity, making diffusionweighted MRI (DWI) surveillance a plausible alternative. Variable Description Value Source c_MRI Cost of MRI $4520 DH hospital charges averaged 20142015 c_Resection&OCR Cost of surgical resection with OCR $54699 DH hospital charges averaged 20142015 c_Revision Cost of revision surgery $30140 DH hospital charges averaged 20142015 c_2ndStageOCR Cost of second stage procedure with OCR $30140 DH hospital charges averaged 20142015 c_SurgResection Cost of primary cholesteatoma resection $48220 DH hospital charges averaged 20142015 e_cholesteatoma Satisfaction of patients living with cholesteatoma 44 Chronic Ear Survey data Jung 2010 e_surg Satisfaction of patients with successful surgical resection 77 Chronic Ear Survey data Jung 2010 e_disease_rec Satisfaction of patients with recurrent disease 50 Chronic Ear Survey data Jung 2010 e_surg_comp Satisfaction of patients after surgical resection when needing revision 74 Chronic Ear Survey data Jung 2010 p_Poor Hearing Probability of poor hearing outcome with single stage procedure requiring revision 1862% Ho 2003, Martin 2009, Stankovic 2008, Vartiainen 1995 p_SurgComp Probability of surgical complications that requires revision 1037% (30%) Ho 2003, Martin 2009, Quaranta 2014, Stankovic 2008, Vartiainen 1995 p_SurgDisease Probability of residual dcholesteatoma 563% (15%) Gaillardin 2012, Hanna 2014, Ho 2003, Lin 2011, Quaranta 2014 Sensitivity Analysis (hearing outcomes) Probability of poor hearing outcome requiring reoperation Net Monetary Benefit Surgery Imaging Hybrid Figure 3. CostEffective Analysis model. Graph showingno one method is significantlymore cost effective (“dominated”) in the model CostEffectiveness Analysis Surgery Imaging Hybrid Undominated Kathryn Noonan DartmouthHitchcock Medical Center [email protected] 7814242103 Contact 1. Jung KH, Cho YS, Hong SH, Chung WH, Lee GJ, Hong SD. Qualityoflife assessment after primary and revision ear surgery using the chronic ear survey. Arch Otolaryngol Head Neck Surg. 2010;136(4):358365. 2. Ho S, Kveton J. Efficacy of the 2staged procedure in the management of cholesteatoma. Arch Otolaryngol Head Neck Surg 2003;(May 2003):541545. 3. Martin TPC, Weller MD, Kim DS, Smith MCF. Results of primary ossiculoplasty in ears with an intact stapes superstructure and malleus handle: Inflammation in the middle ear at the time of surgery does not affect hearing outcomes. Clin Otolaryngol . 2009;34(3):218224. 4. Stankovic MD. Audiologic results of surgery for cholesteatoma: short and longterm followup of influential factors. Otol Neurotol . 2008;29(7):933940. 5. Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol . 1995;(July):590592. 6. Quaranta N, Iannuzzi L, Petrone P, D’Elia A, Quaranta A. Quality of life after cholesteatoma surgery: IntactCanal wall tympanoplasty versus canal walldown tympanoplasty with mastoid obliteration. Ann Otol Rhinol Laryngol. 2014;123(2):8993. 7. Gaillardin L, Lescanne E, Morinière S, Cottier JP, Robier a. Residual cholesteatoma: prevalence and location. Followup strategy in adults. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(3):136140. 8. Hanna BM, Kivekäs I, Wu YH, et al. Minimally invasive functional approach for cholesteatoma surgery. Laryngoscope. 2014;(October):23862392. 9. Lin JW, Oghalai JS. Can radiologic imaging replace secondlook procedures for cholesteatoma? Laryngoscope. 2011;121(1):45. References • Average per patient costs were less with the imaging approach ($82,158) than the hybrid ($91,619) or surgical ($94,310) approach. • The imaging surveillance pathway was only marginally less effective than the other approaches using both the surgeon perspective (cholesteatoma detection rate) and the patient perspective (quality of life measures based on published Chronic Ear Survey data). • Sensitivity analysis was performed to account for the potentially poorer hearing outcomes with a primary ossicular chain reconstruction (OCR) indicating that revision surgery for poor hearing results may be performed in a large portion of patients (59%) before there would be an economic disadvantage to primary OCR with imaging surveillance. • A Markov analysis over the course of treatment also favored the imaging pathway over a staged surgical approach. • Using a combination of literature values and our clinical data we found the surgical, imaging, and hybrid approaches comparable from a cost effectiveness standpoint. • Although high success rates of cholesteatoma detection have been demonstrated using MRI surveillance many would argue against single staged procedures due to the potential for poorer hearing outcomes. Our sensitivity analysis demonstrates that it is cost effective to perform single stage procedures and follow patients with imaging even if a high proportion (59%) of patients require revision surgery for hearing outcomes. Discussion MRI imaging surveillance with primary OCR is a costeffective surveillance pathway for the management of postoperative cholesteatoma patients and a valid alternative to planned second staged procedures Conclusions Results Figure 1. Simplified decision analysis model showing(1) surgical pathway, (2) imaging hybrid pathway, and (3) Imaging pathway. Surgical and hybrid start with initial cholesteatoma resection and imaging pathway starts with cholesteatoma excision with primary OCR. Figure 2. Example of Markov states based on probabilities in the surgical arm. Table 1. Decision analysis values used in model Figure 4. Sensitivity analysis varyingproportion of patients with primary OCR requiringrevision surgery for hearing outcomes. Pathways cross at 59% with poor hearingoutcomes. Surgery Hybrid Imaging Residual disease No disease +OCR Residual disease +OCR No disease +OCR MRI 1 HL or complication Revision Surgery MRI surveillance MRI repeat MRI Revision Surgery MRI+ Revision Surgery Initial Surgery (with or without OCR) Cost, dollars Effectiveness, rate of cholesteatoma eradication Cholesteatoma Secondlook Disease free Surgical complications Revised, disease free Surgical Markov Probability Analysis Stage Probability Methods and Materials
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Transcript of Cost%Effectiveness-Analysis-of-Cholesteatoma-...
Cost-Effectiveness Analysis of Cholesteatoma Management: MRI Surveillance Versus Planned
Second Stage Procedures Kathryn Noonan, MD1;; Clifford Eskey, MD, PhD1;; Daniel Morrison, MD2;; James Saunders, MD1
1Dartmouth Hitchcock Medical Center, 2AtlantiCare New Jersey
Dartmouth-Hitchcock
To compare the cost-effectiveness of magnetic resonance imaging (MRI) surveillance in the assessment of postoperative cholesteatomas versus planned second stage procedures.
Objective
Introduction
• Cost-effectiveness analysis was performed for three postoperative management strategies: 1) Surgical - initial cholesteatoma resection followed by staged second-look procedure with OCR2) Imaging – initial cholesteatoma resection with concurrent OCR followed by post-op DWI at 6 and 18 months3) Hybrid – initial cholesteatoma resection and staged second-look with OCR followed by DWI if residual disease at that surgery
• Average current hospital charges at a tertiary care center were used for cost data.
• Effectiveness estimates and event probabilities used in the decision algorithm were based on published data.
• A Markov analysis was performed to further study the progression through treatment and effectiveness variations between the strategies.
• Sensitivity analysis was preformed to incorporate the variability among probabilities reported in the literature.
Postoperative management of cholesteatoma has historically been challenging due to high recurrence rates and difficulty with accurate detection of residual disease on physical examination. CT imaging frequently results in false positives due to problematic differentiation between scar tissue, postoperative changes, infection, or residual disease. Traditionally, surgical resection and hearing reconstruction is performed as a staged procedure 6 to 18 months after the original surgery. A delayed surgical approach enables accurate detection of postoperative cholesteatomas by direct visualization and the promotion of healthier middle ear mucosa for optimal hearing outcomes. This staged approach however can be expensive, inefficient, and time consuming for patients. New advances in imaging technology now enables the detection of residual disease with high sensitivity, making diffusion-weighted MRI (DWI) surveillance a plausible alternative.
Variable Description Value Sourcec_MRI Cost of MRI $4520 DH hospital charges
averaged 2014-‐2015c_Resection&OCR Cost of surgical resection
with OCR$54699 DH hospital charges
averaged 2014-‐2015c_Revision Cost of revision surgery $30140 DH hospital charges
averaged 2014-‐2015c_2ndStageOCR Cost of second stage
procedure with OCR$30140 DH hospital charges
averaged 2014-‐2015c_SurgResection Cost of primary
cholesteatoma resection$48220 DH hospital charges
averaged 2014-‐2015e_cholesteatoma Satisfaction of patients living
with cholesteatoma44 Chronic Ear Survey data Jung
2010e_surg Satisfaction of patients with
successful surgical resection77 Chronic Ear Survey data Jung
2010e_disease_rec Satisfaction of patients with
recurrent disease50 Chronic Ear Survey data Jung
2010e_surg_comp Satisfaction of patients after
surgical resection when needing revision
74 Chronic Ear Survey data Jung 2010
p_Poor Hearing Probability of poor hearing outcome with single stage procedure requiring revision
18-‐62% Ho 2003, Martin 2009, Stankovic 2008, Vartiainen 1995
p_SurgComp Probability of surgical complications that requires revision
10-‐37%(30%)
Ho 2003, Martin 2009, Quaranta 2014, Stankovic 2008, Vartiainen 1995
p_SurgDisease Probability of residual dcholesteatoma
5-‐63%(15%)
Gaillardin 2012, Hanna 2014, Ho 2003, Lin 2011, Quaranta 2014
Sensitivity Analysis (hearing outcomes)
Probability of poor hearing outcome requiring reoperation
Net Monetary Benefit Surgery
ImagingHybrid
Figure 3. Cost-‐Effective Analysis model. Graph showing no one method is significantly more cost effective (“dominated”) in the model
Cost-Effectiveness Analysis
SurgeryImaging Hybrid Undominated
Kathryn NoonanDartmouth-‐Hitchcock Medical [email protected]‐424-‐2103
Contact1. Jung KH, Cho Y-‐S, Hong SH, Chung W-‐H, Lee GJ, Hong SD. Quality-‐of-‐life assessment after primary and revision ear surgery using the chronic ear survey. Arch Otolaryngol
Head Neck Surg. 2010;136(4):358-‐365.2. Ho S, Kveton J. Efficacy of the 2-‐staged procedure in the management of cholesteatoma. Arch Otolaryngol Head Neck Surg 2003;(May 2003):541-‐545. 3. Martin TPC, Weller MD, Kim DS, Smith MCF. Results of primary ossiculoplasty in ears with an intact stapes superstructure and malleus handle: Inflammation in the middle
ear at the time of surgery does not affect hearing outcomes. Clin Otolaryngol. 2009;34(3):218-‐224.4. Stankovic MD. Audiologic results of surgery for cholesteatoma: short-‐ and long-‐term follow-‐up of influential factors. Otol Neurotol. 2008;29(7):933-‐940.5. Vartiainen E. Factors associated with recurrence of cholesteatoma. J Laryngol Otol. 1995;(July):590-‐592.6. Quaranta N, Iannuzzi L, Petrone P, D’Elia A, Quaranta A. Quality of life after cholesteatoma surgery: Intact-‐Canal wall tympanoplasty versus canal wall-‐down tympanoplasty
with mastoid obliteration. Ann Otol Rhinol Laryngol. 2014;123(2):89-‐93.7. Gaillardin L, Lescanne E, Morinière S, Cottier J-‐P, Robier a. Residual cholesteatoma: prevalence and location. Follow-‐up strategy in adults. Eur Ann Otorhinolaryngol Head
Neck Dis. 2012;129(3):136-‐140.8. Hanna BM, Kivekäs I, Wu YH, et al. Minimally invasive functional approach for cholesteatoma surgery. Laryngoscope. 2014;(October):2386-‐2392.9. Lin JW, Oghalai JS. Can radiologic imaging replace second-‐look procedures for cholesteatoma? Laryngoscope. 2011;121(1):4-‐5.
References
• Average per patient costs were less with the imaging approach ($82,158) than the hybrid ($91,619) or surgical ($94,310) approach.
• The imaging surveillance pathway was only marginally less effective than the other approaches using both the surgeon perspective (cholesteatoma detection rate) and the patient perspective (quality of life measures based on published Chronic Ear Survey data).
• Sensitivity analysis was performed to account for the potentially poorer hearing outcomes with a primary ossicular chain reconstruction (OCR) indicating that revision surgery for poor hearing results may be performed in a large portion of patients (59%) before there would be an economic disadvantage to primary OCR with imaging surveillance.
• A Markov analysis over the course of treatment also favored the imaging pathway over a staged surgical approach.
• Using a combination of literature values and our clinical data we found the surgical, imaging, and hybrid approaches comparable from a cost-effectiveness standpoint.
• Although high success rates of cholesteatoma detection have been demonstrated using MRI surveillance many would argue against single staged procedures due to the potential for poorer hearing outcomes. Our sensitivity analysis demonstrates that it is cost-effective to perform single stage procedures and follow patients with imaging even if a high proportion (59%) of patients require revision surgery for hearing outcomes.
Discussion
MRI imaging surveillance with primary OCR is a cost-effective surveillance pathway for the management of postoperative cholesteatoma patients and a valid alternative to planned second staged procedures
Conclusions
Results
Figure 1. Simplified decision analysis model showing (1) surgical pathway, (2) imaging hybrid pathway, and (3) Imaging pathway. Surgical and hybrid start with initial cholesteatoma resection and imaging pathway starts with cholesteatoma excision with primary OCR.
Figure 2. Example of Markov states based on probabilities in the surgical arm.
Table 1. Decision analysis values used in model
Figure 4. Sensitivity analysis varying proportion of patients with primary OCR requiring revision surgery for hearing outcomes. Pathways cross at 59% with poor hearing outcomes.
Surgery
Hybrid
Imaging
Residual disease
No disease +OCR
Residual disease +OCR
No disease +OCR
MRI 1
HL or complication
Revision Surgery
MRI surveillance
MRI-‐ repeat MRI
Revision Surgery
MRI+ Revision Surgery
Initial Su
rgery (with
or w
ithou
t OCR
)Cost, dollars
Effectiveness, rate of cholesteatoma eradication
CholesteatomaSecond-look Disease freeSurgical complicationsRevised, disease free
Surgical Markov Probability Analysis
Stage
Probability
Methods and Materials
