A model-based cost-effectiveness analysis of a grommets-led care pathway for children with cleft palate affected by otitis media with effusion

There is a paucity of evidence to guide the management of otitis media with effusion (OME), which is a common problem causing significant hearing impairment in children with cleft palate. The insertion of grommets is currently being used to correct hearing impairment and prevent complications of unmanaged OME, but there is ongoing discussion about whether the benefits of grommets outweigh the costs and risks. A decision-tree model was developed to assess the surgical insertion of grommets with two non-surgical alternatives (hearing-aids and do-nothing strategies) in cleft palate children with persistent bilateral OME. The model assumed a 2-year time horizon and a UK National Health Service perspective. Outcomes were valued using quality-adjusted life-years (QALYs) estimated by linking utility values with potential hearing gains measured in decibels. Multiple data sources were used, including reviews of the clinical effectiveness, resource use and utility literature, and supplemented with expert opinion. Uncertainty in the model parameters was assessed using probabilistic sensitivity analysis. Expected value of perfect information analysis was used to calculate the potential value of future research. The results from the probabilistic sensitivity analysis indicated that the grommets strategy was associated with an incremental cost-effectiveness ratio of £9,065 per QALY gained compared with the do-nothing strategy, and the hearing-aids strategy was extended dominated by the grommets strategy. The population expected value of perfect information was £5,194,030 at a willingness to pay threshold of £20,000 per QALY, implying that future research could be potentially worthwhile. This study found some evidence that the insertion of grommets to manage cleft palate children with bilateral OME is likely to be cost-effective, but further research is required to inform this treatment choice.

Economic evaluation of surgical insertion of ventilation tubes for the management of persistent bilateral otitis media with effusion in children

BACKGROUND

The surgical insertion of Ventilation Tubes (VTs) for the management of persistent bilateral Otitis Media with Effusion (OME) in children remains a contentious issue due to the varying opinions regarding the risks and benefits of this procedure. The aim of this study was to evaluate the economic impact of VTs insertion for the management of persistent bilateral OME in children, providing an additional perspective on the management of one of the commonest medical conditions of childhood.

METHODS

A decision-tree model was constructed to assess the cost-effectiveness of VTs strategy compared with the Hearing Aids (HAs) alone and HAs plus VTs strategies. The model used data from published sources, and assumed a 2-year time horizon and UK NHS perspective for costs. Outcomes were computed as Quality-Adjusted Life-Years (QALYs) by attaching a utility value to the total potential gains in Hearing Level in decibels (dBHL) over 12 and 24 months. Modelling uncertainty in the specification of decision-tree probabilities and QALYs was performed through Monte Carlo simulation. Expected Value of Perfect Information (EVPI) and partial EVPI (EVPPI) analyses were conducted to estimate the potential value of future research and uncertainty associated with the key parameters.

RESULTS

The VTs strategy was more effective and less costly when compared with the HAs plus VTs strategy, while the incremental cost-effectiveness ratio for the VTs strategy compared with the HAs strategy was £ 5,086 per QALY gained. At the willingness-to-pay threshold of £ 20,000 per QALY, the probability that the VTs strategy is likely to be more cost-effective was 0.58. The EVPI value at population level of around £ 9.5 million at the willingness-to-pay threshold of £ 20,000 indicated that future research in this area is potentially worthwhile, while the EVPPI analysis indicated considerable uncertainty surrounding the parameters used for computing the QALYs for which more precise estimates would be most valuable.

CONCLUSIONS

The VTs strategy is a cost-effective option when compared with the HAs alone and HAs plus VTs strategies, but the need for additional information from future study is evident to inform this surgical treatment choice. Future studies of surgical and non-surgical treatment of OME in childhood should evaluate the economic impact of pertinent interventions to provide greater context.

Decreasing rates of middle ear surgery in Western Australian children

OBJECTIVE

To investigate temporal, social, demographic, and health care utilization factors associated with myringotomy with ventilation tube insertion (MVTI) in Western Australian (WA) children.

DESIGN

Observational retrospective population-based cohort study using hospital administrative data.

SETTING

All WA hospitals.

PARTICIPANTS

A total of 53 673 children younger than 15 years who underwent surgery for MVTI in the period 1981-2004.

MAIN OUTCOME MEASURES

Age-specific incidence rates and incidence rate ratios.

RESULTS

The rate of MVTI in children younger than 15 years peaked in 1997 at 6.7 per 1000 person-years and decreased to 5.6 per 1000 person-years by 2004. Based on 2004 rates, 8.4% of WA children will undergo at least 1 MVTI procedure before reaching age 15 years. The rate of MVTI was 37% lower in Indigenous children, and the procedures were performed at an older age compared with non-Indigenous children. Higher rates of MVTI were associated with areas of higher economic resources, lower education and occupation status, and living in metropolitan areas.

CONCLUSIONS

The rate of MVTI in WA is showing evidence of a decline, even among children younger than 5 years. There remains an issue regarding equity of access to care for Indigenous children. Increasing parental economic resources may be associated with higher rates of MVTI independent of educational status.

[Comparative analysis of the therapeutic costs to control the recurrent acute otitis media]

In order to assess a cost analysis in the management of recurrent acute otitis media (RAOM) in children, we performed a prospective study with data obtained from 80 patients with RAOM, evaluated between january 1998 and february 2000. A good outcome with the antibiotic prophylaxis was obtained in 67 cases (83,7%), with either amoxicillin or azythromicin. Applying the model of assumptions the control of RAOM with ear tube insertion was obtained in 66 children (82,5%). Thus, the cost of antibiotic chemoprophylaxis was Euro 83,60 for the amoxicillin patients and Euro 116,60 for the azythromicin ones. Surgical approach of this entity with the use of ear tubes costs Euro 392,95 per case. To sum up, in pediatric patients, without medical contraindications, the initial treatment for RAOM is chemoprophylaxis, with ear tubes reserved its failure.

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes

OBJECTIVE

The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT).

METHODS

This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX.

RESULTS

Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars.

CONCLUSION

In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.

Laser assisted myringotomy for otitis media with effusion in children

Otitis media with effusion (OME) is a common childhood illness/disease and a major health care priority in the United States. This article describes a minimally invasive, office-based procedure, effectively used to treat OME.

Laser office ventilation of ears with insertion of tubes

OBJECTIVE

Myringotomy with insertion of pressure equalization tubes has proven to be extremely effective in treating persistent serous otitis media (SOM). This study compares the advantages and disadvantages of this procedure when performed in the operating room or with a laser in an office setting.

PATIENTS AND METHODS

Patients selected either traditional myringotomy and tube (M & T; n = 29) done in an operating room under general anesthesia or Laser Office Ventilation of Ears with Insertion of Tubes (LOVE IT; n = 35) done in an office setting with only topical anesthesia. The reasons for selecting either M&T or LOVE IT and satisfaction with the procedure chosen were evaluated by survey, the results of which were compared statistically. Chart review was performed to determine the time and cost of the procedures, time interval from diagnosis to treatment, tube longevity, and complications.

RESULTS

Overall satisfaction was similar with both procedures. Patients and families were more likely to choose LOVE IT based on the anesthetic technique involved (P < 0.001, chi(2)). M&T required less time to perform, whereas the cost of LOVE IT was less. Tube longevity and complication rates were similar between the two procedures, and all complications were minor.

CONCLUSIONS

LOVE IT is a potential alternative to traditional M&T in the treatment of SOM. LOVE IT is most likely to be selected by patients/parents who wish to avoid a general anesthetic and provides a level of satisfaction similar to that of traditional M&T.

Economic evaluation of ventilation tubes in otitis media with effusion

OBJECTIVE

To determine the costs and effectiveness of treatment with ventilation tubes as compared with watchful waiting in children with persistent otitis media with effusion.

DESIGN

Randomized controlled trial.

SETTING

Institutional practice.

PATIENTS

A total of 187 young children (19 months old) with persistent bilateral otitis media with effusion.

INTERVENTIONS

Treatment with ventilation tubes or watchful waiting.

MAIN OUTCOME MEASURES

The time without effusion, language development, and the costs from a societal perspective during 1-year follow-up.

RESULTS

The mean duration of effusion was 9.2 months in the watchful waiting group and 4.7 months in the ventilation tube group. The language development was comparable in both groups (0.7 month of improvement difference [95% confidence interval, -0.3 to 1.7 months] after correction for confounding variables). Because no statistically significant differences were found in the language development between the treatment groups, we performed a cost minimization analysis. The mean costs per child during 1 year of follow-up were 454 US dollars in the ventilation tube group and 120 US dollars in the watchful waiting group. On average, an additional investment of 334 US dollars per patient was needed for ventilation tube treatment.

CONCLUSION

In the absence of differences in language development and in view of higher costs, treatment with ventilation tubes is not recommended as standard treatment in all young children with persistent otitis media with effusion traced by a population-based screening program.

The burden of otitis media

Otitis media is the most frequent reason that children go to the doctor for illness. In developing countries, where children have limited access to medical care, suppurative complications of otitis media (OM) are frequent and permanent hearing loss results. In developed countries, the most common morbidity of OM is conductive hearing loss due to middle ear effusion. Infants with severe and recurrent OM and persistent middle ear effusion are at risk for problems in behavior and development of speech, language and cognitive abilities. Parent stress is frequent. The cost of otitis media is large (>$5 billion in the United States). Selection and spread of multi-drug resistant bacterial pathogens arising from extensive use of antimicrobial agents for OM is a problem for management of all diseases due to the pathogens. The incidence and severity of OM may diminish with introduction of new bacterial and viral vaccines.

Assessing costs and cost effectiveness of pneumococcal disease and vaccination within Kaiser Permanente

OBJECTIVE

To review studies of the costs of pneumococcal disease and the cost effectiveness of pneumococcal conjugate vaccination conducted in association with the Kaiser Permanente Pneumococcal conjugate Efficacy Trial.

RESULTS

for each birth cohort of 3.8 million infants, routine pneumococcal conjugate vaccination program for healthy infants would prevent more than 12000 (78% of potential) meningitis and bacteremia cases, 53000 (69% of potential) pneumonia cases, and 1 million (8% of potential) otitis media episodes. Before accounting for vaccine costs, the vaccination program would reduce the costs of pneumococcal disease by $342 million in medical and $415 million in work-loss and other costs. Vaccination of healthy infants would result in net savings for society if the vaccine cost less than $46 per dose, and net savings for the health care payer if the vaccine cost less than $18 per dose.

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration

OBJECTIVE

To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting.

STUDY DESIGN

Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals.

METHODS

Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described.

RESULTS

All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements.

CONCLUSIONS

The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.

Comparative cost analysis of myringotomy with insertion of ventilation tubes in Ontario and British Columbia

OBJECTIVE

The purpose of this study was to conduct a comparative cost analysis of myringotomy with insertion of ventilation tube (MVT) for children performed at two regional paediatric centres: The Hospital for Sick Children, and the British Columbia Children's Hospital.

DESIGN

Comparative cost analysis.

SETTING

The Hospital for Sick Children (HSC), Toronto, and the British Columbia Children's Hospital (BCCH), Vancouver.

METHODS

The cost analysis was performed from a health system perspective using a treatment protocol developed through a review of the literature and input from staff from each of the study hospitals. MVT cost estimates were derived, including direct treatment costs and overhead costs.

RESULTS

Total costs per MVT case (in 1994 Canadian dollars: Cdn$ 1.00 approximately US$ 0.75) varied from $390.81 at BCCH to $455.63 at HSC. Regional variations in physician costs accounted for almost 70% of the difference in MVT case costs. The distribution of nonphysician MVT case costs were similar in each study hospital, with direct (nonphysician) surgical costs, preoperative assessment and recovery room costs, and administration accounting for 30%, 26%, and 44% of total nonphysician costs, respectively.

CONCLUSIONS

This study identified the magnitude and determinants of regional variations in the cost of MVT surgery. Such cost estimates serve as an important (but not the sole) ingredient in service cost-effectiveness deliberations and in the formulation of evidence-based care when health care resources are scarce.

Cost-Effectiveness Considerations in Otitis Media Treatment

The costs of treatment of children with otitis media with effusion comprise a substantial part of the total health care expenditure. However, there is little information about the value of therapy expressed in cost-effectiveness terms, and disagreement still exists about optimal therapy. This article considers the elements of cost-effectiveness analysis as they pertain to treatment of young children with otitis media with effusion and develops a first approximation model using data from several sources. The assumptions on which this model is based need to be validated by additional research. Otitis media with effusion treatment costs are high because of the large, and apparently increasing, number of symptomatic cases. Medical therapy, which is the primary treatment modality, consumes two thirds of the expenditures for otitis media with effusion. Surgical therapy is a cost-effective treatment for children in whom medical therapy for otitis media with effusion fails. Medical and surgical therapy are complementary, and each should be included in the analysis of cost-effectiveness.

Theoretical cost effectiveness of management options for children with persisting middle ear effusions

OBJECTIVE

The purpose of this theoretical study is to assess the cost effectiveness of options involving observation, antibiotics alone, corticosteroids alone, corticosteroids plus antibiotics, and surgery to clear persisting middle ear effusions during three visits.

METHODOLOGY

In a hypothetical case the expected average per patient expenditures are calculated using the efficacy rates determined by the meta-analysis of randomized controlled clinical trials involving corticosteroids plus an antibiotic (six trials), corticosteroids alone (three trials), and antibiotic alone (four trials). In this analysis, all children whose bilateral middle ear effusions persist for 12 weeks despite medical management are referred for ventilating tubes.

RESULTS

The most cost-effective intervention combination is corticosteroid plus an antibiotic at visit 1 (6 weeks after diagnosis of acute otitis media) followed by a second antibiotic in nonresponders at visit 2 (9 weeks after diagnosis of acute otitis media) and referral for ventilating tubes in nonresponders at visit 3 (12 weeks after diagnosis of acute otitis media). The expected average expenditures per case to clear the bilateral middle ear effusions is $600.91 based on reimbursement of private practice charges and $350.27 based on Medicaid reimbursement (all payments to providers are based on 1992 data from Colorado). The difference in the expected average total expenditures per case between this most cost-effective approach versus the use of sequential courses of antibiotics followed by surgery is $372.81 ($973.72-$600.91) with full reimbursement of private practice charges and $202.57 ($552.84-$350.27) with Medicaid reimbursement. In clearing the middle ear effusion, the average estimated travel expenses per case is $21.46, and lost parental wages per case are $45.12. When the expenditures associated with an additional 6-month follow-up period are included, the expected average per case expenditures is $1088.54 with reimbursement of private practice charges and @659.00 with Medicaid reimbursement. The difference in the expected average per case expenditures to clear the effusions and follow-up for 6 months between the most cost-effective approach using corticosteroids plus antibiotics at the 6- and 9-week visits followed by surgery in nonresponders at 12 weeks versus sequential courses of antibiotics is $405.30 ($1493.84-$1088.54) with reimbursement of private practice charges and $217.32 ($876.32-$659.00) with Medicaid reimbursement.

RECOMMENDATIONS

Although the analysis does not consider risks, side effects, and parental or provider preferences, the findings suggest that the implementation of cost-effective clinical guidelines can potentially reduce national expenditures for managing persistent middle ear effusions.

Recurrent otitis media: a cost-utility analysis of simulated treatment using tympanostomy tubes vs antibiotic prophylaxis

Using a cost-utility analysis, the effectiveness of tympanostomy tubes was compared to that of antibiotic chemoprophylaxis in young patients with recurrent otitis media. The tympanostomy approach (T-tubes) consisted of placement of a polyethylene grommet in the tympanic membrane, with systemic and local antibiotics administered for one week. The chemoprophylaxis approach consisted of antibiotics in full doses for seven to ten days, followed by continuous antibiotic chemoprophylaxis for six months. Because the T-tube strategy under the model assumptions was more expensive ($396.44 vs $281.30) and yielded slightly less benefit (net utility of .9325 vs. .9476 for initial antibiotic therapy), the chemoprophylaxis option was preferred. We conclude that the initial treatment for recurrent otitis media should consist of acute antibiotics followed by chemoprophylaxis, with T-tubes reserved for treatment failure. Extreme changes in the baseline probabilities of cure or recurrence with antibiotic therapy or in the cost of antibiotic therapy or tympanostomy surgery were required to alter this conclusion. Varying therapy preference (utility) values did not materially alter the conclusions.

The impact of otitis media

Otitis media is one of the most worldwide prevalent diseases that affects children. The socioeconomic costs may exceed 3.5 billion dollars a year in the United States alone in direct and indirect costs. If a vaccine can be developed that will decrease 1% of the illness this would be significant in this country and probably even more valuable in less developed countries.

Private medical insurance and elective surgery during early childhood

The relationship between private medical insurance coverage and rates of elective ENT surgery was studied in a birth cohort of seven-year-old children. This analysis suggested that private medical insurance coverage was associated with differences in patterns of elective surgery with children whose families were covered by insurance being more likely to receive elective ENT surgery by seven years and far more likely to receive this treatment at a private hospital. These trends persisted when the child's history of ear/throat infections and family social and economic background were taken into account statistically.

Heat myringotomy

Heat myringotomy using a commercially available, battery powered device produced an opening in the tympanic membrane that persisted 1 to 3 weeks. The procedure was performed to treat chronic otitis media with effusion (COME) in lieu of ventilation tubes in 10 pediatric and 15 adult ears under office iontophoretic anesthesia. These patients were followed for a minimum of 3 months to assess efficacy. Fifty percent of pediatric ears were controlled, eliminating the need for general anesthesia and tube insertion. Forty percent of adult ears were controlled with heat myringotomy. A description of the procedure, discussion of possible reasons for failure, and analysis of potential cost savings are included.