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-- Head and Neck Surgery
Cost-Effectiveness in Otolaryngology
Mark G. Shrime
Otolaryngology -- Head and Neck Surgery 2012 147: 180
DOI: 10.1177/0194599812446789
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180
ears have received oxymetazoline drops at the time of middle
ear ventilation tube insertion without any adverse outcome.
In our study, we used our validated chinchilla animal model5
to test the ototoxicity of Drixoral, an over-the-counter preparation of oxymetazoline. Our results demonstrate that a one-time
application of oxymetazoline at the time of ventilation tube
insertion does not lead to demonstrable ototoxicity either functionally or morphologically, as measured by distortion product
otoacoustic emission and surface electron microscopy. This
corroborates the findings of Dr Isaacson, using a different
model.3 Although extrapolations from animal studies to humans
should be done carefully, the chinchilla animal model is an
exquisitely sensitive model for toxicity as its round window
membrane (RWM) is 4 to 7 times thinner than the RWM in
humans, thereby allowing a much easier penetration of the toxic
agents into the cochlea. It can be deduced that oxymetazoline,
being safe through the thinner RWM of the chinchilla, may be
also safe in the much thicker human RWM. In our study, oxymetazoline was applied only once after placement of the ventilation tube to mimic the clinical procedure whereby patients
would receive drops of oxymetazoline as a hemostatic agent or
to unblock the tympanostomy tube intraoperatively.
More knowledge will become available in the near future
as to the safety of long-term/prolonged usage of oxymetazoline, as well as its direct effects on cochlear blood flow and
on the electrophysiological activities of cochlear cells. Until
then, the intraoperative use of oxymetazoline to unblock
ventilation tubes or stop bleeding appears to be a safe and
effective tool at the disposal of the otolaryngologist.
Sam J. Daniel, MD, FRCSC
Departments of Otolaryngology–Head & Neck Surgery and
Pediatric Surgery, McGill University, Montreal Children’s
Hospital, Montreal, Quebec, Canada
Email: [email protected]
Otolaryngology–Head and Neck Surgery 147(1)
Disclosures
Competing interests: Sam J. Daniel received payment for development of educational material and consultant fees from Merck (previously Schering-Plough).
Sponsorships: None.
Funding source: None.
References
1.Daniel SJ, Akinpelu OV, Sahmkow S, Funnell WR, Akache F.
Oxymetazoline ototoxicity in a chinchilla animal model. Otolaryngol Head Neck Surg. 2012;146:114-118.
2.Kumar VV, Gaughan J, Isaacson G, Szeremeta W. Oxymetazoline is
equivalent to ciprofloxacin in preventing postoperative otorrhea or
tympanostomy tube obstruction. Laryngoscope. 2005;115:363-365.
3. Isaacson G, Buttaro BA, Mazeffa V, Li G, Frenz DA. Oxymetazoline solutions inhibit middle ear pathogens and are not ototoxic.
Ann Otol Rhinol Laryngol. 2005;114:645-651.
4.Seidman MD. Is oxymetazoline really safe for middle ear use?
Laryngoscope. 2005;115:1321-1323.
5.Daniel SJ, Sahmkow S, Akinpelu OV. Is ototopical nystatin
ototoxic? A chinchilla model. Otolaryngol Head Neck Surg.
2011;145:1022-104.
Cost-Effectiveness in Otolaryngology
DOI: 10.1177/0194599812446789
Singer et al have published a case series of 307 patients undergoing total or completion thyroidectomy whom they have
treated with postoperative calcium carbonate supplementation
without biochemical assays of either calcium or parathyroid
hormone levels.1 They find that only 7.5% of their patients
required additional supplementation, and only 2 (0.65%)
required admission using this protocol. Because they assert
that the cost of a 3-week regimen of calcium supplementation
Figure 1. Cost-effective strategies by probability of hospital admission and cost of a hospital admission. The most cost-effective strategy at
any combination of probability and cost is color-coded
according to the legend at right. Ionized calcium assays are the most cost-effective
Downloaded from oto.sagepub.com at Harvard University on July 4, 2012
strategy across a broad range of costs and probabilities..
Letters to the Editor
is $15, compared with up to $293 for biochemical parathyroid
hormone assays, they conclude that “prophylactic calcium
supplementation without routine laboratory assessment
proved to be . . . safe and cost-effective.”
Unfortunately, their data do not support this claim.
“Cost-effective” does not mean “cheapest” (see, for example,
Russell et al2). For an intervention to be cost-effective, it must
either be less costly and more effective than its competitor intervention or more costly and more effective than its competitor. By
these metrics, immediate calcium supplementation does not necessarily qualify as a cost-effective intervention.
The authors do not give enough information for a rigorous
cost-effectiveness analysis to be performed on their data.
However, making a few assumptions (that biochemical testing
decreases the risk of hypocalcemia, both inpatient and outpatient; that the authors’ probabilities are applicable to the general population; that the authors’ costs are correct; and that the
cost of a hospital admission is not zero, which it is implicitly
assumed to be in the authors’ article), supplementation without biochemical assays is cost-effective only across a small
range of probabilities and costs. Ionized calcium testing is
more cost-effective than supplementation across a very reasonable set of probabilities and costs (Figure 1), many of
which are similar to those found in the published literature.3
While it is true that the nominal cost of calcium supplementation is lower than the nominal cost of biochemical
assays, it is erroneous to claim that it is therefore a more costeffective intervention.
Mark G. Shrime, MD, MPH
Harvard Interfaculty Initiative in Health
Policy, Cambridge, Massachusetts, USA
Email: [email protected]
181
Effective Method”1 and for providing an opportunity to clarify the objective of our approach.
We sought to simplify the management of patients undergoing thyroid surgery using an approach that is cost-effective.
We use the common definition of cost-effective, namely, “economical in terms of tangible benefits produced by money
spent” (Webster’s Dictionary) or “the minimal expenditure of
dollars, time, and other elements necessary to achieve the
health care result deemed necessary and appropriate”
(Mosby’s). We specifically disagree that to be “cost-effective,”
an intervention “must be less costly and more effective, or
more costly and more effective,” as proposed by Dr Shrime.
Neither do we agree that “biochemical testing decreases
the risk of hypocalcemia.” Testing represents a way to diagnose the condition. A patient who needs to be admitted after
surgery needs to be admitted regardless of how this need is
determined. The cost of this admission is independent of the
approach used to reach that conclusion, and indeed a very
small minority of patients (0.65% in our experience) will
require admission.
Regrettably, Dr Shrime appears to have misunderstood that
what is cost-effective (and safe and simple) is the supplementation of all patients with the intention of sending them home
rather than the acquisition of an expensive battery of tests.
Interestingly, a recent independent analysis reached the same
conclusions regarding cost-effectiveness as we did (and
favored routine supplementation over acquisition of the parathyroid hormone assay).2
Our data are clear. This is an effective and safe strategy
(and by the way, it is less costly). We encourage Dr Shrime to
consider pursuing routine supplementation in his patients
because we are confident he will promptly adopt this approach.
Disclosures
Michael C. Singer, MD
David J. Terris, MD
Georgia Health Sciences University,
Augusta, Georgia, USA
Email: [email protected]
Competing interests: None.
Sponsorships: None.
Funding source: None.
References
1. Singer MC, Bhakta D, Seybt MW, Terris DJ. Calcium management after thyroidectomy: a simple and cost-effective method.
Otolaryngol Head Neck Surg. 2012;146:362-365.
2.Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC.
The role of cost-effectiveness analysis in health and medicine.
Panel on Cost-Effectiveness in Health and Medicine. JAMA.
1996;276:1172-1177.
3.Shrime MG, Goldstein DP, Seaberg RM, et al. Cost-effective
management of low-risk papillary thyroid carcinoma. Arch Otolaryngol Head Neck Surg. 2007;133:1245-1253.
Cost-Effective by Any Definition:
Response to “Cost-Effectiveness in
Otolaryngology,” from Mark G. Shrime
Disclosures
Competing interests: David J. Terris directed a series of thyroid
courses sponsored by Johnson & Johnson.
Sponsorships: None.
Funding source: None.
References
1.Singer MC, Bhakta D, Seybt MW, Terris DJ. Calcium management after thyroidectomy: a simple and cost-effective method.
Otolaryngol Head Neck Surg. 2012;146:362-365.
2.Wang TS, Cheung K, Roman SA, Sosa JA. To supplement or
not to supplement: a cost-utility analysis of calcium and vitamin D repletion in patients after thyroidectomy. Ann Surg Oncol.
2011;18:1293-1299.
DOI: 10.1177/0194599812446790
We thank Dr Shrime for his interest in our article “Calcium
Management after Thyroidectomy: A Simple
Cost- at Harvard University on July 4, 2012
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