Cost-effectiveness of intraoperative nerve monitoring in avoidance of bilateral recurrent laryngeal nerve injury in patients undergoing total thyroidectomy.

BACKGROUND: Intraoperative nerve monitoring (IONM) provides dynamic neural information and is recommended for high-risk thyroid surgery. In this analysis, the cost-effectiveness of IONM in preventing bilateral recurrent laryngeal nerve (RLN) injury was investigated. METHODS: A Markov chain model was constructed based on IONM use. The base-case patient was defined as a 40-year-old woman presenting with a 4·1-cm left-sided papillary thyroid cancer who developed RLN injury with loss of monitoring signal during planned bilateral thyroidectomy. It was hypothesized that, if the surgeon had used IONM, the RLN injury would have been detected and the operation would have been concluded as a thyroid lobectomy to avoid the risk of contralateral RLN injury. Cost in US dollars was converted to euros; probabilities and utility scores were identified from the literature and government resources. Length of follow-up was set as 20 years, and willingness-to-pay (WTP) as €38 000 (US $50 000) per quality-adjusted life-year (QALY). RESULTS: At the end of year 20, the not using IONM strategy accrued €163 995·40 (US $215 783·43) and an effectiveness of 14·15 QALYs, whereas use of the IONM strategy accrued €170 283·68 (US $224 057·48) and an effectiveness of 14·33 QALYs. The incremental cost-effectiveness ratio, comparing use versus no use of IONM, was €35 285·26 (US $46 427·97) per QALY, which is below the proposed WTP, indicating that IONM is the preferred and cost-effective management plan. A Monte Carlo simulation test that considered variability of the main study factors in a hypothetical sample of 10 000 patients showed IONM to be the preferred strategy in 85·8 per cent of the population. CONCLUSION: Use of IONM is cost-effective in patients undergoing bilateral thyroid surgery.

Surgeon volume impact on outcomes and cost of adrenal surgeries.

INTRODUCTION: The number of adrenal surgeries performed in the United Stated is continuing to increase. Identifying factors associated with favorable outcomes can have a major impact on cost-differences. We aim to assess the impact of surgeon volume on both clinical outcomes and cost following adrenal surgery. MATERIALS AND METHODS: A cross-sectional analysis was performed utilizing data from the Nationwide Inpatient Sample, 2003-2009. Surgeon volumes included (adrenalectomies/year): low-volume (1), intermediate-volume (2-6), and high-volume (≥7). RESULTS: A total of 7045 patients were included. Surgeries performed by low-volume surgeons were associated with a higher risk of postoperative complications [OR: 1.66, 95% CI: (1.23, 2.24)]. During the study period, if all operations performed by low-volume surgeons were selectively referred to intermediate-volume surgeons, a 7.7% cost savings would have been incurred. Potential savings were even higher (8.1%) if the operations had been performed by the high-volume surgeons. With the conservative assumption that there are 5000 adrenalectomies per year in the United States, the high-volume surgeons would produce savings of $8.8 million over a span of 14 years. CONCLUSION: A surgeon's expertise is associated with favorable outcomes. Our model estimates that considerable cost savings are attainable with appropriate referrals to high volume endocrine surgeons.

Comparison of inpatient and outpatient thyroidectomy: Demographic and economic disparities.

BACKGROUND: Thyroidectomy is increasingly being performed as an outpatient procedure. In this study, we aim to examine patient characteristics and clinical factors associated with outpatient thyroid surgeries as compared to inpatient procedures. METHODS: A cross-sectional study for the period of 2007-2010. Inpatients and outpatients were selected from the Nationwide Inpatient Sample and State Ambulatory Surgery and Services Databases, respectively. All patients were adults (≥18 years) who underwent thyroidectomy in the States of Florida and New York. RESULTS: A total of 25,267 outpatients, and 8219 inpatients were included. Outpatients were more likely to be female, White, have private insurance, and have one or no comorbidities (p < 0.001 each). Thyroid surgeries performed for thyroid conditions other than malignancy were more common in the outpatient settings (p < 0.05 each). High-volume surgeons were more likely to perform ambulatory thyroidectomy (p < 0.001). Post-outpatient thyroidectomy complications were higher for lower volume surgeons (p < 0.001). Moreover, hospital charges for outpatient surgeries performed by lower volume surgeons were significantly higher compared to high-volume surgeons (p < 0.001). CONCLUSIONS: Racial and economic disparities exist in the utilization of ambulatory thyroidectomy. Experienced surgeons are more likely to provide ambulatory thyroidectomy, and surgeries performed by them are associated with more favorable outcomes and lower hospital charges.