The value of frontal sinusotomy for chronic rhinosinusitis with nasal polyps—A cost utility analysis

Abstract

Objectives/Hypothesis: The number of surgical procedures performed for frontal sinusitis and the associated costs have increased dramatically over the past decade. The purpose of this study was to evaluate the cost-effectiveness of endoscopic frontal sinusotomy (EFS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP).Study Design: Cohort-style Markov decision-tree economic model with a 36-year time horizon. Methods: Matched cohorts of CRSwNP patients who underwent endoscopic sinus surgery (ESS) with (n 5 139) and without (n 5 49) EFS were compared to each other and to patients (n 5 139) from the Medical Expenditures Survey Panel database who underwent medical management for chronic rhinosinusitis. Multi-year health utility values were calculated from responses to the EuroQol 5-Dimension instrument. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).Results: Decision analysis showed that ESS without EFS proved more cost-effective than ESS with EFS or medical management. ESS without EFS compared to medical management yielded an ICER of $9,004/quality-adjusted life year (QALY). ESS with EFS compared to ESS without EFS yielded an ICER of $62,310/QALY. At a willingness-to-pay (WTP) threshold of $50,000/QALY, ESS without EFS was more cost-effective than ESS with EFS with 52.1% certainty. These results were robust to one-way analysis and probabilistic sensitivity analysis.Conclusions: ESS remains a cost-effective intervention compared to medical therapy alone for patients with CRSwNP. In this study, the addition of frontal sinusotomy during ESS for patients with CRSwNP was not found to be cost-effective at a WTP threshold of $50,000/QALY, but may be cost effective at a higher threshold of $100,000/QALY.

Cost and operative time estimation itemized by component procedures of endoscopic sinus surgery

“…Studies have commonly referenced a value of “cost” for ESS as a charge of roughly $8600 (2016 USD) 2,14,17 . These estimates of charges have also been used repeatedly in mathematical models to report on cost‐effectiveness of ESS 3‐5 . Unfortunately, these charge data do not assist health‐care providers in reducing cost and improving value, as they have limited relationship to actual cost.…”

“…Earlier work has generally described the cost of ESS as a single procedure, although ESS is actually a variable combination of discrete component procedures 2‐5 . Despite this precedent in the existing literature, this description is inadequate for meaningful calculations of cost and value, analogous to investing costs of all “open neck surgery.” Characterized by only anatomic site and endoscopic approach, significant variation in time, cost, and outcomes is anticipated.…”

Operative time and cost variability for functional endoscopic sinus surgery

“…Based on the range of published ESS charges, 6 an average charge of $8,968 2014 USD has been used in modeling studies to determine cost-effectiveness of ESS. 10,21,22 Additional studies have used an estimated average charge of $8,612 2016 USD and $8,634 2016 USD. 12,23,24 These specific estimates, and others in the literature, are based on charges billed to health plans (from MarketScan Commercial Claims and Encounters Database).…”

“…10,21,22,24 This has impacted subsequent studies utilizing inadequate published data, as illustrated by a study on the cost-effectiveness of ESS with or without frontal sinus surgery which uses an identical average charge ($8,968 2014 USD) for surgery in both groups, likely due to lack of available cost data specific to the two groups. 21 The true costs for three different common combinations of ESS reported in the present study may be useful in future cost-effectiveness models. The significant variation in cost associated with the extent of surgery additionally highlights the importance of considering extent of surgery when assessing the value of ESS.…”

Systematic literature review of humanistic and economic burdens of chronic rhinosinusitis with nasal polyposis

“…Cost-effectiveness evaluations were reported in six studies (see study characteristics in Supplementary Table 19) [114][115][116][117][118][119] . Five of these studies were US-based [114][115][116][117]119 and one was Canadian 118 . Four US studies [114][115][116][117] reported treatments that were considered cost-effective at a willingness-to-pay (WTP) threshold of $50,000 (USD) per quality-adjusted life-year (QALY).…”