HSC Section 8_April 2017

TABLE II. Charges for Individual Components of Care.

Mean (CI 95%), in $USD

Charges

Direct Cost

Total Cost

737. (612.–861.)

Consultation visit

158. (127.–189.5)

270. (222.5–318.0) 4,598. (4,672.–4,925.)

16,032. (14,707.–17,357.)

Surgical procedure

3,196. (2.899.–3,494.)

244. (175.–313.)

Postoperative visit

38. (27.–49.)

77. (54.–99.)

2,231. (1,987.–2,475.)

CT temporal bone

194. (151.–238.) 153. (140.–165.)

375. (319.–432.) 282. (259.–305.)

833. (743.–923.)

Audiology visit

Each dollar figure rounded to nearest whole dollar. CI 5 confidence interval; CT 5 computed tomography; USD 5 U.S. dollar.

preserve or improve hearing. 16 Cholesteatoma removal can be a tedious undertaking, and there is a risk of recurrence or residual cholesteatoma left behind, despite best efforts. A second-look operative strategy after CWU tympanoplasty with mastoidectomy has been historically used to evaluate for recurrent or resid- ual disease, as well as opportunity to perform OCR. However, there are significant differences in opinion among otologists regarding the optimal surgical strat- egy. 15 Compared to previously published studies of CWU and CWD approaches for cholesteatoma and recurrence incidence at second-look, our recurrence rate after CWU. 7–10 In our study, we found that choles- teatoma recurrence rate after primary CWU tympanoplasty-mastoidectomy in all patients is low at 2.5%, and 4.4% in the subgroup of patients who under- went a second-look strategy. In patients with no second look planned, 7.5% of patients required an unantici- pated second-look procedure and recurrence was found in all, and none had residual. The patients who we included in our study had no prior otologic surgery. The majority of surgical procedures were performed by fellowship-trained neurotologists and were first attempts at surgical management. The follow-up inter-

val was over 2.5 years for our single-stage cohort and over 3.5 years for our second-look patients. Considering the low recurrence rate, automatic second-look procedures are not always necessary. In approximately half of our CWU patients, the decision not perform a second look was made due to high cer- tainty that all cholesteatoma was removed at the origi- nal surgery. A small group of these CWU patients developed a recurrence, but none had evidence of resid- ual cholesteatoma. We believe our follow-up time was sufficient to allow for recurrence or residual disease to declare itself. The other half of our patients had a planned second look because the surgeon deemed there was a high likelihood of incomplete resection at the orig- inal surgery. We found a high residual cholesteatoma rate in these patients. This indicates that performing a second-look is justified when the surgeon is not sure that all of the cholesteatoma was removed at the pri- mary procedure. We were not surprised that charges for the tympa- noplasty with mastoidectomy procedure were the most expensive component of care. In general, operative pro- cedures are among the more costly healthcare interven- tions owing to the substantial amount of human

TABLE III. Cost of Care for Patients in Second-Look and No Second-Look Strategy Cohorts.

No Second Look

Second Look

P Value*

Follow-up in days

916.0 (577.6–1254.5)

1312.6 (1018.4–1606.8)

0.08

Consultation clinic visits

1

1

–

Surgical procedures

1

2

–

0.0007

Postoperative visits

6.32 (4.58–8.06)

10.4 (8.92–11.9)

CT temporal bone, N

0.88 (0.56–1.2)

1 (0.73–1.27)

0.58

Audiology clinic visits

4.90(4.21–5.59)

3.88 (3.03–4.74)

0.07

< .0001

$ 23,529 . (22,512.–24,547.)

$41,411. (40,590.–42,231.)

Cost of care

Each dollar figure rounded to nearest whole dollar. *One-way ANOVA. Two-tailed ANOVA 5 analysis of variance; CT 5 computed tomography.

Crowson et al.: Second-Look Tympanoplasty-Mastoidectomy

102