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Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea

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Abstract

Purpose

We performed an economic evaluation using a decision-tree model to analyze the relative cost effectiveness from the United States Centers for Medicare and Medicaid Services (CMS) perspective of two different methods of tonsillectomy (traditional total tonsillectomy and partial intracapsular) for pediatric obstructive sleep apnea (OSA).

Materials and Methods

Procedural costs were drawn from published literature and Medicare values. Effectiveness and probabilities were drawn from medical literature. Primary intervention was monopolar-technique total tonsillectomy or microdebrider-assisted partial intracapsular tonsillectomy. Secondary interventions included operative control of hemorrhage, treatment of severe dehydration, or revision tonsillectomy. The decision model starts with pediatric patients with OSA, choosing between total and partial tonsillectomy. Outcomes were measured by costs (US dollars), effectiveness [quality-adjusted life year (QALY)], and a willingness-to-pay threshold of US$100,000/QALY. Base case analysis, probabilistic sensitivity analysis (PSA) and deterministic sensitivity analyses were performed. Primary outcome was incremental cost-effectiveness ratio (ICER) for each of the two tonsillectomy techniques.

Results

Base case analysis demonstrated that total tonsillectomy was more cost effective at US$12,453.40 per QALY gained. In PSA, 82.84% of the simulations show total tonsillectomy to be the more cost-effective strategy. Deterministic sensitivity analyses showed that when the rate of OSA recurrence is lower than 3.12%, partial tonsillectomy would be more cost effective. When the failure rate of partial tonsillectomy is below 1.0%, it is more cost effective even when total tonsillectomy is 100% successful.

Conclusion

Study results suggest that overall monopolar-technique total tonsillectomy is more cost effective. However, with varying adjustments for disutility caused by procedural complications, intracapsular tonsillectomy could become a more cost-effective technique for treating pediatric OSA.

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References

  1. Bin-Hasan S, Katz S, Nugent Z, Nehme J, Lu Z, Khayat A, et al. Prevalence of obstructive sleep apnea among obese toddlers and preschool children. Sleep Breath. 2018;22(2):511–15. https://doi.org/10.1007/s11325-017-1576-4.

    Article  PubMed  Google Scholar 

  2. Bower CM, Gungor A. Pediatric obstructive sleep apnea syndrome. Otolaryngol Clin North Am. 2000;33(1):49–75.

    Article  PubMed  CAS  Google Scholar 

  3. Verhulst SL, Van Gaal L, De Backer W, Desager K. The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev. 2008;12(5):339–46.

    Article  PubMed  Google Scholar 

  4. Tarasiuk A, Reuveni H. The economic impact of obstructive sleep apnea. Curr Opin Pulm Med. 2013;19(6):639–44.

    Article  PubMed  Google Scholar 

  5. Koltai PJ, Solares CA, Mascha EJ, Xu M. Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope. 2002;112(8 Pt 2 Suppl 100):17–9.

  6. Solares CA, Koempel JA, Hirose K, Abelson TI, Reilly JS, Cook SP, et al. Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. Int J Pediatr Otorhinolaryngol. 2005;69(1):21–6.

    Article  PubMed  Google Scholar 

  7. Stucken EZ, Grunstein E, Haddad J Jr, Modi VK, Waldman EH, Ward RF, et al. Factors contributing to cost in partial versus total tonsillectomy. Laryngoscope. 2013;123(11):2868–72.

    Article  PubMed  Google Scholar 

  8. Gan K, Tomlinson C, El-Hakim H. Post-operative bleeding is less after partial intracapsular tonsillectomy than bipolar total procedure. Int J Pediatr Otorhinolaryngol. 2009;73(5):667–70.

    Article  PubMed  Google Scholar 

  9. Schmidt R, Herzog A, Cook S, O’Reilly R, Deutsch E, Reilly J. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg. 2007;133(9):925–8.

    Article  PubMed  Google Scholar 

  10. Sobol SE, Wetmore RF, Marsh RR, Stow J, Jacobs IN. Postoperative recovery after microdebrider intracapsular or monopolar electrocautery tonsillectomy: a prospective, randomized, single-blinded study. Archives of Otolaryngology –. Head Neck Surg. 2006;132(3):270–4.

    Google Scholar 

  11. Derkay CS, Darrow DH, Welch C, Sinacori JT. Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: microdebrider vs electrocautery. Otolaryngol Head Neck Surg. 2006;134(1):114–20.

    Article  PubMed  Google Scholar 

  12. Sorin A, Bent JP, April MM, Ward RF. Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope. 2004;114(2):297–300.

    Article  PubMed  Google Scholar 

  13. Wennberg J. Gittelsohn. Small area variations in health care delivery. Science. 1973;182(4117):1102–8.

    Article  PubMed  CAS  Google Scholar 

  14. Petitti DB. Meta-analysis, decision analysis, and cost-effectiveness analysis: methods for quantitative synthesis in medicine: methods for quantitative synthesis in Medicine. New York: Oxford University Press; 1999.

    Google Scholar 

  15. Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for reporting cost-effectiveness analyses. Panel on cost-effectiveness in health and medicine. JAMA. 1996;276(16):1339–41.

    Article  PubMed  CAS  Google Scholar 

  16. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA. 1996;276(15):1253–8.

    Article  PubMed  CAS  Google Scholar 

  17. Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316(10):1093–103.

    Article  PubMed  Google Scholar 

  18. WHO guide to cost-effectiveness analysis. Making choices in health. 2003. http://www.who.int/choice/publications/p_2003_generalised_cea.pdf. Accessed 15 Nov 2017.

  19. Colen TY, Seidman C, Weedon J, Goldstein NA. Effect of intracapsular tonsillectomy on quality of life for children with obstructive sleep-disordered breathing. Arch Otolaryngol Head Neck Surg. 2008;134(2):124–7.

    Article  PubMed  Google Scholar 

  20. Tunkel DE, Hotchkiss KS, Carson KA, Sterni LM. Efficacy of powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope. 2008;118(7):1295–302.

    Article  PubMed  Google Scholar 

  21. Ericsson E, Graf J, Lundeborg-Hammarstrom I, Hultcrantz E. Tonsillotomy versus tonsillectomy on young children: 2 year post surgery follow-up. J Otolaryngol Head Neck Surg. 2014;43(1):26.

    Article  PubMed  Google Scholar 

  22. Goldstein NA, Stewart MG, Witsell DL, Hannley MT, Weaver EM, Yueh B, et al. Quality of life after tonsillectomy in children with recurrent tonsillitis. Otolaryngol Head Neck Surgery. 2008;138(1 Suppl):S9–16.

    Article  Google Scholar 

  23. Franco RA, Rosenfeld RM, Rao M. Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg. 2000;123(1):9–16.

    Article  PubMed  Google Scholar 

  24. Gold MR, Franks P, McCoy KI, Fryback DG. Toward consistency in cost-utility analyses: using national measures to create condition-specific values. Med Care. 1998;36(6):778–92.

    Article  PubMed  CAS  Google Scholar 

  25. Tengs TO, Wallace A. One thousand health-related quality-of-life estimates. Med Care. 2000;38(6):583–637.

    Article  PubMed  CAS  Google Scholar 

  26. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R, Burns JJ, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 suppl):S1–30.

    Article  PubMed  Google Scholar 

  27. Cooper JD, Smith KJ, Ritchey AK. A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children. Pediatr Blood Cancer. 2010;55(6):1153–9.

    Article  PubMed  Google Scholar 

  28. Chang JJ, Buchanan P, Geremakis C, Sheikh K, Mitchell RB. Cost analysis of tonsillectomy in children using medicaid data. J Pediatr. 2014;164(6):1346.e1–1351.e1.

    Article  Google Scholar 

  29. Hultcrantz E, Linder A, Markstrom A. Long-term effects of intracapsular partial tonsillectomy (tonsillotomy) compared with full tonsillectomy. Int J Pediatr Otorhinolaryngol. 2005;69(4):463–9.

    Article  PubMed  Google Scholar 

  30. Ishman SL, Yang CJ, Cohen AP, Benke JR, Meinzen-Derr JK, Anderson RM, et al. Is the OSA-18 predictive of obstructive sleep apnea: Comparison to polysomnography. Laryngoscope. 2015;125(6):1491–5. https://doi.org/10.1002/lary.25098.

    Article  PubMed  Google Scholar 

  31. Kang KT, Weng WC, Lee CH, Lee PL, Hsu WC. Discrepancy between objective and subjective outcomes after adenotonsillectomy in children with obstructive sleep apnea syndrome. Otolaryngol–Head Neck Surg. 2014;151(1):150–8.

    Article  PubMed  Google Scholar 

  32. Wang H, Fu Y, Feng Y, Guan J, Yin S. Tonsillectomy versus tonsillotomy for sleep-disordered breathing in children: a meta analysis. PLoS One. 2015;10(3):e0121500.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  33. Doshi HK, Rosow DE, Ward RF, April MM. Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy. Int J Pediatr Otorhinolaryngol. 2011;75(11):1395–8.

    Article  PubMed  Google Scholar 

  34. Wood JM, Cho M, Carney AS. Role of subtotal tonsillectomy (‘tonsillotomy’) in children with sleep disordered breathing. J Laryngol Otol. 2014;128(SupplementS1):S3–7.

    Article  PubMed  Google Scholar 

  35. Zagolski O. Why do palatine tonsils grow back after partial tonsillectomy in children? Eur Arch Otorhinolaryngol. 2010;267(10):1613–7.

    Article  PubMed  Google Scholar 

  36. Weinstein MC, O’Brien B, Hornberger J, Jackson J, Johannesson M, McCabe C, et al. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices-Modeling Studies. Value Health. 2003;6(1):9–17.

    Article  PubMed  Google Scholar 

  37. Shott SR. Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6):449–54.

    Article  PubMed  Google Scholar 

  38. Gallagher TQ, Wilcox L, McGuire E, Derkay C. Analyzing factors associated with major complications after adenotonsillectomy in 4776 patients: comparing three tonsillectomy techniques. Otolaryngol Head Neck Surg. 2010;142(6):886–92. https://doi.org/10.1016/j.otohns.2010.02.019.

    Article  PubMed  Google Scholar 

  39. Walton J, Ebner Y, Stewart MG, April MM. Systematic review of randomized controlled trials comparing intracapsular tonsillectomy with total tonsillectomy in a pediatric population. Arch Otolaryngol Head Neck Surg. 2012;138(3):243–9. https://doi.org/10.1001/archoto.2012.16.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery–Otolaryngology, Yale School of Medicine, New Haven, USA

    Kenneth Bagwell

  2. Department of Diagnostic Radiology, Yale School of Medicine, New Haven, USA

    Xiao Wu

  3. Connecticut Pediatric Otolaryngology, LLC, Shelton, USA

    Eric D. Baum

  4. Department of Diagnostic Radiology, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA

    Ajay Malhotra

Authors
  1. Kenneth Bagwell
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  2. Xiao Wu
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  3. Eric D. Baum
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  4. Ajay Malhotra
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Contributions

AM: Study concept and design, acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content, study supervision. XW: Acquisition of data, analysis and interpretation, critical revision of the manuscript for important intellectual content. KB: Acquisition of data, critical revision of the manuscript for important intellectual content. EB: critical revision of the manuscript for important intellectual content, study supervision.

Corresponding author

Correspondence to Ajay Malhotra.

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Bagwell, K., Wu, X., Baum, E.D. et al. Cost-Effectiveness Analysis of Intracapsular Tonsillectomy and Total Tonsillectomy for Pediatric Obstructive Sleep Apnea. Appl Health Econ Health Policy 16, 527–535 (2018). https://doi.org/10.1007/s40258-018-0396-4

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  • DOI: https://doi.org/10.1007/s40258-018-0396-4

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