Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e496-e503
World Neurosurgery

Original Article
Cost-Effectiveness of Endoscopic Versus Microscopic Transsphenoidal Surgery for Pituitary Adenoma

https://doi.org/10.1016/j.wneu.2017.11.046Get rights and content

Background

Endoscopic transsphenoidal surgery (ETPS) has become increasingly popular for resection of pituitary tumors, whereas microscopic transsphenoidal surgery (MTPS) also remains a commonly used approach. The economic sustainability of new techniques and technologies is rarely evaluated in the neurosurgical skull base literature. The aim of this study was to determine the cost-effectiveness of ETPS compared with MTPS.

Methods

A Markov model was constructed to conduct a cost-utility analysis of ETPS versus MTPS from a single-payer health care perspective. Data were obtained from previously published outcomes studies. Costs were based on Medicare reimbursement rates, considering covariates such as complications, length of stay, and operative time. The base case adopted a 2-year follow-up period. Univariate and multivariate sensitivity analyses were conducted.

Results

On average, ETPS costs $143 less and generates 0.014 quality-adjusted life years (QALYs) compared with MTPS over 2 years. The incremental cost-effectiveness ratio (ICER) is −$10,214 per QALY, suggesting economic dominance. The QALY benefit increased to 0.105 when modeled to 10 years, suggesting that ETPS becomes even more favorable over time.

Conclusions

ETPS appears to be cost-effective when compared with MTPS because the ICER falls below the commonly accepted $50,000 per QALY benchmark. Model limitations and assumptions affect the generalizability of the conclusion; however, ongoing efforts to improve rhinologic morbidity related to ETPS would appear to further augment the marginal cost savings and QALYs gained. Further research on the cost-effectiveness of ETPS using prospective data is warranted.

Introduction

The transsphenoidal approach to the pituitary gland was first developed in the early 20th century by Schloffer, Cushing, and Hirsch.1 Utilization expanded rapidly with the introduction of the operating microscope by Jules Hardy in the 1960s, and again with improvements in surgical safety and efficacy established by Wilson, Weiss, Laws, and others in the 1980s.2 Sinonasal morbidity was mitigated by the microscopic endonasal approach described by Griffith and Veerapen in 1987; this was further improved on by advances described by Cooke and Jones in 1994.3 This latter approach has become the most widely implemented in present day pituitary surgery.3 Endoscopy represents one of the latest major advancements in the evolution of pituitary surgical technique.

Various authors have suggested that endoscopic transsphenoidal pituitary surgery (ETPS) may have certain advantages compared with microscopic transsphenoidal pituitary surgery (MTPS).4, 5 For example, endoscopy provides improved visualization that results in improved likelihood of gross total tumor resection, increased endocrine remission rates, improved visual outcomes, and decreased likelihood of tumor recurrence.6, 7, 8, 9, 10 Theodosopoulos et al.11 demonstrated that the extent of gross total resections with ETPS was 66.7% and that only 14.8% of subtotal resections were initially misclassified (via endoscopic visualization) as gross total resection. This contrasted with a misclassification rate of 66% with MTPS.11 The endoscopic endonasal approach has also been associated with fewer surgical complications and shorter hospital stay.6, 7, 8, 9, 10

In the United States alone, >5,000 people undergo pituitary adenoma resection each year, with an associated surgical cost of >$100 million.12 In an era of scrutinized allocation of medical resources, it is important to examine if the clinical advantages of ETPS versus MTPS are also cost-effective.6, 10, 12, 13, 14, 15, 16, 17, 18, 19 A cost-utility analysis (CUA) is usually used to determine cost-effectiveness in health care, with utility referring to quality of life data (in units of quality-adjusted life years [QALYs]). Ideally, any increased cost associated with novel interventions or technologies is offset by improved QALYs to result in a favorable incremental cost-effectiveness ratio (ICER). Rarely, an increase in QALYs can be achieved for less cost, a situation referred to as economic dominance. The purpose of this study was to perform a CUA of ETPS versus MTPS for management of pituitary tumors.

Section snippets

Study Population

The Markov model was populated with a synthesis of input values from different sources. Quality of life data and complication probabilities were derived from a nonblinded multicenter exploratory prospective cohort study comparing 235 MTPSs and ETPSs.20 This was supplemented by cost data, where appropriate, from Oosmanally et al.,21 Little et al.,22 and Rudmik et al.23 Eligible patients from the multicenter cohort study were ≥18 years of age with pituitary pathology that had a planned primary or

Results

Data from 235 patients from the nonblinded multicenter exploratory prospective cohort study were analyzed.20 A Markov model was used to determine cost and utility (QALYs) over a 2-year time period for a patient with a pituitary tumor undergoing ETPS versus MTPS. The results are summarized in Table 2.

Discussion

In this study, we derived the ICER of ETPS compared with MTPS using 6-month trial data and conducted robust univariate and multivariate sensitivity analyses. ETPS was shown to be cost-effective based on the commonly accepted willingness-to-pay threshold of $50,000 per QALY.30, 31 This remains true while varying input parameters in multiple sensitivity analyses, reaffirming the stability of the model. From a third-party payer perspective, ETPS imparts greater quality of life at less cost than

Conclusions

This study is among the first to report the comparative cost-effectiveness of ETPS over MTPS for pituitary tumors at 2 years. It also appears reasonable that refinements in ETPS that improve rhinologic morbidity would be expected to further augment the cost savings and QALY benefit of ETPS over MTPS. Although the results appear consistent with similar investigations, given the significant assumptions and limitations, it represents a best-case scenario and should be considered informative and

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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