Cost Benefit and Utility Decision Analysis of Turbinoplasty with Adenotonsillectomy for Pediatric Sleep-Disordered Breathing.

OBJECTIVES: Use decision analysis techniques to assess the potential utility gains/losses and costs of adding bilateral inferior turbinoplasty to tonsillectomy/adenoidectomy (T/A) for the treatment of obstructive sleep-disordered breathing (oSDB) in children. Use sensitivity analysis to explore the key variables in the scenario. STUDY DESIGN: Cost-utility decision analysis model. SETTING: Hypothetical cohort. SUBJECTS AND METHODS: Computer software (TreeAge Software, Williamstown, Massachusetts) was used to construct a decision analysis model. The model included the possibility of postoperative complications and persistent oSDB after surgery. Baseline clinical and quality-adjusted life year (QALY) parameters were estimated using published data. Cost data were estimated from Centers for Medicare and Medicaid 2018 databases ( www.cms.gov ). Sensitivity analyses were completed to assess for key model parameters. RESULTS: The utility analysis of the baseline model favored the addition of turbinoplasty (0.8890 vs 0.8875 overall utility) assuming turbinate hypertrophy was present. Sensitivity analysis indicated the treatment success increase (%) provided by concurrent turbinoplasty was the key parameter in the model. A treatment success increase of 3% of turbinoplasty was the threshold where concurrent turbinoplasty was favored over T/A alone. The incremental cost-effectiveness ratio (ICER) of $27,333/QALY for the baseline model was favorable to the willingness-to-pay threshold of $50,000 to $100,000/QALY for industrialized nations. CONCLUSIONS: The addition of turbinoplasty for children with turbinate hypertrophy to T/A for the treatment of pediatric oSDB is beneficial from both a utility and cost-benefit analysis standpoint even if the benefits of turbinoplasty are relatively modest.

The relationship of the uvula with snoring and obstructive sleep apnea: a systematic review.

Currently, the relationship between uvula size and sleep-disordered breathing (snoring and obstructive sleep apnea) lacks data for objective interpretation. This study conducted a systematic review of the international literature for research describing the measurable characteristics of the uvula (i.e., size, length, width) and any association with snoring and obstructive sleep apnea (OSA). PubMED, Scopus, Google Scholar, Embase, and the Cochrane Library were each systematically searched from inception through November 15, 2016. We screened 1037 titles and abstracts. We conducted a full review of 54 downloaded articles. Sixteen articles met inclusion and exclusion criteria. The 16 studies included a total of 2604 patients. The selected articles included data and information for (1) normative data for uvular size in the control groups, (2) snoring and uvula size, (3) OSA and uvula size, and (4) overall uvula function. Our review noted variability in findings; however, in general, a uvular length > 15 mm was considered elongated and a uvular width > 10 mm was considered to be wide. The studies included in this systematic review reveal a relationship between uvula size, snoring, and OSA. Further, larger uvulas appear associated with more severe snoring and OSA. The direct correlation between uvula size and its relationship specifically to snoring and OSA remain as topics for future prospective research.

Comparison of Pediatric Intracapsular Tonsillectomy and Extracapsular Tonsillectomy: A Cost and Utility Decision Analysis.

Objectives To use decision analysis modeling to compare utility and cost outcomes of intracapsular tonsillectomy (ICT) and extracapsular tonsillectomy (ECT). To use sensitivity analysis to determine the most important factors influencing outcomes favoring one surgical method versus another. Study Design Decision analysis model. Setting Hypothetical cohort. Subjects and Methods A decision analysis model was created with computer software comparing the results of ICT and ECT. The model featured complications with completion tonsillectomy, such as postsurgical bleed, dehydration, and tonsillar regrowth. Outcomes were quantified with a utility scale ranging from 0.95 (1 surgical procedure without complications) to 0.55 (ICT, regrowth requiring completion ECT, post-ECT bleeding). Costs measured out-of-pocket costs for an insured patient and factored in different recovery times for ECT versus ICT. Results Based on baseline parameters, ECT had higher cumulative utility than ICT. Utility model results were highly dependent on the value of having a single uncomplicated surgery, as well as on the tonsillar regrowth rate. Utility was equal at a regrowth rate of 1.64%; rates above this value favored ECT. The base cost model showed that ICT ($4177.92) was less expensive than ECT ($4546.91), although ICT with regrowth had the highest outcome cost ($8393.91). ECT and ICT costs were equal at a tonsil regrowth rate of 17.8% and at a recovery period of 7.4 days. Conclusion Utility decision modeling based on best estimates for baseline parameters suggests that ECT may be slightly superior to ICT, but cost analysis suggests the opposite. However, the comparative results are highly dependent on subtle changes in the tonsil regrowth rate and the potential difference in recovery time.

How much does the type of tympanostomy tube matter? A utility-based Markov decision analysis.

OBJECTIVES: To use a utility-based Markov decision analysis model to compare outcomes of short-term grommet tympanostomy tubes (TTs), intermediate-type tubes, and permanent T-Tubes and to use a detailed sensitivity analysis to determine the most important factors influencing outcomes with one type of TT versus another. STUDY DESIGN: Markov decision analysis. SETTING: Hypothetical cohort. SUBJECTS AND METHODS: A Markov cohort decision analysis model was created using computer software (TreeAge Software, Inc, Williamstown, Massachusetts) comparing the 3 types of TT. Published data were used to determine key baseline model parameters. The model featured potential complications including eardrum perforation, early TT extrusion/blockage, and the need for possible repeat TT placement after extrusion. Outcomes were quantified using a 0.95 (1 procedure, full recovery) to 0.6 (failed myringoplasty) utility scale. Utility values were discounted over time to incorporate real-life inconvenience. RESULTS: The intermediate TT accumulated superior total utility in 2-, 4-, and 6-year models (2.48, 3.96, and 5.27 total utility) compared with grommets (2.32, 3.82, 5.18) and T-Tubes (2.42, 3.86, 5.18). Examining a hypothetically otherwise healthy 3000-child cohort, T-Tubes resulted in an increased overall persistent perforation rate (7.9% vs 0.2%, P < .001, χ(2)). Sensitivity analysis indicated that the rate of repeat TT placement, the utility assigned to having a functional tube in place, and the inconvenience utility discount factor over time were the driving factors of the model. CONCLUSION: The intermediate TT may produce optimal outcomes as it combines a balance of a lower perforation rate than T-Tubes and a longer period of ventilation than grommet tubes.

Influence of neurobehavioral incentive valence and magnitude on alcohol drinking behavior.

The monetary incentive delay (MID) task is a widely used probe for isolating neural circuitry in the human brain associated with incentive motivation. In the present functional magnetic resonance imaging (fMRI) study, 82 young adults, characterized along dimensions of impulsive sensation seeking, completed a MID task. fMRI and behavioral incentive functions were decomposed into incentive valence and magnitude parameters, which were used as predictors in linear regression to determine whether mesolimbic response is associated with problem drinking and recent alcohol use. Alcohol use was best explained by higher fMRI response to anticipation of losses and feedback on high gains in the thalamus. In contrast, problem drinking was best explained by reduced sensitivity to large incentive values in mesolimbic regions in the anticipation phase and increased sensitivity to small incentive values in the dorsal caudate nucleus in the feedback phase. Altered fMRI responses to monetary incentives in mesolimbic circuitry, particularly those alterations associated with problem drinking, may serve as potential early indicators of substance abuse trajectories.