Comparative analysis of cost of endoscopic endonasal minimally invasive and sublabial-transseptal approaches to the pituitary.код для вставкиСкачать
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: firstname.lastname@example.org 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. References 1. 2. 3. 4. 5. 6. 7. Badie B, Nguyen P, Preston JK. Endoscopic-guided direct endonasal approach for pituitary surgery. Surg Neurol. 2000;53:168–172; discussion 172–163. Baird A, Sullivan T, Zafar S, Rock J. Quality of life in patients with pituitary tumors: a preliminary study. Qual Manag Health Care. 2003;12:97–105. Liu JK, Das K, Weiss MH, Laws ER Jr, Couldwell WT. The history and evolution of transsphenoidal surgery. J Neurosurg. 2001;95:1083–1096. Lanzino G, Laws ER Jr. Pioneers in the development of transsphenoidal surgery: Theodor Kocher, Oskar Hirsch, and Norman Dott. J Neurosurg. 2001;95:1097–1103. Landolt AM. History of pituitary surgery from the technical aspect. Neurosurg Clin N Am. 2001;12:37– 44, vii-viii. Cushing H. The Weir Mitchell Lecture. Surgical experiences with pituitary disorders. JAMA. 1914;63:1515–1525. Jankowski R, Auque J, Simon C, Marchal JC, Hepner H, Wayoff M. Endoscopic pituitary tumor surgery. Laryngoscope. 1992;102:198–202. 8. 9. 10. 11. 12. 13. Jho HD, Carrau RL, Ko Y, Daly MA. Endoscopic pituitary surgery: an early experience. Surg Neurol. 1997;47:213–222; discussion 222–213. Sheehan MT, Atkinson JL, Kasperbauer JL, Erickson BJ, Nippoldt TB. Preliminary comparison of the endoscopic transnasal vs the sublabial transseptal approach for clinically nonfunctioning pituitary macroadenomas. Mayo Clin Proc. 1999;74:661–670. Ouaknine GER, Siomin V, Veshchev I, Razon N, Salame K, Stern N. The one-nostril transnasal transsphenoidal extramucosal approach: the analysis of surgical technique and complications in 529 consecutive cases. Oper Tech Otolaryngol Head Neck Surg. 2000;11:261–267. Sonnenburg RE, White D, Ewend MG, Senior B. The learning curve in minimally invasive pituitary surgery. Am J Rhinol. 2004;18:259–263. Ogawa T, Matsumoto K, Nakashima T, et al. Hypophysis surgery with or without endoscopy. Auris Nasus Larynx. 2001;28:143–149. Jarrahy R, Berci G, Shahinian HK. Assessment of the efficacy of endoscopy in pituitary adenoma resection. 14. 15. 16. 17. 18. 19. Arch Otolaryngol Head Neck Surg. 2000;126:1487– 1490. Nasseri SS, McCaffrey TV, Kasperbauer JL, Atkinson JL. A combined, minimally invasive transnasal approach to the sella turcica. Am J Rhinol. 1998;12:409– 416. Dew LA, Haller JR, Major S. Transnasal transsphenoidal hypophysectomy: choice of approach for the otolaryngologist. Otolaryngol Head Neck Surg. 1999;120:824–827. Dong H, Coyle D, Buxton M. Value of information analysis for a new technology: computer-assisted total knee replacement. Int J Technol Assess Health Care. 2007;23:337–342. Claxton K, Cohen JT, Neumann PJ. When is evidence sufficient? Health Aff (Millwood). 2005;24:93– 101. Steinbrook R. Health care and the American Recovery and Reinvestment Act. N Engl J Med. 2009;360:1057–1060. Ebert C, Senior B. A review of minimally invasive pituitary surgery: the evolution from maximally to International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011 248 Cost analysis of approaches to the pituitary minimally invasive surgery. Otorinolaringol. 2009;59: 97–105. 20. Senior BA, Ebert CS, Bednarski KK, et al. Minimally invasive pituitary surgery. Laryngoscope. 2008;118:1842–1855. 21. Kassam AB, Gardner PA, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM. Expanded endonasal approach, a fully endoscopic transnasal approach for the resection of midline suprasellar craniopharyngiomas: a new classification based on the infundibulum. J Neurosurg. 2008;108:715–728. 22. Snyderman C, Carrau R, Kassam A. Who is the skull base surgeon of the future? Skull Base. 2007;17:353– 355. 23. Snyderman CH, Carrau RL, Kassam AB, et al. Endoscopic skull base surgery: principles of endonasal oncological surgery. J Surg Oncol. 2008;97:658–664. 24. Snyderman CH, Pant H, Carrau RL, Prevedello D, Gardner P, Kassam AB. What are the limits of en- 249 25. 26. 27. 28. 29. doscopic sinus surgery?: the expanded endonasal approach to the skull base. Keio J Med. 2009;58:152– 160. Morita A, Shin M, Sekhar LN, Kirino T. Endoscopic microneurosurgery: usefulness and cost-effectiveness in the consecutive experience of 210 patients. Neurosurgery. 2006;58:315–321. Red Book 2008: pharmacy’s fundamental reference. Montvale, NJ: Thomson Healthcare; 2008. U.S. Department of Labor, Bureau of Labor Statistics. www.bls.gov. Accessed May 1, 2009. Welton JM, Zone-Smith L, Fischer MH. Adjustment of inpatient care reimbursement for nursing intensity. Policy Polit Nurs Pract. 2006;7:270– 280. White DR, Sonnenburg RE, Ewend MG, Senior BA. Safety of minimally invasive pituitary surgery (MIPS) compared with a traditional approach. Laryngoscope. 2004;114:1945–1948. International Forum of Allergy & Rhinology, Vol. 1, No. 4, July/August 2011 30. Tabaee A, Anand VK, Barrón Y, et al. Endoscopic pituitary surgery: systematic review and meta-analysis. J Neurosurg. 2009;111:545– 554. 31. Graham SM, Iseli TA, Karnell LH, Clinger JD, Hitchon PW, Greenlee JD. Endoscopic approach for pituitary surgery improves rhinologic outcomes. Ann Otol Rhinol Laryngol. 2009;118:630– 635. 32. Karabatsou K, O’Kelly C, Ganna A, Dehdashti AR, Gentili F. Outcomes and quality of life assessment in patients undergoing endoscopic surgery for pituitary adenomas. Br J Neurosurg. 2008;22:630– 635. 33. Suberman TA, Zanation AM, Ewend MG, Senior BA, Ebert CS Jr. Sinonasal quality-of-life before and after endoscopic endonasal minimally invasive pituitary surgery. Int Forum Allergy Rhinol. (in press).