1
|
Langlie JA, Pasick LJ, Rosow DE. Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis. Laryngoscope 2023; 133:3436-3442. [PMID: 37278490 DOI: 10.1002/lary.30800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied. METHODS Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI. RESULTS Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%. CONCLUSIONS SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED. LEVEL OF EVIDENCE NA Laryngoscope, 133:3436-3442, 2023.
Collapse
Affiliation(s)
- Jake A Langlie
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Luke J Pasick
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - David E Rosow
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
2
|
O'Dell K, Huang V, Acevedo J, Reder L, Johns M, Ding L. Serial In-Office Steroid Injections for Airway Stenosis: Long-Term Benefit and Cost Analysis. Laryngoscope 2023; 133:2673-2679. [PMID: 36692123 DOI: 10.1002/lary.30578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/20/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate the long-term benefit of serial in-office steroid injections (SISI) in the treatment of subglottic and proximal tracheal stenosis (SG/PTS). Evaluate cost of SISI compared to endoscopic dilation (ED). STUDY DESIGN Retrospective study and cost analysis. METHODS All patients with SGS/PTS with at least two consecutive in-office steroid injections between 2013 and 2021 were evaluated. Patients with less than 2 years of follow-up data after the initial SISI series were excluded. Demographics, etiology of stenosis, total injections performed, time between steroid series, surgery-free interval (SFI) and adverse events were collected. For patients with known surgical history before SISI, pre-SISI SFI was compared. Institutional billing records and the national CMS average reimbursement were evaluated. Total charges for three treatment strategies (ED alone, ED with post-operative SISI and primary intervention with SISI) were also compared. RESULTS Forty-nine patients were included; 29 (59%) idiopathic, 11 (22%) traumatic and 9 (18%) rheumatologic. Mean (SD) follow-up time after the first SISI was 3.41 years (1.5), range (2.08-7.25 years). 79% (39/49) did not require additional surgery during the entire follow-up period. The SFI improved from a mean 13.5 months (SD 12.6; range 2-42 months) pre-SISI to a mean (SD) of 42 months (SD 20.2; range 10-87 months) (p < 0.0001) after SISI. Annual average charges for ED alone in our cohort was $15,383.28, compared to $7,070.04 for SISI. CONCLUSIONS SISI are an effective treatment for patients with SG/PTS. In-office steroid injections could offer cost savings for the patient. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2673-2679, 2023.
Collapse
Affiliation(s)
- Karla O'Dell
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Valerie Huang
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Joseph Acevedo
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lindsay Reder
- Department of Otolaryngology, Head and Neck Surgery, Kaiser Permanente Baldwin Park, Los Angeles, California, USA
| | - Michael Johns
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Li Ding
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
3
|
Moroni L, Giudice L, Lanzillotta M, Cariddi A, Ramirez GA, Bozzolo EP, Germinario B, Gallina G, Viscardi S, Carretta A, Dagna L. Role of systemic immunosuppression on subglottic stenosis in granulomatosis with polyangiitis: Analysis of a single-centre cohort. Eur J Intern Med 2023; 114:108-112. [PMID: 37156712 DOI: 10.1016/j.ejim.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Subglottic stenosis (SGS) is a potentially life-threatening manifestation of granulomatosis with polyangiitis (GPA). Endoscopic dilation is effective, but relapses are frequent and the benefit of systemic immunosuppression in this setting is still controversial. We aimed to investigate the role of immunosuppressive treatment on SGS relapse risk. METHODS This is a retrospective observational study based on review of medical charts among our cohort of patients with GPA. RESULTS Twenty-one patients with SGS-GPA were identified, with a prevalence of 20% among our entire GPA cohort (n = 105). Compared to patients without SGS, patients with SGS-GPA had an earlier disease onset (mean age 30.2 vs. 47.3 years, p<0.001), and lower BVAS (mean 10.5 vs 13.5; p = 0.018). Five patients didn't receive systemic immunosuppression for SGS and they all (100%) relapsed after the first procedure, while among medical treatment group relapse rate was 44% (p = 0.045). When single treatment regimens are considered, rituximab (RTX) and cyclophosphamide (CYC) yielded a protective role towards the need of subsequent dilation procedure after the first if compared with absence of medical treatment. Patients with SGS and generalized disease, who initially received either a RTX- or a CYC-based induction treatment, and higher cumulative doses of glucocorticoids, showed a delayed median time to SGS relapse (36 vs. 12 months, p = 0.024). CONCLUSIONS Subglottic stenosis is highly prevalent in patients with GPA and may define a milder systemic disease subset occurring more frequently in younger patients. Systemic immunosuppression provides benefit in preventing recurrence of SGS in GPA patients and regimens based on cyclophosphamide or rituximab might have a non-redundant role in this setting.
Collapse
Affiliation(s)
- Luca Moroni
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy.
| | - Laura Giudice
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Marco Lanzillotta
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Adriana Cariddi
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Giuseppe A Ramirez
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Enrica P Bozzolo
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Bruno Germinario
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Gabriele Gallina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| | - Stefano Viscardi
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy; Unit of Thoracic Surgery, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Angelo Carretta
- Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy; Unit of Thoracic Surgery, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy; Vita-Salute San Raffaele University, Faculty of Medicine, Via Olgettina 58, 20132 Milan, Italy
| |
Collapse
|
4
|
Krol RM, Remmelts HHF, Klaasen R, Frima A, Hagen EC, Kamalski DMA, Heijstek MW, Spierings J. Systemic and Local Medical or Surgical Therapies for Ear, Nose and/or Throat Manifestations in ANCA-Associated Vasculitis: A Systematic Literature Review. J Clin Med 2023; 12:jcm12093173. [PMID: 37176613 PMCID: PMC10179364 DOI: 10.3390/jcm12093173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Ear, nose and throat (ENT) manifestations are common in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), yet how to treat these manifestations remains controversial. Therefore, we systematically reviewed the literature on the efficacy of therapies on ENT manifestations in AAV. METHODS A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline, Embase and Cochrane libraries, including clinical studies between January 2005 and January 2022, in adults with AAV and ENT involvement, reporting on the effects of local and systemic therapy. The critical appraisal was performed using tools provided by the Cochrane Library and the level of evidence (LoE) was scored according to the Oxford Centre for Evidence-based Medicine. RESULTS After screening 5609 identified studies, 136 full-text articles were assessed. Finally, 31 articles were included for critical appraisal and data-extraction. Nearly all studies (n = 29) were retrospective and scored low on LoE. The included studies evaluated local interventions (n = 11), glucocorticoids combined with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) (n = 8), rituximab (n = 6), or mepolizumab (n = 6). Due to heterogeneity across studies meta-analysis was not performed. Four studies on mepolizumab for sinonasal symptoms (n = 92) showed response in 33-100% and relapse in 35%. Local therapy for subglottic stenosis was effective in 80-100% of patients in 11 studies (n = 157), but relapses were common (up to 83%). In five studies, hearing improvement was observed in 56-100%, with better outcomes when glucocorticoids were combined with csDMARDs compared to glucocorticoids only. CONCLUSION Response rates of ENT manifestations varied widely in studies and relapses were observed frequently. Heterogeneity among studies impaired comparison.
Collapse
Affiliation(s)
- Roline M Krol
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Hilde H F Remmelts
- Department of Nephrology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Annelies Frima
- Department of Otorhinolaryngology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - E Christiaan Hagen
- Department of Nephrology, Meander Medical Center, 3813 TZ Amersfoort, The Netherlands
| | - Digna M A Kamalski
- Department of Otorhinolaryngology-Head and Neck Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Marloes W Heijstek
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Julia Spierings
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| |
Collapse
|