How cost effective is tracheostomy versus endoscopic management in the treatment of bilateral vocal fold paralysis (BVFP)?
Endoscopic management of BVFP appears to be more cost-effective than tracheostomy.
Background: Traditionally, surgical management with tracheostomy was the treatment of choice for BVFP, but advances in endoscopic laryngeal surgery over the past 30 years have enabled practitioners to avoid tracheostomy and its attendant morbidity. Though endoscopic BVFP management is a well-studied alternative to tracheostomy, its economic and quality-of-life benefits are not well understood.
Study design: Cost-effectiveness analysis through a review of literature; additional information from CDC life tables, Medicare and World Health Organization data, and consumer price index ratios from the U.S. Bureau of Labor Statistics.
Setting: Massachusetts Eye and Ear Infirmary, Boston.
Synopsis: In the short term, tracheostomy strategy total cost was $7,894.78, with a utility value of 0.845. The endoscopic strategy total cost was $9,295.32, with a utility of 0.890. Over the long term, endoscopic management dominates tracheostomy, with a higher overall cost ($53,708.15 versus $17,860.88) and a lower utility (14.93 vs. 15.72 QALYs [quality-adjusted life years]). In the short term, the cost-effectiveness of the two options became equal if the tracheostomy cost dropped to $673.50 (base $1,513.17) or when the endoscopic cost rose to $5,014.99 (base $4,310.61). When tracheostomy utility was increased to 0.867, or when dysphonia utility was decreased to 0.874, the strategies became equivalent in cost-effectiveness. The probability that the endoscopic management strategy was cost-effective was 65.1% at a willingness-to-pay (WTP) of $50,000/QALY. When long-term costs were factored in, endoscopic management was cost-effective at any WTP. Limitations include the prevalence of small, retrospective, single-institution BVFP studies, utility estimates not entirely specific to BVFP, varying methodologies for tracheostomy and dysphonia utilities, and a lack of data regarding long-term BVFP endoscopic management technique outcomes.
Citation: Naunheim MR, Song PC, Franco RA, Alkire BC, Shrimel MG. Surgical management of bilateral vocal fold paralysis: A cost-effectiveness comparison of two treatments. Laryngoscope. 2016;126:691–697.