Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding.

BACKGROUND: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding. METHODS: This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered. RESULTS: Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment. CONCLUSIONS: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.

Cost-effectiveness of infant orthopedic treatment regarding speech in patients with complete unilateral cleft lip and palate: a randomized three-center trial in the Netherlands (Dutchcleft).

OBJECTIVE: To investigate the cost-effectiveness of infant orthopedic treatment (IO), compared with no such treatment in children with complete unilateral cleft lip and palate (UCLP) focusing on the effects on speech development at age 2.5 years. DESIGN: In a three-center prospective, randomized clinical trial (Dutchcleft), two groups of children with complete UCLP were followed longitudinally: one group was treated with IO based on a modified Zurich approach in the first year of life (IO group) and the other group did not receive this treatment (non-IO group). PATIENTS: The participants had complete UCLP without soft tissue bands or other malformations. They were born at term and their parents were native Dutch speakers. OUTCOME MEASURES: The effect of IO on speech development at age 2.5 years was measured blindly by five expert listeners judging the "total impression of speech quality" on a 10-point equal-appearing interval scale. Costs were measured from a societal viewpoint in Euro. RESULTS AND CONCLUSION: The IO group (n = 10) obtained a statistically significant higher rating, compared with the non-IO group (n = 10). The effect size was large, indicating that the improvement may be considered a clinically important change. The cost for treatment by the orthodontist was higher in the IO group. For both groups, the mean cost was related to the mean rating for "total impression of speech quality." The resulting cost-effectiveness for IO, compared to non-IO was 1041 for 1.34 point speech quality improvement. The financial investment that is necessary to obtain this improvement seems limited. Thus, from the perspective of speech development, the cost-effectiveness of IO over non-IO seems acceptable at this point in time.

A randomized prospective clinical trial of the effect of infant orthopedics in unilateral cleft lip and palate: prevention of collapse of the alveolar segments (Dutchcleft).

OBJECTIVE: To study the effect of infant orthopedics (IO) on maxillary arch form and position of the alveolar segments. DESIGN: Prospective two-arm randomized, controlled trial in parallel with three participating academic cleft palate centers. Treatment was assigned by means of a computerized balanced allocation method. SETTING: Cleft palate centers of Amsterdam, Nijmegen, and Rotterdam, the Netherlands. PATIENTS, PARTICIPANTS: Infants with complete unilateral cleft lip and palate and no other malformations. INTERVENTIONS: One group (IO+) wore passive maxillary plates during the first year of life; the other group (IO-) did not. All other interventions were the same. MAIN OUTCOME MEASURE(S): The presence of contact and/or overlap (collapse) between the maxillary segments at maxillary casts made shortly after birth, at 15, 24, 48, 58, and 78 weeks. Survival experience of contact and collapse with time as well as the frequencies of different arch forms and severity of collapse were evaluated. RESULTS: Comparable arch forms with no contact or overlap of the maxillary segments were seen at birth in both groups. With time the frequency of collapse increased, with no significant differences between groups. No significant group differences were found with respect to the survival experience of contact and collapse or for the severity of collapse at the end of the observational period. CONCLUSIONS: Infant orthopedics does not prevent collapse and can be abandoned as a tool to improve maxillary arch form.

Use of technopolymer clasps in prostheses for patients due to have radiation therapy.

Patients with large oral defects as a result of a maxillectomy procedure, who are due to have postoperative radiotherapy, need to have the density of the defect restored to ensure standardised radiation distribution. This is achieved with various types of boluses that often require tissue surface positioning stents to help support them. Traditional metal-clasp retained stents were discarded as the clasps caused backscatter of the radiation beams. A radiolucent material was needed to retain these prostheses. Dental D, an acetal resin was used in the fabrication of a positioning stent. It was assessed in terms of ease of manufacture, cost, fit, retention and radiolucency. The material was found to be more costly and time-consuming to manufacture than conventional metal-retained acrylic resin prostheses, but its radiolucency made it ideal for use in patients during radiotherapy treatment. Future studies will determine if the long-term strength of the material will allow the clasps to be used in a definitive prosthesis and thus help offset the initial time and costs.

Nasoalveolar molding and gingivoperiosteoplasty versus alveolar bone graft: an outcome analysis of costs in the treatment of unilateral cleft alveolus.

OBJECTIVE: The purpose of this study was to compare the financial impact of two treatment approaches to the unilateral cleft alveolus. The recently advocated nasoalveolar molding (NAM; and gingivoperiosteoplasty (GPP; at the time of lip repair were compared with the traditional approach of secondary alveolar bone graft. DESIGN: The records of all patients (n = 30) with unilateral cleft lip and alveolus treated by a single surgeon during 1985 through 1988 were examined retrospectively. The patients were divided into two groups: group 1 patients (n = 14) were treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition; group 2 patients (n = 16) were treated by NAM, GPP, lip repair, and primary nasal repair. Patients who required secondary alveolar bone graft after GPP were noted. The cost of treatment by each protocol was calculated in 1998 dollars. RESULTS: The average cost of treatment for a patient treated by lip repair, primary nasal repair, and secondary alveolar bone graft prior to eruption of permanent dentition was $22,744. Of the 16 patients treated by NAM, GPP, lip repair, and primary nasal repair, 10 required no further treatment of the unilateral cleft alveolus; six patients required secondary alveolar bone graft. The average per-patient treatment cost in this group was $19,745. The average cost savings of NAM and GPP, compared with alveolar bone graft is $2999. CONCLUSIONS: The treatment of unilateral cleft alveolus by nasoalveolar molding and gingivoperiosteoplasty results in substantial cost savings, compared with treatment by secondary alveolar bone graft.

Short-term cost-effectiveness analysis of presurgical orthopedic treatment in children with complete unilateral cleft lip and palate.

OBJECTIVE: The aim of this article was to investigate cost-effectiveness in cleft palate treatment using cost-effectiveness of presurgical orthopedic treatment (PSOT) as an example. DESIGN: A three-center randomized clinical trial compared PSOT with non-PSOT for children with unilateral cleft lip and palate (UCLP, n=52). PATIENTS: The inclusion criteria for the trial were: complete UCLP, no other malformations, born at term, both parents Caucasian, trial entrance preferably within 2 weeks after birth, and informed consent by the parents. INTERVENTIONS: PSOT was performed by means of a passive plate according to Hotz and Gnoinski. MAIN OUTCOME MEASURE: The short-term cost-effectiveness of PSOT was based on the time taken for the surgical lip closure procedure. Medical and nonmedical costs until surgical lip closure at 18 weeks of age were analyzed. RESULTS: The durations of the surgical lip closure procedures did not differ significantly (57.2 minutes for PSOT and 56.4 minutes for non-PSOT). The mean medical cost for PSOT treatment was US$852. The non-PSOT treatment group had a significantly different mean medical cost (US$304). Mean travel costs and indirect nonmedical costs were US$128 and US$231 for PSOT and US$79 and US$130 for non-PSOT, respectively. CONCLUSIONS: The combination of a clinical trial and an economic evaluation makes it possible to relate effects to costs involved in treatment alternatives. Longer-term costs and effects will be incorporated into an extended cost-effectiveness analysis to determine the cost-effectiveness of PSOT.

The relative value of provider work for maxillofacial prosthetic services.

The results of a national survey of members of the American Academy of Maxillofacial Prosthetics who estimated the relative value of provider work for nine existing and two proposed coded maxillofacial prosthetic services is reported. The work estimates are a necessary component of a larger effort by the Health Care Financing Administration to establish a resource-based relative value scale for reimbursement for all Medicare services. Analysis of the survey data reveals agreement regarding the relative value of work for maxillofacial services compared with other established medical procedures and that the median values for each service are acceptable initial estimates.

Patient appointments during interim obturation: is it cost-effective?

PURPOSE: The purpose of this study was to quantify the number of patient appointments needed during the interim obturator service period in the Department of Dental Oncology at MD Anderson Cancer Center (Houston, TX). MATERIALS AND METHODS: A retrospective study evaluating 100 patient records of patients who underwent maxillectomies between 1989 and 1993. RESULTS: Of the 100 patients analyzed, 42 patients had a definitive prosthesis fabricated within 90 days after surgery. On average, 12 appointments (range, 6-24 appointments) were recorded for each patient during this 90-day global interim obturator period. CONCLUSIONS: The 12 appointments reflect a considerable amount of clinical and laboratory effort and reinforces the national concern of proper reimbursement.

Maxillofacial prosthetics: a preliminary analysis of Resource Based Relative Value Scale.

A study done by the American Academy of Maxillofacial Prosthetics to evaluate the Medicare Resource Based Relative Value Scale (RBRVS) as it relates to maxillofacial prosthetics. The method of RBRVS formulation is described. The degree of difficulty and treatment time were determined for nine Physicians' Current Procedural Terminology-edition 4 (CPT-4) codified maxillofacial procedures. A preliminary survey indicates that practice expense and malpractice expense ratios were 66% and 1%, respectively. Correlation of maxillofacial procedures to other medical procedures was not performed because an additional study with a greater sample size is needed.