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Comparative analysis of cost of endoscopic endonasal minimally invasive and sublabial-transseptal approaches to the pituitary.

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ORIGINAL ARTICLE
Comparative analysis of cost of endoscopic endonasal minimally invasive
and sublabial-transseptal approaches to the pituitary
Nadine Oosmanally, MSPH1 , John E. Paul, PhD1 , Adam M. Zanation, MD2 , Matthew G. Ewend, MD3 ,
Brent A. Senior, MD2 , Charles S. Ebert Jr, MD, MPH2
Background: Two surgical approaches to the pituitary are
commonly used: the sublabial-transseptal (SLTS) approach
using microscopy and the endonasal endoscopic minimally
invasive (MIPS) approach. Although outcomes are similar
for both procedures, MIPS has become increasingly prevalent over the last 15 years. Limited cost analysis data comparing the 2 alternatives are available.
Methods: A retrospective analysis of cost and volume data
was performed using data from the published literature and
University of North Carolina at Chapel Hill (UNC) Hospitals. A sensitivity analysis of the parameters was used to
evaluate the uncertainty in parameter estimates.
Results: The total cost in real dollars ranges from $11,438
to $12,513 and $18,095 to $21,005 per patient per procedure for MIPS and SLTS, respectively, with a cost difference
ranging between $5582 and $9567 per patient per procedure. The sensitivity analysis indicates that the total cost
for MIPS is most sensitive to: (1) average length of stay,
(2) nursing costs, and (3) number of total complications,
P
ituitary tumors account for approximately 15% of all
brain tumors and are the third most common type of tumor treated in neurological practice.1,2 Surgical approaches
to the pituitary have evolved over the last 100 years as technological advances have been made.
1
Departments of Health Policy and Management, Gillings School of
Global Public Health, University of North Carolina–Chapel Hill, Chapel
Hill, NC; 2 Otolaryngology–Head and Neck Surgery, Division of
Rhinology, Allergy and Sinus Surgery, University of North
Carolina–Chapel Hill, Chapel Hill, NC; 3 Neurosurgery, University of
North Carolina–Chapel Hill, Chapel Hill, NC
Correspondence to: Charles S. Ebert, Jr., University of North
Carolina–Chapel Hill, Department of Otolaryngology–Head and Neck
Surgery, CB #7070, Chapel Hill, NC 27599–7070; e-mail:
cebert@med.unc.edu
Potential conflict of interest: None provided.
Received: 9 September 2010; Revised: 9 December 2010; Accepted: 4
January 2011
DOI: 10.1002/alr.20048
View this article online at wileyonlinelibrary.com.
whereas the total cost for SLTS is most sensitive to: (1) average length of stay, (2) nursing cost, and (3) operating time.
MIPS is less costly than SLTS between 94% and 98% of the
time.
Conclusion: The results indicate that MIPS is less costly
than SLTS at a large academic center. Future research
should compare the outcomes and quality of life (QoL)
associated with the 2 surgeries to improve the data used
to determine the cost-effectiveness of MIPS compared to
C 2011 ARS-AAOA, LLC.
SLTS. Key Words:
cost analysis; minimally invasive pituitary surgery; MIPS;
pituitary; sublabial-transseptal; SLTS
How to Cite this Article:
Oosmanally N, Paul JE, Zanation AM, Ewend MG,
Senior BA, Ebert CS Jr. Comparative analysis of cost of
endoscopic endonasal minimally invasive and sublabialtransseptal approaches to the pituitary. Int Forum Allergy
Rhinol, 2011; 1:242–249
Sir Victor Horsley performed the first successful removal
of a pituitary tumor in 1889 via a transcranial approach.3–5
The early transcranial approaches were burdened by mortality rates ranging from 20% to 80%.3 This high mortality
rate provided the motivation for development of extracranial (transnasal) approaches to the sella. In 1909, Theodore
Kocher performed the first transnasal hypophysectomy by
resecting the septum via a midline incision over the nasal
dorsum, without violating the frontal, ethmoid, or maxillary sinuses.3 After further modifying these techniques,
Harvey Cushing used the sublabial-transseptal (SLTS) approach to decrease mortality rates to 5.6%.6 The SLTS
approach further evolved with the introduction of the operating microscope, microscopic operating techniques, and
intraoperative fluoroscopy.
In the late 1980s, the endoscope was introduced for
the management of sinonasal inflammatory disorders and
was championed by Wigand, Messerklinger, Stammberger,
Kennedy, and others. With the techniques utilized in the
management of inflammatory sphenoid sinus disease, the
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
242
Cost analysis of approaches to the pituitary
endoscope was rapidly incorporated for transsphenoidal
approaches to the pituitary gland. Jankowski et al.7 first
reported successful endoscopic transsphenoidal pituitary
surgery in 3 patients in 1992. In 1997, Jho et al.8 reported a series of 46 patients describing the safety, efficacy, and advantages of the endoscopic transsphenoidal
approach. This marked the beginning of the modern era of
endoscopic endonasal minimally invasive pituitary surgery
(MIPS).
The SLTS approach typically utilizes a microscope, which
results in a conical view of the operative field and a limited line of sight.9–11 In contrast, the endonasal endoscopic
approach confers a view that is in closer proximity to the
operative field, has the ability to achieve multiple angulations of vision, and has been shown to result in fewer
complications.9–15
The decision to adopt or reimburse a health technology is increasingly dependent on cost-effectiveness analysis (CEA). The CEA compares the costs of health outcomes associated with comparable interventions in order
to facilitate decisions on which intervention is the preferred
choice based on society’s willingness to pay.16 For example, the British National Institute for Clinical Excellence
(NICE) provides guidance on whether to adopt or reimburse health technologies. As part of their guidance, all
relevant comparators are included in the analyses and all
evidence is assembled systematically in a manner that can
be reproduced.17
As health care costs have continued to rise in the United
States, there has been increased emphasis on evaluating
the effectiveness of health care alternatives. The emerging value in comparative effectiveness research is demonstrated by the American Recovery and Reinvestment Act
of 2009, which allocates $1.1 billion in funding for comparative effectiveness research.18 Overall, a cost-analysis
comparing the 2 surgeries is valuable. When cost data is
interpreted in light of quality of life (QoL) before and
after pituitary surgery, decision-makers, such as hospitals and payers, can implement policies for a preferred
alternative.
To date there have been no cost comparison analyses of these commonly used approaches to the pituitary. Despite similar surgical outcomes, there has been
an increase use of MIPS (endonasal endoscopic) approaches to resect pituitary tumors. Our hypothesis is
that MIPS is a more cost-effective method for surgical
management of pituitary tumors compared to SLTS approaches. Our goal was to test this hypothesis at a single
institution.
Materials and methods
The MIPS (endonasal endoscopic) approach referred to in
this analysis has been described.19,20 In this case, MIPS does
not refer to expanded endonasal approaches as described
by other authors.21–24
243
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
Resources and costs
Cost and volume data for the MIPS and STLS approaches
were obtained from the published literature and the University of North Carolina at Chapel Hill (UNC) Hospitals.
Specifically, probabilities on clinical outcomes and data on
resources, extracted from studies comparing MIPS to SLTS,
were utilized in the analysis. The focus of the analysis was
centered on costs that differed between the 2 types of surgical intervention. Assumptions were made that large pieces
of capital equipment that are routinely used by neurosurgeons and otolaryngologists would not have to be purchased. The real costs (not billed costs) associated with
each type of surgery were determined and aggregated to
determine a total cost per patient for comparison.
Sensitivity analysis
A 1-way deterministic sensitivity analysis of the parameters was used to evaluate the uncertainty in parameter
estimates included in the analysis. The sensitivity analysis
tested the range of each parameter between the minimum
and maximum values. If a range for a model parameter was
unavailable in the literature, a plausible range was determined based on the methods used in other analyses. The
model was developed in Microsoft Excel (Redmond, WA),
and the sensitivity analysis was conducted using Crystal
Ball software (Oracle, Redwood Shores, CA).
Further analysis was performed assessing the expected
difference between the value of the optimal decision based
on perfect information and the value of a decision based on
imperfect information. A Monte Carlo simulation of 1000
trials was run using the parameters included in the model
to determine the expected frequency of savings that results
from the selection of a particular alternative over another.
Estimates of the cost of resources used are provided in
Tables 1, 2, and 3.25,26 If a parameter range was not available, the ranges were estimated using methods from the
literature or based on physician interviews (C.S.E., B.A.S.,
M.G.E., A.M.Z.). Costs are presented in 2008 U.S. dollars,
adjusting for inflation when necessary.27 Only resources
that differed between the 2 surgeries were included in the
analysis, in order to show the overall difference in costs.
Excluding resources that were the same for both procedures had no effect on the outcomes when comparing the
costliness of the 2 surgeries. The medications administered
during surgery, such as anesthesia, are the same for both
procedures.
The average neurosurgeon and otolaryngologist hours
per patient were estimated using physician interviews and
the peer-reviewed literature. A range of 20% above and
below the mean was used for the range. In addition, the average cost per hour was estimated using the average salaries
for each specialty and an estimate of the average number
of hours per week. The daily nursing hours provided for
each patient were obtained from a study that investigated
the billing for nursing hours and reimbursement for patient
care. The total number of nurse care hours was 11.6 per
Oosmanally et al.
TABLE 1. Estimates of the cost of resources utilized by the SLTS approach to the pituitary
Parameter
Mean
Minimum
Maximum
Source
1
Operating time (minutes)
161
75
275
Badie et al.
Length of stay (days)
5.1
3
14
Badie et al.1
Recovery time: after discharge (days)
21
17
25
Medical records/physician interview
Complications
0.9
0.7
1.1
Senior et al.20
50
40
52
Medical records/physician interview
Neurosurgeon (hours/day)
3
2.4
3.6
Medical records/physician interview
Otolaryngologist (hours/day)
3
2.4
3.6
Medical records/physician interview
Medications
Percocet (number of tablets)
Staffing
Nurses (hours/day)
a
11.9 (5.35)
a
Welton et al.28
Value in parentheses indicates standard deviation when available.
SLTS = sublabial transseptal.
TABLE 2. Estimates of the cost of resources utilized by the endoscopic endonasal (MIPS) approach to the pituitary
Parameter
Mean
Operating time (minutes)
Minimum
Maximum
Source
1
116
90
175
Badie et al.
Length of stay (days)
3
1
9
Suberman et al.33
Recovery time: after discharge (days)
14
11
17
Medical records/physician interview
Complications
0.4
0.3
0.7
Senior et al.20
20
16
24
Medical records/physician interview
Neurosurgeon (hours/day)
2
1.6
2.4
Senior et al.20
Otolaryngologist (hours/day)
2
1.6
2.4
Senior et al.20
Medications
Percocet (number of tablets)
Staff
Nurses (hours/day)
a
11.7 (5.35)a
Welton et al.28
Value in parentheses indicate standard deviation when available.
MIPS = minimally invasive pituitary surgery.
TABLE 3. Estimates of differential costs and resources used in the 2 surgical approaches to the pituitary∗
Parameter
Mean
Minimum
Maximum
Procedure
$4,491
$3,593
$5,389
UNC Hospitals
$630
$470
$694
Morita et al.25
Complication treatments
$5,000
$400
$6,000
Estimation
Percocet (per tablet)
$1.34
$1.07
$1.58
Red Book26
Neurosurgeon (per hour)
$188
$150
$225
Calculated estimate
Otolaryngologist (per hour)
$125
$100
$150
Calculated estimate
Hospital stay per day
Source
Staff
Nurses (per day)
$411 ($235)
a
∗
U.S. dollars (2008).
a
Number in parentheses indicates standard deviation when available.
Welton et al.28
UNC = University of North Carolina.
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
244
Cost analysis of approaches to the pituitary
TABLE 4. Comparison of total costs for the SLTS and the
endoscopic endonasal MIPS approach to the pituitary∗
Procedure
Total costs
Total costs
SLTS
$18,095 (15% variance)
$21,005 (20% variance)
MIPS
$12,513 (10% variance)
$11,438 (20% variance)
Difference
$5,582
$9,567
∗
Results are provided using a variability of 10% and 20% around mean values for
the MIPS approach and 15% and 20% around mean values for the SLTS approach.
MIPS = minimally invasive pituitary surgery; SLTS = sublabial-transseptal approach.
day. The total cost for the hours was $411 with a standard
deviation of $235.28 Charge data on patients who have undergone MIPS were obtained from UNC Health Care and
the procedure cost of $4,491 (Table 3) was estimated as
60% of the mean charge for the MIPS procedure to account for hospital overhead. The range of the costs for the
MIPS procedure was determined as 20% below and above
the value for mean cost (another analysis using 10% above
and below the mean cost was also performed). Since the
2 procedures use the same diagnosis-related group (DRG)
and data was only available on MIPS from UNC, it was
assumed that the mean procedure cost for the 2 surgeries
was the same. A range of 20% above and below the mean
was also used for the SLTS procedure. In addition, an analysis was performed using 15% above and below the mean
cost.
Results
Total costs
The total costs for each procedure were calculated using
the mean quantities and costs associated with the total resources utilized per procedure (Table 3). The total cost for
MIPS is $11,438, and the total cost for SLTS is $21,005.
When using a narrower range of variability (10% above
and below the mean cost for MIPS and 20% for SLTS), the
total cost for SLTS changes to $18,095 while the cost for
MIPS is $12,513. Thus, the cost difference between the 2
procedures is $9,567 and $5,582, respectively, which indicates that MIPS is less expensive than SLTS (Table 4).
Sensitivity analysis
The range of each parameter between the minimum and
maximum values, in Table 1, was tested, and the top 5 results are reported in tornado diagrams (Figs 1 and 2). Bars
at the top of the chart have the greatest effect on the total
cost and those toward the bottom have less effect on the
total cost. The total costs for SLTS is most sensitive to the
average length of stay, nursing cost, operating time, cost of
hospital stay, and neurosurgeon cost (Fig. 3). The MIPS approach costs are most sensitive to the average length of stay,
nursing cost, nursing time, total number of complications,
and the procedure cost (Fig. 4).
The tornado diagrams (Figs. 1 and 2) also indicate that
the variables have a direct effect on the total costs for both
FIGURE 1. Tornado diagram indicating variable sensitivity on the total costs for the SLTS approach to the pituitary. SLTS = sublabial transeptal.
245
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
Oosmanally et al.
FIGURE 2. Tornado diagram indicating the variable sensitivity on the total cost of the endoscopic endonasal (MIPS) approach to the pituitary. MIPS =
minimally invasive pituitary surgery.
FIGURE 3. Results of sensitivity analysis for the total cost of the SLTS approach to the pituitary. SLTS = sublabial transeptal.
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
246
Cost analysis of approaches to the pituitary
FIGURE 4. Results of sensitivity analysis for the cost of the endoscopic endonasal (MIPS) approach to the pituitary. MIPS = minimally invasive pituitary
surgery.
procedures because the positive is to the right of the base
values. The variables that contribute most the overall cost
are average length of stay that contribute to 77% of the
variation in total cost for SLTS, while average length of stay
contributes to 52% of the variation in total cost for MIPS
(Figs 3 and 4). In addition, the expected value of perfect
information using a Monte Carlo simulation indicated that
MIPS is less costly than SLTS 98% of the time. When using
a stricter range on the variables (10% and 15% above and
below mean values), MIPS is less costly 94% of the time.
Discussion
Over the last 30 years, advances in endoscopic surgery
have led to a renaissance of endonasal endoscopic pituitary surgery. As a result of this evolution, the endoscopic
endonasal approach has become more prevalent, with the
presumed goal of improving patient care. In fact, MIPS has
been found to reduce operative time,9–11 decrease intraoperative blood loss,12 provide better images of intrasellar and parasellar structures,14 enhance differentiation
between normal glandular tissue and tumor,13 shorten hospital stays, and produce superior patient satisfaction with
little need for nasal packing.15 Moreover, the MIPS approach alleviates the need for external incisions and alleviates the risks of tooth numbness, deprojection of the
nose, and denture difficulties noted with the sublabial
approach.11,15 In addition, MIPS decreases occurrence of
septal perforations and nasal obstruction seen after the
247
International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011
transnasal transseptal approach.11,15 Major complications
associated with either approach are similar and include
intracranial hemorrhage, death, vision loss, cerebrospinal
leak, and diabetes insipidus, while minor complications include epistaxis, lip anesthesia, and septal deviation.29
These data are the first to compare costs of the commonly used approaches to the pituitary. The results show
that at our institution MIPS is a more cost-effective method
for surgical management of pituitary tumors compared to
SLTS. The sensitivity analysis indicates that the total costs
of the 2 surgeries are significantly influenced by average
length of stay and nursing costs. Reducing the length of
stay and nurse time spent in patient care can help contain
hospital costs because they contribute to so much of the
variation in total cost for both procedures. As technical refinements in MIPS have been made over the last 10 years,
the length of hospital postoperative stay has continued to
decrease to as low as 1.4 days30 and may continue to decrease. Furthermore, the resources utilized during a hospital
stay, including beds and nursing staff, could potentially be
allocated to other areas of need if the MIPS procedure were
used. For example, operating rooms could be freed to be
used for other procedures. Alternatively, a greater volume
of MIPS procedures can be performed because of shorter
operating room time.
From a cost perspective, pituitary surgery (both SLTS and
MIPS approaches) typically entails a multidisciplinary team
approach that involves various medical and surgical subspecialists. Specifically, for both approaches the participation
Oosmanally et al.
of a neurosurgeon and an otolaryngologist is, in general,
necessary. Endonasal endoscopic techniques may require
additional resources and additional training for neurosurgeons, which is not currently a standard part of their surgical training. However, this may not represent an insurmountable hurdle. A retrospective study of the first 45 cases
of MIPS surgery at UNC showed that the MIPS procedure
can be learned quickly with the added benefit of shorter
operative time.11 Furthermore, this study also factored into
account components needed for resident training.11
Because there is limited data demonstrating long-term
health outcomes of MIPS compared to SLTS, the incentive to invest in the technology and additional training
may be limited. However, the reduced need for healthcare
services associated with MIPS, such as nasal packing and
other treatments for minor complications, may provide additional value for using the procedure.2 MIPS can also reduce costs and use of hospital resources, since a shorter
recovery time and length of stay is associated with the procedure.
From a patient perspective, a few studies have shown
MIPS to have minimal impact on patient overall QoL and
improved rhinologic-specific QoL compared to SLTS.31–33
More specifically, with decreased tissue dissection MIPS
results in less postoperative pain medication utilization,
which may be considered analogous with improved QoL
(Tables 1 and 2). Thus, there is less impact on labor productivity and other daily activities due to shorter recovery
time and less severe complications. Most individuals place
a greater value on having a shorter length of stay in the
hospital and a shorter recovery time so that they can return
to the workforce or to meeting family needs.
For these reasons, patients may also be more receptive
to MIPS as this approach is less invasive with a equally
low rates of minor and major complications.19,20,29 Consequently, when considering productivity from a patient or
societal perspective in the short term, MIPS appears to be
the better choice because patients endure less pain and discomfort and noted by requiring less medication, and are
able to recuperate quickly.
Several limitations to this analysis should be noted. The
primary limitation is the decision of which variables to include in the model. The model parameters were based on
available data in the peer-reviewed literature and on information gathered from physician interviews and medical
records. In particular, conclusive information about MIPS
in the literature is limited. The availability of accurate data,
such as data ranges, was another limitation. Necessary parameter estimates were made using information from the
peer-reviewed literature comparing the 2 procedures and
from consultations with surgeons from UNC (see Sensitivity analysis, above). A potential source of bias may be
due to the fact that since 1999, the authors have transitioned to resect pituitary tumors via endonasal endoscopic
approaches (MIPS). As a result, patient volumes and outcomes may differ significantly between UNC and other hospitals, where the procedure is a new option. Furthermore,
the dearth of published information on QoL and costs of
pituitary surgery also make it difficult to make a conclusive
decision on which surgery should be recommended. Additional research on the outcomes and QoL associated with
the 2 surgeries is necessary to determine a more definitive
conclusion on the cost-effectiveness of MIPS compared to
SLTS.
Conclusion
This study marks the first cost analysis comparison of the
SLTS and endoscopic endonasal (MIPS) approaches to the
pituitary. Based on the data from a large academic institution, MIPS is less costly than SLTS. Focus of future research
should examine the outcomes and QoL associated with the
2 surgeries to improve the data used to determine the costeffectiveness of MIPS compared to SLTS.
Acknowledgments
Presented at the American Rhinologic Society Meeting,
September 25, 2010 Boston, MA.
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