Comparative cost analysis between definitive radiotherapy and transoral surgery for oropharyngeal squamous cell carcinoma: A SEER-Medicare analysis.

INTRODUCTION: Primary radiotherapy (RT) and transoral surgery (TOS) are effective local therapy treatments for oropharyngeal squamous cell carcinoma (OPSCC), but their cost profiles differ. We compared the one-year costs of these competing treatments using a large claims-based database. METHODS: Eligible individuals were patients in the SEER-Medicare registry diagnosed with OPSCC between 2000 and 2011. Patients were categorized as receiving either primary RT +/- chemotherapy, or TOS +/- adjuvant RT or chemoradiotherapy (CRT), and all treatment costs from 1 month prior to diagnosis to 1 year after diagnosis were calculated. Univariable and multivariable linear regression models were used to determine predictors of payer expenditure. Patient-borne pharmacy costs were also analyzed. RESULTS: The cohort included 3497 patients (73% RT, 27% TOS), of whom 73% were locally advanced. The mean total 13 month costs for RT alone, CRT, TOS alone, TOS + RT and TOS + CRT were $39,083, $63,537, $25,468, $36,592, and $99,919, respectively, for early-stage patients. For locally advanced individuals, the mean costs were $45,049, $68,099, $40,626, $53,729, and $71,397, respectively. On multivariable analysis, the adjusted increase in total costs versus RT alone were $21,844, -$5431, $7984, and $28,581 for CRT, TOS alone, TOS + RT, and TOS + CRT, respectively. The difference between CRT and TOS + RT became non-significant for TOS patients undergoing transoral surgery plus neck dissection. Cisplatin was associated with significant less cost than cetuximab and taxane-based chemotherapy. CONCLUSION: In this population of elderly patients, transoral surgery was generally associated with less expensive treatment, with the addition of chemotherapy serving as the main driver of increased cost.

Cost for treatment and follow-up of thyroid cancer increases according to the severity of disease.

BACKGROUND: The aim of this study was to provide an analysis of thyroid cancer-related health care costs over a 5-year period, according to the extent of thyroid surgery. METHODS: The study included 33 patients from our institutional database who underwent thyroid cancer surgery in 2010. Patients were divided into four groups based on surgical extent: (1) hemithyroidectomy, (2) total thyroidectomy, (3) total thyroidectomy with ipsilateral radical neck dissection, and (4) total thyroidectomy with bilateral radical neck dissection and mediastinal dissection. Costs for admission and outpatient follow-up for 5 years were analyzed. RESULTS: Costs for outpatient follow-up and admission, and overall cost increased with increasing stage of disease and increasing extent of thyroid surgery. Patients who underwent only hemithyroidectomy had the lowest costs for outpatient follow-up and admission, as well as the lowest overall cost. CONCLUSION: Over the 5-year follow-up period, surgery performed at an early disease stage was the most cost-effective.

Cost-effectiveness analysis in papillary thyroid carcinoma patients with different neck dissection strategy: A retrospective cohort study.

BACKGROUND: There are two surgical strategies for bilateral neck dissection (BND), simultaneous and two-stage operations. The aim of the study was to compare the cost-effectiveness BND with this two operations in papillary thyroid carcinoma (PTC) patients. MATERIALS AND METHODS: Consecutive PTC patients undergoing BND were studied retrospectively, and were classified into simultaneous group (Group A) and two-stage group (Group B). Demographic, medical costs, complication and surgical variables were recorded. RESULTS: This study included 256 PTC patients, of which 175 (68.4%) underwent simultaneous BND and 81 (31.6%) patients underwent two-stage. Patients in Group B spent almost twice as much on medical costs as patients in Group A ($4145.3 vs. $7352.5). Group A patients also had shorter hospital stays (11.71 ±â€¯5.12 vs. 23.10 ±â€¯7.11, P < .0001) and surgery times (203.61 ±â€¯61.43min vs. 279.58 ±â€¯71.59min, P < .0001). The average radioactive iodine therapy delay was 67 days in Group B. There was no significant difference in complications (34 vs. 18, P = .605) or disease-free-survival (93.71% vs. 90.12%, P = .243) between the two groups. No difference was found in rates of recurrent laryngeal nerve invasion/resection (12 vs. 11, P = .08; 10 vs. 6, P = .353) or tracheotomy (32 vs. 14, P = .846). However, internal jugular vein invasions were more common in patients with two-stage BND (7 vs. 9, P = .029). CONCLUSION: Simultaneous BND is the most cost-effective strategy for the management of PTC patients without bilateral internal jugular veins invasion, due to lower treatment cost and the ability to avoid RAI delay.

Cost-effectiveness analysis of PET-CT-guided management for locally advanced head and neck cancer.

BACKGROUND: A recent large United Kingdom (UK) clinical trial demonstrated that positron-emission tomography-computed tomography (PET-CT)-guided administration of neck dissection (ND) in patients with advanced head and neck cancer after primary chemo-radiotherapy treatment produces similar survival outcomes to planned ND (standard care) and is cost-effective over a short-term horizon. Further assessment of long-term outcomes is required to inform a robust adoption decision. Here we present results of a lifetime cost-effectiveness analysis of PET-CT-guided management from a UK secondary care perspective. METHODS: Initial 6-month cost and health outcomes were derived from trial data; subsequent incidence of recurrence and mortality was simulated using a de novo Markov model. Health benefit was measured in quality-adjusted life years (QALYs) and costs reported in 2015 British pounds. Model parameters were derived from trial data and published literature. Sensitivity analyses were conducted to assess the impact of uncertainty and broader National Health Service (NHS) and personal social services (PSS) costs on the results. RESULTS: PET-CT management produced an average per-person lifetime cost saving of £1485 and an additional 0.13 QALYs. At a £20,000 willingness-to-pay per additional QALY threshold, there was a 75% probability that PET-CT was cost-effective, and the results remained cost-effective over the majority of sensitivity analyses. When adopting a broader NHS and PSS perspective, PET-CT management produced an average saving of £700 and had an 81% probability of being cost-effective. CONCLUSIONS: This analysis indicates that PET-CT-guided management is cost-effective in the long-term and supports the case for wide-scale adoption.

Cost-Effectiveness Analysis of Elective Neck Dissection in Patients With Clinically Node-Negative Oral Cavity Cancer.

Purpose Recently, a large randomized trial found a survival advantage among patients who received elective neck dissection in conjunction with primary surgery for clinically node-negative oral cavity cancer compared with those receiving primary surgery alone. However, elective neck dissection comes with greater upfront cost and patient morbidity. We present a cost-effectiveness analysis of elective neck dissection for the initial surgical management of early-stage oral cavity cancer. Methods We constructed a Markov model to simulate primary, adjuvant, and salvage therapy; disease recurrence; and survival in patients with T1/T2 clinically node-negative oral cavity squamous cell carcinoma. Transition probabilities were derived from clinical trial data; costs (in 2015 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios, expressed as dollar per quality-adjusted life-year (QALY), were calculated with incremental cost-effectiveness ratios less than $100,000/QALY considered cost effective. We conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. Results Our base-case model found that over a lifetime the addition of elective neck dissection to primary surgery reduced overall costs by $6,000 and improved effectiveness by 0.42 QALYs compared with primary surgery alone. The decrease in overall cost despite the added neck dissection was a result of less use of salvage therapy. On one-way sensitivity analysis, the model was most sensitive to assumptions about disease recurrence, survival, and the health utility reduction from a neck dissection. Probabilistic sensitivity analysis found that treatment with elective neck dissection was cost effective 76% of the time at a willingness-to-pay threshold of $100,000/QALY. Conclusion Our study found that the addition of elective neck dissection reduces costs and improves health outcomes, making this a cost-effective treatment strategy for patients with early-stage oral cavity cancer.

Sentinel node biopsy versus elective neck dissection. Which is more cost-effective? A prospective observational study.

OBJECTIVE: The aim of this prospective not randomized observational study was to determine the costs and outcomes of sentinel lymph node biopsy (SNB) vs elective neck dissection (END) among patients with early oral squamous cell carcinoma (OSCC). MATERIALS AND METHODS: Seventy-three consecutive patients were divided according to neck staging method. Patients took the decision themselves after receiving detailed information of both suggested treatment tools. False negative (FN) and negative predictive value (NPV) were assessed. Log-rank test was used to compare disease-free survival (DFS) and overall survival (OS). Only direct costs were analysed. Cost information derived from volumes for hospital stay, surgery and neck outcome were obtained from an internal database of tertiary health care center. RESULTS: Thirty-two patients underwent SNB and 41 underwent an END (levels I-III). Average follow-up time was 48.2 months (range 7-80). Five neck recurrences were recorded in the SNB group (range 11-21). Seven neck recurrences occurred in the END group (range 9-16). No significant differences were found in DFS or OS. True negative patients in SNB group incurred in 42% less costs than END group. FN regardless of radiotherapy, was also lower in the SNB group. However, pN+ patients generated 23% more costs in the SNB group. CONCLUSION: In this not randomized observational study with an average follow-up period of 48.2 months, SNB appear to confer less cost than END, with similar prognosis.

Cost-utility of sentinel lymph node biopsy in cT1-T2N0 oral cancer.

OBJECTIVES: To calculate the cost-utility of different strategies for the detection of occult lymph node metastases in cT1-T2N0 oral cancer. METHODS: A decision tree followed by a Markov model was designed to compare the cost-utility of the following strategies: (a) USgFNAC (ultrasound guided fine needle aspiration cytology), (b) SLNB (sentinel lymph node biopsy), (c) USgFNAC and, if negative, SLNB (d) END (elective neck dissection). Data was collected from 62 patients in four Dutch head and neck centres. Utilities were measured with the EQ5D questionnaire and resource use was recorded from patient charts. Costs were calculated from a hospital perspective. Uncertainty was explored with scenario analyses and probabilistic sensitivity analyses. RESULTS: With a 5- or 10-year time horizon, SLNB results in the highest number of additional quality-adjusted life years (QALYs, 0.12 and 0.26, respectively) for the smallest additional costs (€56 and €74, respectively) compared to USgFNAC. With a lifetime horizon END results in the highest number of additional QALYs (0.55) for an additional €1.626 per QALY gained compared to USgFNAC. When we make different assumptions regarding the duration of disutilities (⩾5 years) or the improvement (⩾3%) of sensitivity of SLNB, SLNB is the most favourable strategy from all time horizons. CONCLUSION: SLNB is a good diagnostic strategy to evaluate cT1-T2N0 oral cancer. SLNB is the preferred strategy in a 5- or 10-year time horizon. From a lifetime horizon, END may be preferred. SLNB may become the optimal strategy from all time horizons if its sensitivity can be slightly improved.

[Application of fibrin sealant in patients operated on for differentiated thyroid cancer. What do we improve?]. / Aplicación de sellante de fibrina en pacientes operados por cáncer diferenciado de tiroides. ¿Qué mejoramos?

BACKGROUND: In recent years, several publications have shown that new adhesives and sealants, like Tissucol(®), applied in thyroid space reduce local complications after thyroidectomies. STUDY AIMS: To demonstrate the effectiveness of fibrin glue Tissucol(®) in reducing the post-operative hospital stay of patients operated on for differentiated thyroid carcinoma in which total thyroidectomy with central and unilateral node neck dissection was performed (due to the debit drains decrease), with consequent cost savings. MATERIAL AND METHODS: A prospective randomised study was conducted during the period between May 2009 and October 2013 on patients with differentiated thyroid carcinoma with cervical nodal metastases, and subjected to elective surgery. Two groups were formed: one in which Tissucol(®) was used (case group) and another where it was not used (control group). Patients were operated on by surgeons specifically dedicated to endocrine surgical pathology, using the same surgical technique in all cases. RESULTS: A total of 60 total thyroidectomies with lymph node dissection were performed, with 30 patients in the case group, and 30 patients in control group. No statistically significant differences were observed in most of the studied variables. However, the case group had a shorter hospital stay than the control group with a statistically significant difference (p<0.05). CONCLUSION: Implementation of Tissucol(®) has statistically and significantly reduced the hospital stay of patients undergoing total thyroidectomy with neck dissection, which represents a significant reduction in hospital costs. This decrease in hospital stay has no influence on the occurrence of major complications related to the intervention.

Analysis of Charges Associated with Definitive Nonsurgical Therapy for Early-Stage Lateralized Tonsil Cancer.

OBJECTIVE: The cost of treatment as it affects comparative effectiveness is becoming increasingly more important. Because cost data are not readily available, we evaluated the charges associated with definitive nonsurgical therapy for early-stage lateralized tonsil cancers. METHODS: Patients treated with unilateral radiation therapy (RT) for T1 or T2 tonsil cancer between 1995 and 2007 were retrospectively reviewed. Total and radiation-specific charges, from 3 months before to 4 months after radiation, were adjusted for inflation. All facets of treatment were evaluated for significant associations with total billing. RESULTS: Eighty-four patients were identified. Three-year overall survival, disease-specific survival, and recurrence-free survival were 97 % [95 % confidence interval (CI) 0.88-0.99], 98 % (95 % CI 0.89-1), and 96 % (95 % CI 0.88-0.99), respectively. The median for radiation-specific charges was $60,412 (range $16,811-$84,792). The median for total charges associated with treatment was $109,917 (range $36,680-$231,895). Total billing for treatment was significantly associated with the year of diagnosis (p = 0.008), intensity-modulated radiation therapy versus wedge pair RT (p = 0.005), preradiation direct laryngoscopy (p < 0.0001), chemotherapy (p < 0.0001), gastrostomy tube placement (p = 0.004), and postradiation neck dissection (p = 0.005). CONCLUSIONS: Although cost data for treatment are not readily available, historically, the recovery rate is approximately 30 %. The charges associated with definitive nonsurgical therapy for early-stage lateralized tonsil cancer have a wide range likely due to treatment-related procedures, the use of chemotherapy, and evolving RT technologies. These benchmark data are important given renewed interested in primary surgery for tonsil cancer. Cost of care, disease control, and functional outcomes will be critical for comparisons of effectiveness when selecting treatment modalities.

Cost-effectiveness of positron emission tomography-CT in the evaluation of cancer of unknown primary of the head and neck.

BACKGROUND: Positron emission tomography (PET)-CT is a useful diagnostic adjunct for cancer unknown primary (CUP) of the head and neck; however, the increased cost has not been justified with an economic evaluation in this patient population. METHODS: A decision tree analysis was performed from the perspective of the third party payer. Primary outcome was cost per life year gained ($/LYG). The 2 comparative groups were: (1) PET-CT followed by panendoscopy versus (2) panendoscopy alone. RESULTS: The incremental cost-effectiveness ratios for N1, N2, and N3 CUP were $369.83/LYG, $329.43/LYG, and $4900.28/LYG, respectively. The sensitivity analysis demonstrated a 96.8%, 97.1%, and 60.1% certainty that PET-CT is cost-effective for CUP with N1, N2, and N3 disease, respectively. CONCLUSION: The use of PET-CT in patients with N1 and N2 CUP is the cost-effective choice. The cost-effectiveness in N3 CUP is questionable and should be used on an individual case basis.

Cost-effectiveness of selective neck dissection versus modified radical neck dissection for treating metastases in patients with oral cavity cancer: A modelling study.

BACKGROUND: Choosing between a more or less extensive neck dissection implies a tradeoff between survival, quality of life, and costs. The purpose of this study was to determine if selective neck dissection (level I-III or I-IV) is cost-effective compared with modified radical neck dissection (level I-V) in patients with cT1-2 oral squamous cell carcinoma (OSCC) with singular nodal disease confined to level I or II. METHODS: A decision-analytic model was developed to model quality-adjusted life years (QALYs) and costs over a lifetime horizon, based on literature. RESULTS: The selective neck dissection strategy resulted in an expected health loss of 0.06 QALY and savings of €1351 per patient compared to modified radical neck dissection. The results were sensitive to differences in regional failure probabilities between the strategies. CONCLUSION: With the evidence used in this model, selective neck dissection was not cost-effective compared to modified radical neck dissection. Prospective research on regional failure is needed to provide optimal treatment for patients with OSCC.

BRAF mutation in papillary thyroid cancer: A cost-utility analysis of preoperative testing.

BACKGROUND: Papillary thyroid carcinoma (PTC) with BRAF mutation carries a poorer prognosis. Prophylactic central neck dissection (CND) reduces locoregional recurrences, and we hypothesize that initial total thyroidectomy (TT) with CND in patients with BRAF-mutated PTC is cost effective. METHODS: This cost-utility analysis is based on a hypothetical cohort of 40-year-old women with small PTC [2 cm, confined to the thyroid, node(-)]. We compared preoperative BRAF testing and TT+CND if BRAF-mutated or TT alone if BRAF-wild type, versus no testing with TT. This analysis took into account treatment costs and opportunity losses. Key variables were subjected to sensitivity analysis. RESULTS: Both approaches produced comparable outcomes, with costs of not testing being lower (-$801.51/patient). Preoperative BRAF testing carried an excess expense of $33.96 per quality-adjusted life-year per patient. Sensitivity analyses revealed that when BRAF positivity in the testing population decreases to 30%, or if the overall noncervical recurrence in the population increases above 11.9%, preoperative BRAF testing becomes the more cost-effective strategy. CONCLUSION: Outcomes with or without preoperative BRAF testing are comparable, with no testing being the slightly more cost-effective strategy. Although preoperative BRAF testing helps to identify patients with higher recurrence rates, implementing a more aggressive initial operation does not seem to offer a cost advantage.

Economic analyses in squamous cell carcinoma of the head and neck: a review of the literature from a clinical perspective.

The purpose of this review was to describe cost-effectiveness and cost analysis studies across treatment modalities for squamous cell carcinoma of the head and neck (SCCHN), while placing their results in context of the current clinical practice. We performed a literature search in PubMed for English-language studies addressing economic analyses of treatment modalities for SCCHN published from January 2000 to March 2013. We also performed an additional search for related studies published by the National Institute for Health and Clinical Excellence in the United Kingdom. Identified articles were classified into 3 clinical approaches (organ preservation, radiation therapy modalities, and chemotherapy regimens) and into 2 types of economic studies (cost analysis and cost-effectiveness/cost-utility studies). All cost estimates were normalized to US dollars, year 2013 values. Our search yielded 23 articles: 13 related to organ preservation approaches, 5 to radiation therapy modalities, and 5 to chemotherapy regimens. In general, studies analyzed different questions and modalities, making it difficult to reach a conclusion. Even when restricted to comparisons of modalities within the same clinical approach, studies often yielded conflicting findings. The heterogeneity across economic studies of SCCHN should be carefully understood in light of the modeling assumptions and limitations of each study and placed in context with relevant settings of clinical practices and study perspectives. Furthermore, the scarcity of comparative effectiveness and quality-of-life data poses unique challenges for conducting economic analyses for a resource-intensive disease, such as SCCHN, that requires a multimodal care. Future research is needed to better understand how to compare the costs and cost-effectiveness of different modalities for SCCHN.

Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective.

BACKGROUND: The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone. METHODS: A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates. RESULTS: Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%. CONCLUSIONS: TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.

Sentinel node biopsy in papillary thyroid cancer--what is the potential?

PURPOSE: Sentinel node biopsy (SNB) may identify lymph node metastases in patients with papillary thyroid cancer (PTC), enabling selective application of central node dissection (CND). The aim of this study was to assess the feasibility of implementing SNB in patients undergoing thyroidectomy for a cytologically indeterminate/suspicious/malignant thyroid nodule and to determine the potential improvement in clinical outcomes and the costs associated with the SNB technique. METHODS: The treatment strategies and clinical and pathological outcomes of two retrospective cohorts of patients who underwent preoperative thyroid FNA over a 5-year period in two different centres were studied. The potential for implementing the SNB technique and the benefits and costs associated with implementation were estimated. RESULTS: In centre 1, in 819 adult patients who had thyroid fine-needle aspiration cytology, the final cytology was indeterminate, suspicious and diagnostic of malignancy in 113, 29 and 28 patients, respectively. One hundred eight patients were 'suitable' for SNB. Twenty-three of these patients had PTC, six of whom underwent CND. Of these six patients, node metastasis was absent in five--the cohort in whom prophylactic CND may have been avoided consequent to a negative 'sentinel node' biopsy. Morbidity attributable to CND may have been avoided in up to four patients over a 5-year period. Costs associated with implementation of SNB outweighed any potential savings. Analysis of 491 patients in centre 2 confirmed that the benefit of SNB in PTC was similarly limited; morbidity attributable to CND may have been avoided in up to seven patients over a 5-year period. CONCLUSIONS: Even under ideal conditions (assuming 100 % node identification rate and 0 % false negative rate), the potential short- to medium-term benefit of sentinel node biopsy in patients with thyroid cancer in centres implementing a policy of selective or routine prophylactic CND is low.

A cost-minimization analysis comparing total thyroidectomy alone and total thyroidectomy with prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma.

BACKGROUND: Total thyroidectomy (TT) with prophylactic central neck dissection (pCND) remains controversial for clinically nodal-negative (cN0) papillary thyroid carcinoma (PTC), and the issue of cost rarely has been examined. We evaluated whether pCND at the time of TT is more cost-saving than TT alone in the medium- to long-term. METHODS: For a hypothetical group of 50-year-old females with a 1.5-cm cN0 PTC, a decision-tree model using TreeAge Software was developed to simulate outcomes and compare the 20-year accumulative direct cost between TT alone and TT+pCND strategies. Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. Cost estimate of surgical procedures, complications, and radioiodine (RAI) ablation was based on government gazette. RESULTS: The cost accrued per patient for the primary operation under TT alone and TT+pCND strategies were USD 6,702.81 and USD 10,062.35, respectively, whereas the cost for the reoperative procedure were USD 12,981.40 and USD 12,509.09, respectively. The 20-year accumulative cost for TT alone and TT+pCND strategies were USD 19,888.36 and USD 22,760.86, respectively. The incremental cost per patient was USD 2,872.50. In the univariate and bivariate sensitivity analyses, no change in conclusion was seen by varying the rates of complications, annualized locoregional recurrences and RAI, or by extending the model to 50 years. CONCLUSIONS: From a pure economic institution's perspective, TT+pCND is more expensive in the medium- and long-term and seems less justified compared with TT alone for cN0 PTC.

A cost-utility analysis for prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma.

BACKGROUND: Although prophylactic central neck dissection (pCND) may reduce future locoregional recurrence after total thyroidectomy (TT) for low-risk papillary thyroid carcinoma (PTC), it is associated with a higher initial morbidity. We aimed to compare the long-term cost-effectiveness between TT with pCND (TT+pCND) and TT alone in the institution's perspective. METHODS: Our case definition was a hypothetical cohort of 100,000 nonpregnant female patients aged 50 years with a 1.5-cm cN0 PTC within one lobe. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between TT+pCND and TT alone after a 20-year period. Outcome probabilities, utilities, and costs were estimated from the literature. The threshold for cost-effectiveness was set at US$50,000 per quality-adjusted life year (QALY). Sensitivity and threshold analyses were used to examine model uncertainty. RESULTS: Each patient who underwent TT+pCND instead of TT alone cost an extra US$34.52 but gained an additional 0.323 QALY. In fact, in the sensitivity analysis, TT+pCND became cost-effective 9 years after the initial operation. In the threshold analysis, none of the scenarios that could change this conclusion appeared clinically possible or likely. However, TT+pCND became cost-saving (i.e., less costly and more cost-effective) at 20 years if associated permanent vocal cord palsy was kept ≤ 1.37 %, permanent hypoparathyroidism was ≤ 1.20 %, and/or postoperative radioiodine ablation use was ≤ 73.64 %. CONCLUSIONS: In the institution's perspective, routine pCND for low-risk PTC began to become cost-effective 9 years after initial surgery and became cost-saving at 20 years if postoperative radioiodine use and/or permanent surgical complications were kept to a minimum.

Effect of occurrence of infection-related never events on length of stay and hospital charges in patients undergoing radical neck dissection for head and neck cancer.

OBJECTIVE: To estimate the impact of infection-related never events (postoperative pneumonia, Clostridium difficile infection, infection with microorganisms resistant to penicillin, postoperative infections, and decubitus ulcers) following radical neck dissections for head and neck cancers. STUDY DESIGN: The 2008 Nationwide Inpatient Sample was used to select hospitalizations with HNC that underwent radical neck dissections. Predictor variables were occurrence of never events and other patient- and hospital-level factors. Outcome variables were hospitalization charges and length of stay (LOS). Regression analyses were used to measure the association between predictors and outcomes. RESULTS: Among 10,660 hospitalizations, prevalence of never events ranged from 0.2% to 5.0%. Mean hospitalization charge and LOS were $75,654 and 6.8 days, respectively. Never events were associated with 5.6-10.0 longer LOS and $49,153-$124,057 excess charges. CONCLUSION: Occurrence of never events was associated with at least 5.6 longer hospital days and $49,153 charge compared with hospitalizations without a never event.