Multidose Botulinum Toxin A for Intralaryngeal Injection: A Cost Analysis.

OBJECTIVES: Botulinum toxin A (BtxA) injection is the mainstay treatment for laryngeal dystonias. BtxA product labeling states that reconstituted toxin should be used within 4 hours on a single patient despite several studies that have demonstrated multidose BtxA to be safe and effective. Many insurance carriers mandate the use of an outside pharmacy which necessitates a single-use approach. This study compares the cost savings of multidose BtxA for laryngeal dystonia compared to single-use. STUDY DESIGN: This is a retrospective review and projected cost savings analysis. METHODS: Records and billing information were reviewed for patients receiving BtxA for intralaryngeal injection at a single laryngology division in 2015. Inclusion criteria included CPT 64617 or J0585; exclusion criteria included CPT 64616. The price of BtxA 100 unit vial for calculation was $670. RESULTS: A total of 142 patients were seen for intralaryngeal BtxA injection resulting in 337 visits over 1 year. The average BtxA dose per visit was 2.86 units with an average of 3.06 procedure visits per year. The calculated cost of BtxA treatment using a single vial approach was found to be $2,050 per patient per year. If billed instead for $7/unit with 5 units wastage charge per visit, the yearly per patient charge is $168. Single vial-use of BtxA injection thus represents a 1,118% price increase versus multidose use. When estimated for yearly prevalence of spasmodic dysphonia, multidose BtxA use would save almost $100 million annually. CONCLUSIONS: Multidose botulinum toxin A application utilizing per unit billing is significantly less expensive than per single-use vial billing and would save the health-care system significant amount of money without any sacrifice in safety or effectiveness.

Cost Analysis of Channeled, Distal Chip Laryngoscope for In-office Laryngopharyngeal Biopsies.

OBJECTIVE: Given that financial considerations play an increasingly prominent role in clinical decision-making, we sought (1) to determine the cost-effectiveness of in-office biopsy for the patient, the provider, and the health-care system, and (2) to determine the diagnostic accuracy of in-office biopsy. STUDY DESIGN: Retrospective, financial analyses were performed. METHODS: Patients who underwent in-office (Current Procedural Terminology Code 31576) or operative biopsy (CPT Code 31535) for laryngopharyngeal lesions were included. Two financial analyses were performed: (1) the average cost of operating room (OR) versus in-office biopsy was calculated, and (2) a break-even analysis was calculated to determine the cost-effectiveness of in-office biopsy for the provider. In addition, the diagnostic accuracy of in-office biopsies and need for additional biopsies or procedures was recorded. RESULTS: Of the 48 patients included in the current study, 28 underwent in-office biopsy. A pathologic sample was obtained in 26 of 28 (92.9%) biopsies performed in the office. Of these patients, 16 avoided subsequent OR procedures. The average per patient cost was $7000 and $11,000 for in-office and OR biopsy, respectively. Break-even analysis demonstrated that the provider could achieve a profit 2 years after purchase of the necessary equipment. CONCLUSION: In-office laryngopharyngeal biopsies are accurate and, overall, more cost-effective than OR biopsies. Purchase of the channeled, distal chip laryngoscope and biopsy forceps to perform in-office biopsies can be profitable for a provider with a videolaryngoscopy tower. In-office biopsy should be considered the initial diagnostic tool for suspected laryngopharyngeal malignancies noted on videolaryngoscopy.

Delayed otolaryngology referral for voice disorders increases health care costs.

BACKGROUND: Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/voice disorders. METHODS: Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9(th) Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS: There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist ≤1 month after the first primary care visit, patients in the >1-month and ≤3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS: Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders.

Factors influencing the health care expenditures of patients with laryngeal disorders.

OBJECTIVE: To identify factors related to the health care spending of patients with laryngeal disorders. STUDY DESIGN AND SETTING: Retrospective analysis of data from a large, nationally representative administrative US claims database. SUBJECTS AND METHODS: Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008, and who were continuously enrolled for 12 months were included. Age, sex, comorbidity, geography, provider type, visit type, and type of laryngeal pathology were collected. To identify which factors were related to the direct costs, a generalized linear regression with gamma distribution was used. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with a laryngeal disorder and 12 months of follow-up data were identified (mean [SD] age, 47.3 [21.3] years; 63.5% female). Age, sex, geographic region, number of comorbid conditions, type of provider, visit type, and laryngeal pathology were significantly associated with the health care expenditures (all P values <.05). Costs increased with increasing age and were greater for male patients, higher in the South and Northeast compared with the West and North-central regions, greater in 2008 compared with 2004, higher for inpatient compared with outpatient care, higher with increasing number of comorbid conditions, and lower if a patient was treated by a primary care physician only. Among the various laryngeal pathologies, the greatest direct costs were for laryngeal cancer and patients with multiple diagnoses. CONCLUSION: This study identified multiple factors associated with the health care expenditures of patients with laryngeal disorders.

Direct health care costs of laryngeal diseases and disorders.

OBJECTIVES/HYPOTHESIS: To estimate the annual direct costs associated with the diagnosis and management of laryngeal disorders. STUDY DESIGN: Retrospective analysis of data from a large, nationally representative, administrative US claims database. METHODS: Patients with a laryngeal disorder based on International Classification of Diseases,Ninth Revision-Clinical Modification codes from January 1, 2004 to December 31, 2008 and who were continuously enrolled for 12 months were included. Data regarding age, gender, geographic location, and type of physician providing the diagnosis were collected. Medical encounter, medication, and procedure costs were determined. Total and mean costs per person for 12 months were determined. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with 12 months follow-up, mean age of 47.3 years (standard deviation: 21.3), and 63.5% female were identified. Acute and chronic laryngitis, nonspecific causes of dysphonia, and benign vocal fold lesions were the most common etiologies. The total annual direct costs ranged between $178,524,552 to $294,827,671, with mean costs per person between $577.18 and $953.21. Pharmacy claims accounted for 20.1% to 33.3%, procedure claims 50.4% to 69.9%, and medical encounter claims 16.3% to 8.6% of overall direct costs. Antireflux medication accounted for roughly 10% and antibiotics 6% of annual direct costs. CONCLUSIONS: This study establishes the economic impact of the assessment and management of patients with laryngeal disorders and permits cost comparisons with other diseases.

Office-based laser surgery of the larynx: cost-effective treatment at the office's expense.

OBJECTIVE: While office-based laser surgery (OBLS) for benign laryngeal disease is cost-effective for the patient, the financial impact on the office offering the service has not been characterized. We hypothesize that OBLS offers savings to the patient that are not widely realized because of the financial liability the technology poses. STUDY DESIGN: A 2-part financial analysis. SETTING: (1) Hospital operating room and (2) non-facility-based office. SUBJECTS AND METHODS: First, the average cost and reimbursements for 50 patients undergoing OBLS were compared with those of 50 patients undergoing operative direct laryngoscopy with laser (DLL). Second, a detailed financial comparison was performed on a self-paired series of patients who had each undergone both OBLS and DLL for benign laryngeal disease. RESULTS: When compared with DLL, OBLS provides more than a $5000 per-case cost savings for the third-party payer. Average DLL reimbursement was $6453.44 per case, including hospital, anesthesiologist, and surgeon reimbursements of $5150, $745.66, and $357.78, respectively. Based on the calculated hospital cost of $2069.15 per case, the hospital profited more than $3000 per DLL. For OBLS in a non-facility office setting, the average reimbursement was $643.08 per case, with procedure and laser fiber reimbursements of $596.52 and $46.56, respectively. Based on office expenditures of $1388.06 per case, the office lost more than $500 per OBLS case. CONCLUSION: OBLS in a non-facility-based office setting leads to a net financial loss for the office, making OBLS-associated health care cost savings unlikely to be widely realized unless reimbursement patterns are changed.

Cost-identification analysis of total laryngectomy: an itemized approach to hospital costs.

OBJECTIVES: To understand the contribution of intraoperative and postoperative hospital costs to total hospital costs, examine the costs associated with specific hospital services in the postoperative period, and recognize the impact of patient factors on hospital costs. STUDY DESIGN: Case series with chart review. SETTING: Large tertiary care teaching hospital system. SUBJECTS AND METHODS: Using the Pittsburgh Head and Neck Organ-Specific Database, 119 patients were identified as having total laryngectomy with bilateral selective neck dissection and primary closure from 1999 to 2009. Cost data were obtained for 112 patients. Costs include fixed and variable costs, adjusted to 2010 US dollars using the Consumer Price Index. RESULTS: Mean total hospital costs were $29,563 (range, $10,915 to $120,345). Operating room costs averaged 24% of total hospital costs, whereas room charges, respiratory therapy, laboratory, pharmacy, and radiology accounted for 38%, 14%, 8%, 7%, and 3%, respectively. Median length of stay was 9 days (range, 6-43), and median Charlson comorbidity index score was 8 (2-16). Patients with ≥1 day in the intensive care unit had significantly higher hospital costs ($46,831 vs $24,601, P < .01). The authors found no significant cost differences with stratification based on previous radiation therapy ($27,598 vs $29,915 with no prior radiation, P = .62) or hospital readmission within 30 days ($29,483 vs $29,609 without readmission, P = .97). CONCLUSION: This is one of few studies in surgery and the first in otolaryngology to analyze hospital costs for a relatively standardized procedure. Further work will include cost analysis from multiple centers with investigation of global cost drivers.

Indirect laryngeal surgery in the clinical voice laboratory: the renewal of a lost art.

Since the advent of precision instruments and safe techniques for direct laryngoscopic surgery under general anesthesia, indirect laryngeal surgery has become very uncommon. A review of the recent literature finds that few authors advocate indirect surgery under topical anesthesia, and many otolaryngologists dismiss this technique as being either of only historical interest or an idiosyncratic method practiced only by a handful of clinicians. The societal mandate for cost-effective healthcare and the availability of relatively low-cost, high-quality endoscopes and video equipment warrant a renewed and broader interest in this type of surgery. In this article, we review a series of 27 indirect surgical procedures performed under topical anesthesia in the clinical voice laboratory. We discuss the indications, outcomes, advantages, and disadvantages of this surgery, and we present a brief analysis of its cost-effectiveness. We conclude that indirect laryngeal surgery in the clinical voice laboratory is an effective, safe, efficient, and less costly alternative to some procedures routinely performed under general anesthesia.

Health care costs of laryngeal surgery.

The total costs of various laryngeal surgeries were considered from initial visit through one year postoperatively. For the four most widely used procedures, average costs were: laryngoscopy with biopsy, $1,000.00; hemilaryngectomy, $5,035.00; total laryngectomy $6,010.00; and supraglottic laryngectomy and neck dissection, $12,096.00. Most ancillary service charges decrease as length of hospitalization increases except for pharmacy and respiratory therapy. Physicians whose decisions affect health care should also take cognizance of health care costs.