Reconstruction After Salvage Total Laryngectomy: A Cost‐effectiveness Analysis

Acevedo, Joseph R.; Yu, Jeffrey C.; Cameron, Brian; Nurimba, Margaret; Hay, Joel W.; Kokot, Niels

doi:10.1177/0194599820936264

Cited by 6 publications

(6 citation statements)

References 31 publications

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“…The financial impact of immunotherapy is especially clear when compared with the cost of standard treatment options for head and neck cancer such as surgery, intensity‐modulated radiation therapy (IMRT), and chemotherapy. Using data from the Centers for Medicaid & Services (CMS), Acevedo et al estimated the cost of a total laryngectomy with free flap reconstruction to be $36 762 to $47 064 or roughly half of the estimated cost of immunotherapy per patient calculated here 56 . When accounting for the heterogeneity and varying complexity of surgical procedures for head and neck cancer, the average cost has been estimated to be as low as $18 140 57 .…”

Section: Discussionmentioning

confidence: 99%

Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma

et al. 2020

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Background Delays in treatment of head and neck squamous cell carcinoma (HNSCC) are known to increase disease recurrence, generating the need for additional salvage treatment, often with immunotherapy. Methods Three treatment metrics were identified: time from diagnosis to treatment initiation (TTI), time from surgery to postoperative radiotherapy (surg → PORT), and total treatment package time (TPT). Financial toxicity was calculated using hazard ratios, pembrolizumab cost, and dosing data for a Veterans Health Administration (VHA) institutional cohort (n = 338) and a standardized cohort (n = 100). Results Estimated financial toxicity for the VHA cohort was $2 047 407, $316 545, and $1 114 101 for TTI, surg → PORT, and TPT, respectively. Estimated financial toxicity for the standardized patient cohort was $454 028, $544 576, and $1 879 628 for TTI, surg → PORT, and TPT, respectively. Conclusions Failure to meet established HNSCC treatment metrics generates significant, yet avoidable, institutional financial toxicity which is particularly relevant to integrated single‐payer systems such as the VHA in the modern immunotherapy era.

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Section: Discussionmentioning

confidence: 99%

Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma

et al. 2020

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“…In the United States, $150,000 per QALY gained is in the range of generally accepted “willingness to pay” thresholds. 15 It is important to note that willingness-to-pay thresholds vary by person, region, health care system, or country. We considered anything <$150,000 per QALY as cost-effective over its comparator (www.ICER.org).…”

Section: Methodsmentioning

confidence: 99%

“…The cost‐effectiveness of each strategy was then determined by calculating an incremental cost‐effectiveness ratio (ICER), which represents the incremental cost of each QALY gained between the 2 strategies (ICER = Cost 1 – Cost 2 / QALY 1 – QALY 2 ). In the United States, $150,000 per QALY gained is in the range of generally accepted “willingness to pay” thresholds 15 . It is important to note that willingness‐to‐pay thresholds vary by person, region, health care system, or country.…”

Section: Methodsmentioning

confidence: 99%

Cost‐effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis

Acevedo

Hsu

et al. 2021

Otolaryngol.--head neck surg.

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Objective To compare the cost-effectiveness of sialendoscopy with gland excision for the management of submandibular gland sialolithiasis. Study Design Cost-effectiveness analysis. Setting Outpatient surgery centers. Methods A Markov decision model compared the cost-effectiveness of sialendoscopy versus gland excision for managing submandibular gland sialolithiasis. Surgical outcome probabilities were found in the primary literature. The quality of life of patients was represented by health utilities, and costs were estimated from a third-party payer’s perspective. The effectiveness of each intervention was measured in quality-adjusted life-years (QALYs). The incremental costs and effectiveness of each intervention were compared, and a willingness-to-pay ratio of $150,000 per QALY was considered cost-effective. One-way, multivariate, and probabilistic sensitivity analyses were performed to challenge model conclusions. Results Over 10 years, sialendoscopy yielded 9.00 QALYs at an average cost of $8306, while gland excision produced 8.94 QALYs at an average cost of $6103. The ICER for sialendoscopy was $36,717 per QALY gained, making sialendoscopy cost-effective by our best estimates. The model was sensitive to the probability of success and the cost of sialendoscopy. Sialendoscopy must meet a probability-of-success threshold of 0.61 (61%) and cost ≤$11,996 to remain cost-effective. A Monte Carlo simulation revealed sialendoscopy to be cost-effective 60% of the time. Conclusion Sialendoscopy appears to be a cost-effective management strategy for sialolithiasis of the submandibular gland when certain thresholds are maintained. Further studies elucidating the clinical factors that determine successful sialendoscopy may be aided by these thresholds as well as future comparisons of novel technology.

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“…We read the recent publication titled “Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis” with interest. 1 We have significant concerns with several methodological factors that bias the results of the study. The authors state numerous times that flap reconstruction in this setting results in more significant long-term morbidity.…”

mentioning

confidence: 99%

“…We read the recent publication titled “Reconstruction After Salvage Total Laryngectomy: A Cost‐effectiveness Analysis” with interest 1 . We have significant concerns with several methodological factors that bias the results of the study.…”

mentioning

confidence: 99%

Letter to the Editor Regarding “Reconstruction After Salvage Total Laryngectomy: A Cost‐effectiveness Analysis”

Bollig¹,

Pipkorn²

2021

Otolaryngol.--head neck surg.

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We appreciate the opportunity to respond to this letter. In fact, this is Dr Lou's 22nd ''letter to the editor'' in tympanic membrane (TM) repair, mainly referring to his own studies.Dr Lou claimed that failure of TM healing is due to lack of epithelial migration, not absence of the fibrous layer, and that biological scaffold is not required. We do not agree. TM wound healing is complex. Chronicity may arise from reepithelialization of perforation margin, 1 lack of structural support in guiding tissue as TM is suspended in midair, and lack of growth factors. 2 As the fibrous layer is the last to migrate across a perforation, it occasionally fails to migrate, leaving a dimeric structure. While the perforation looks healed, this atypical neomembrane is associated with suboptimal hearing, retraction pockets, atelectatic TM, and, ultimately, cholesteatoma. 3 To enhance TM healing, both scaffolds and growth factors are commonly used with different underlying mechanisms. Scaffolds provide structural support to guide regenerating tissue and act as a carrier to retain growth factors, while growth factors induce cellular proliferation and migration. 2,3 For traumatic perforations, various studies have reported favorable results with the single use of scaffolds or growth factors. These scaffolds include silk, collagen, calcium alginate, and chitosan, while growth factors include basic fibroblast growth factor (bFGF) and epidermal growth factor. 2 Growth factors are typically applied as ear drops. Scaffolds vary in their attributes, and selecting a suitable scaffold is critical. 3 Currently, Gelfoam is the most commonly used carrier, despite possible adverse effects such as fibrosis. 3,4 Moreover, Gelfoam loses its scaffold function in early stages, 3 and this may be the main reason for suboptimal outcomes in many studies. 5 In our study, we have shown that treatment with an acellular collagen scaffold (ACS) as a carrier for bFGF results in the successful TM repair of traumatic perforations. Most important, using various modalities (otoscopy, optical coherence tomography, histology, transmission electron microscopy), we were able to show that combination of ACS as scaffold and bFGF as growth factors resulted in the formation of trilaminar TM with uniform thickness, densely packed with collagen fibers. Not only does this improve TM closure rates, but this better reconstructed TM also shows improved hearing outcomes, further supporting the role of a bioscaffold in combination with growth factors.

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Reconstruction After Salvage Total Laryngectomy: A Cost‐effectiveness Analysis

Cited by 6 publications

References 31 publications

Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma

Institutional financial toxicity of failure to adhere to treatment guidelines for head and neck squamous cell carcinoma

Cost‐effectiveness Analysis of Submandibular Gland Preservation With Sialendoscopy for the Management of Sialolithiasis

Letter to the Editor Regarding “Reconstruction After Salvage Total Laryngectomy: A Cost‐effectiveness Analysis”

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