September 2019 HSC Section 1 Congenital and Pediatric Problems

Am J Otolaryngol 39 (2018) 418–422

L.K. House et al.

A3. Tree 3

Fig. A3. Tree 3.

Table B Assumptions. 100% prevalence of CRS in treated patients

Table E Sensitivity analysis.

Baseline value used

Range of values Threshold value to change ICER

All patients have equal response rates (i.e. does not account for polyposis, immunode fi ciency, decrease mucociliary clearance, previous surgery) All patients are treated to resolution or maximum therapy All BCD procedures are able to be successfully completed No dropouts or withholding surgery No change in medical therapy costs, regardless of procedure performed All patients have already been treated conservatively with antibiotics and allergy treatment, if relevant.

Cost of adenoidectomy

$1954

$0 – $5954 ( ± $4000)

$4412 for tree 1 $4541 for tree 2 $3671 for tree 3 $2381 for tree 1 Not feasible for tree 2 $1720 for tree 3 0.09 for tree 1 0.02 for tree 2 0.19 for tree 3 $9092 for tree 1 $9572 for tree 2 $3809 for tree 3 Not feasible

Cost of BCD

$4836

$836 – $8836 ( ± $4000)

E ffi cacy of adenoidectomy 0.55

0.1 – 0.99

Table C Average costs for services in the analysis. Professional fee

E ffi cacy of BCD

0.82

0.1 – 0.99

Addition of CT scan after failed initial procedure

$0

$0 – 10,000

Hospital fee

Total

Adenoidectomy

$214 $386 $615 $258

$1743 $5449 $4700 $4578

$1957 $5835 $5315 $4836

Adenoidectomy and BCD

FESS BCD

The study does not account for comorbid conditions or the pre- valence of disease. There is a large body of research that attempts to predict responders and nonresponders to these surgical therapies. Comorbid diseases such as asthma and allergy can decrease the success rates of these procedures, whereas a patient with obvious adenoiditis may be more likely to respond [ 21 ]. The presence or absence of poly- posis or anatomic abnormalities like concha bullosa or Haller cells was also not addressed. Another limitation is that it does not account for the cost or variable timing of CT imaging. In most situations, the physician would not order imaging of the sinuses prior to performing adenoidectomy for CRS but would instead order this only if adenoidectomy fails or if they were planning to perform BCD at the same time. This would only increase the cost of adenoidectomy with up-front BCD. Another limitation in the study relates to the success rates used listed in Table A . Balloon catheter dilation with simultaneous adenoi- dectomy was assumed to be at least as successful as balloon catheter dilation. To our knowledge, there is no published literature reporting success rates or outcomes for balloon catheter dilation with adenoi- dectomy. For these reasons, assumptions were made to estimate the success rate. In our study we had to select treatment algorithms for pediatric chronic rhinosinusitis in patients who have failed medical management in order to evaluate whether the upfront use of balloon catheter dilation

Table D Costs and e ff ectiveness.

Tree 1

Tree 2

Tree 3

well. There are many limitations of this study, as there are with any cost e ff ective analysis. The main limitation is that we have to make many assumptions in our study. We also have to choose treatment algorithms for our decision trees, which do not account for the individualized treatment needs of many patients. Our study assumes that a limited FESS is providing an adequate surgical procedure for patients, however, some patients need more than a limited FESS to provide cure. Also, there are inevitably some patients in which adenoidectomy would not be considered as a fi rst step to treatment. Examples of these types of patients may be the older pediatric patients, such as teenagers and patients with cystic fi brosis. $4349, 95% $4133, 92% $4100, 92% Adenoid +BCD (cost, e ff ectiveness) $6792, 98% $6705, 97% $5835, 82% Cost di ff erence $2443 $2572 $1702 E ff ectiveness di ff erence 3% 5% − 10% ICER 81, 431 51, 445 − 17, 189 Adenoid arm (cost, e ff ectiveness)

131