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El Sayed Ahmad Y, Gallois Y, Sol JC, Boetto S, Attal J, Sabatier J, Debs R, Deguine O, Marx M. Evolution in the management of vestibular schwannoma: a single-center 15-year experience. Eur Arch Otorhinolaryngol 2023; 280:4885-4894. [PMID: 37195345 DOI: 10.1007/s00405-023-08009-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE To highlight the changes in the management of vestibular schwannoma (VS) since 2004 with a focus on small- to middle-size VS. METHODS Retrospective analysis of the decisions made in skull base tumor board between 2004 and 2021. RESULTS 1819 decisions were analyzed (average age 59.25, 54% females). Overall, 850 (47%) cases were allocated to a Wait and Scan (WS) approach, 416 (23%) received radiotherapy and 553 (30%) were treated surgically (MS). All stages considered WS increased from 39% before 2010 to 50% after 2010. Similarly, Stereotactic Radio Therapy (SRT) increased from 5 to 18%. MS decreased from 46 to 25%. It was more commonly proposed to younger patients and larger tumors, p < 0.001. For Koos stages 1, 2, and 3 there was a statistically significant increase in SRT, and a decrease in MS, p < 0.001. WS also increased for stages 1 and 2. However, such a trend was not observed for stage 3. MS remained the primary treatment modality for stage 4 tumors throughout the study period, p = 0.057. The significance of advanced age as a factor favoring SRT decreased over time. The opposite is true for serviceable hearing. There was also a decrease in the percentage of the justification "young age" in the MS category. CONCLUSION The is a continuing trend towards non-surgical treatment. Small- to medium-sized VS witnessed an increase in both WS and SRT. There is only an increase in SRT for moderately large VS. Physicians are less and less considering young age as a factor favoring MS over SRT. There is a tendency towards favoring SRT when hearing is serviceable.
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Affiliation(s)
- Youssef El Sayed Ahmad
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France.
| | - Yohan Gallois
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
| | | | - Sergio Boetto
- Neuro-Surgery Department, CHU de Toulouse, Purpan, 31000, Toulouse, France
| | - Justine Attal
- Radiotherapy Department, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Jean Sabatier
- Department of Neuroradiology, Purpan Hospital, Toulouse, France
| | - Rachel Debs
- Department of Neurology, Pierre-Paul Riquet/Purpan University Hospital, Toulouse, France
| | - Olivier Deguine
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
| | - Mathieu Marx
- Department of Otology, Otoneurology and Pediatric Otolaryngology, Pierre-Paul Riquet Hospital, Toulouse University hospital, Toulouse, France
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Nabuurs CH, Kievit W, Haegens L, Grutters JPC, Kunst HPM. A first exploration of the economic consequences of an autonomous surgical robot for lateral skull base surgery: an early health technology assessment. Int J Technol Assess Health Care 2023; 39:e46. [PMID: 37522518 DOI: 10.1017/s0266462323000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Lateral skull base procedures, such as translabyrinthine approach (TLA), are challenging. An autonomous surgical robot might be a solution to these challenges. Our aim is to explore in an early phase the economic consequences of an autonomous surgical robot compared with conventional TLA. METHODS An early decision analytic model was constructed in order to perform a step-wise threshold analyses and a sensitivity analysis to analyze the impact of the several factors on the incremental costs. RESULTS Using surgical robot results in incremental costs - EUR 5,562 per procedure - compared to conventional TLA. These costs are most reduced by higher number of procedures, followed by lower price of the robot, saved operation time, and reduced risk of complication, respectively. CONCLUSIONS The incremental costs of using an autonomous surgical robot can be decreased by choosing applications with a high turnover rate, a long operation time, and a high complication rate.
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Affiliation(s)
- Cindy H Nabuurs
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Rare Cancers, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Academic Alliance Skull Base Pathology Radboudumc - MUMC+, Nijmegen, The Netherlands
| | - Wietske Kievit
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Rare Cancers, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Academic Alliance Skull Base Pathology Radboudumc - MUMC+, Nijmegen, The Netherlands
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lex Haegens
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus P M Kunst
- Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Rare Cancers, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Academic Alliance Skull Base Pathology Radboudumc - MUMC+, Nijmegen, The Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Marinelli JP, Lohse CM, Carlson ML. Introducing an Evidence-Based Approach to Wait-And-Scan Management of Sporadic Vestibular Schwannoma. Otolaryngol Clin North Am 2023; 56:445-457. [PMID: 37019767 DOI: 10.1016/j.otc.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
The advent of MRI has led to more sporadic vestibular schwannomas diagnosed today than ever before. Despite the average patient being diagnosed in their sixth decade of life with a small tumor and minimal symptoms, population-based data demonstrate that more tumors per capita are treated today than ever before. Emerging natural history data justify either an upfront treatment approach or the "Size Threshold Surveillance" approach. Specifically, if the patient elects to pursue observation, then existing data support the tolerance of some growth during observation in appropriately selected patients up until a specific size threshold range (about 15 mm of CPA extension). The current article discusses the rationale behind a shift in the existing observation management approach, where initial detection of growth typically begets treatment, and outlines the application of a more flexible and nuanced approach based on existing evidence.
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4
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Vergara Olmos G, Dabiri S, Rutka J. Editorial. Decision-making in the surgical management of a vestibular schwannoma: when timing is everything (cum sincere omnia). J Neurosurg 2022; 136:1285-1286. [PMID: 34653982 DOI: 10.3171/2021.5.jns21981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gabriela Vergara Olmos
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
| | - Sasan Dabiri
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
| | - John Rutka
- 1Division of Otology/Neurotology, Department of Otolaryngology-Head and Neck Surgery, University Health Network, University of Toronto, Ontario, Canada
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5
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Macielak RJ, Wallerius KP, Lawlor SK, Lohse CM, Marinelli JP, Neff BA, Van Gompel JJ, Driscoll CLW, Link MJ, Carlson ML. Defining clinically significant tumor size in vestibular schwannoma to inform timing of microsurgery during wait-and-scan management: moving beyond minimum detectable growth. J Neurosurg 2022; 136:1289-1297. [PMID: 34653971 DOI: 10.3171/2021.4.jns21465] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Detection of vestibular schwannoma (VS) growth during observation leads to definitive treatment at most centers globally. Although ≥ 2 mm represents an established benchmark of tumor growth on serial MRI studies, 2 mm of linear tumor growth is unlikely to significantly alter microsurgical outcomes. The objective of the current work was to ascertain where the magnitude of change in clinical outcome is the greatest based on size. METHODS A single-institution retrospective review of a consecutive series of patients with sporadic VS who underwent microsurgical resection between January 2000 and May 2020 was performed. Preoperative tumor size cutpoints were defined in 1-mm increments and used to identify optimal size thresholds for three primary outcomes: 1) the ability to achieve gross-total resection (GTR); 2) maintenance of normal House-Brackmann (HB) grade I facial nerve function; and 3) preservation of serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery class A/B). Optimal size thresholds were obtained by maximizing c-indices from logistic regression models. RESULTS Of 603 patients meeting inclusion criteria, 502 (83%) had tumors with cerebellopontine angle (CPA) extension. CPA tumor size was significantly associated with achieving GTR, postoperative HB grade I facial nerve function, and maintenance of serviceable hearing (all p < 0.001). The optimal tumor size threshold to distinguish between GTR and less than GTR was 17 mm of CPA extension (c-index 0.73). In the immediate postoperative period, the size threshold between HB grade I and HB grade > I was 17 mm of CPA extension (c-index 0.65). At the most recent evaluation, the size threshold between HB grade I and HB grade > I was 23 mm (c-index 0.68) and between class A/B and C/D hearing was 18 mm (c-index 0.68). Tumors within 3 mm of the 17-mm CPA threshold displayed similarly strong c-indices. Among purely intracanalicular tumors, linear size was not found to portend worse outcomes for all measures. CONCLUSIONS The probability of incurring less optimal microsurgical outcomes begins to significantly increase at 14-20 mm of CPA extension. Although many factors ultimately influence decision-making, when considering timing of microsurgical resection, using a size threshold range as depicted in this study offers an evidence-based approach that moves beyond reflexively recommending treatment for all tumors after detecting ≥ 2 mm of tumor growth on serial MRI studies.
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Affiliation(s)
| | | | | | | | | | - Brian A Neff
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jamie J Van Gompel
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- 1Department of Otolaryngology-Head and Neck Surgery
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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6
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Wijn SRW, Hentschel MA, Beynon AJ, Kunst HPM, Rovers MM. Auditory brainstem response prior to MRI compared to standalone MRI in the detection of vestibular schwannoma: A modelling study. Clin Otolaryngol 2021; 47:295-303. [PMID: 34784107 PMCID: PMC9298692 DOI: 10.1111/coa.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
Objectives To determine the cost‐effectiveness of auditory brainstem response prior to MRI (ABR‐MRI) compared to standalone MRI to diagnose vestibular schwannoma. Design A state transition model was developed to simulate costs and effects (quality‐adjusted life years [QALY]) for both diagnostic strategies for patients suspected of a vestibular schwannoma. Model input was derived from literature, hospital databases and expert opinions. Scenario and sensitivity analyses addressed model uncertainty. Results Over a lifetime horizon, ABR‐MRI resulted in a limited cost‐saving of €68 or €98 per patient (dependent on MRI sequence) and a health loss of 0.005 QALYs over standalone MRI. ABR‐MRI, however, did miss patients with other important pathology (2% of the population) that would have been detected when using standalone MRI. In total, €14 203 or €19 550 could be saved per lost QALY if ABR‐MRI was used instead of standalone MRI. The results were sensitive to the detection rate of vestibular schwannoma and health‐related quality of life of missed patients. Conclusion The cost‐saving with ABR‐MRI does not seem to outweigh the number of missed patients with VS and other important pathologies that would have been detected when using standalone MRI.
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Affiliation(s)
- Stan R W Wijn
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mayke A Hentschel
- Department of Otolaryngology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Academic Alliance Skull Base Pathology, Radboud University Medical Centre & Maastricht University Medical Centre, Nijmegen & Maastricht, The Netherlands
| | - Andy J Beynon
- Department of Otolaryngology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Academic Alliance Skull Base Pathology, Radboud University Medical Centre & Maastricht University Medical Centre, Nijmegen & Maastricht, The Netherlands
| | - Henricus P M Kunst
- Department of Otolaryngology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Academic Alliance Skull Base Pathology, Radboud University Medical Centre & Maastricht University Medical Centre, Nijmegen & Maastricht, The Netherlands.,Department of Otorhinolaryngology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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7
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Macielak RJ, Thao V, Borah BJ, Moriarty JP, Marinelli JP, Van Gompel JJ, Carlson ML. Lifetime Cost and Quality-Adjusted Life-Years Across Management Options for Small- and Medium-Sized Sporadic Vestibular Schwannoma. Otol Neurotol 2021; 42:e1369-e1375. [PMID: 34282100 DOI: 10.1097/mao.0000000000003266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the growing emphasis on healthcare costs, limited data address this aspect of care within the vestibular schwannoma (VS) literature. We sought to determine which strategy confers the lowest lifetime cost and greatest quality-adjusted life-years (QALYs) for patients with small- to medium-sized sporadic VS tumors. STUDY DESIGN A Markov model was created to determine the most cost-effective management algorithm. Tumor characteristics, magnetic resonance imaging surveillance schedule, treatment outcomes, and health-related quality of life values were derived from previously published data. Cost estimates were based on CMS Fee Schedule reimbursement rates. SETTING Economic Evaluation Service within the Kern Center for the Science of Healthcare Delivery. PATIENTS Patients diagnosed with small- to medium-sized sporadic VS. INTERVENTIONS Upfront microsurgery following diagnosis, upfront radiosurgery following diagnosis, observation with microsurgery reserved for observed tumor growth, and observation with radiosurgery reserved for observed tumor growth. RESULTS Across patient ages at time of diagnosis ranging from 18 to 70 years, observation with subsequent radiosurgery used for tumor growth was the most cost-effective management algorithm while upfront microsurgery was the least. When presented with a hypothetical 50-year-old patient, the strategy with the lowest lifetime cost and highest QALYs was observation with subsequent radiosurgery reserved for tumor growth ($32,161, 14.11 QALY), followed by observation with microsurgery reserved for tumor growth ($34,503, 13.94 QALY), upfront radiosurgery ($43,456, 14.02 QALY), and lastly, upfront microsurgery ($47,252, 13.60 QALY). Sensitivity analyses varying mortality rates, estimated costs, health-related quality of life, and progression to nonserviceable hearing demonstrated consistent ranking among treatments. CONCLUSIONS When considering initial management of small- and medium-sized sporadic VSs, neither lifetime cost nor QALYs support upfront microsurgery or radiosurgery, even for younger patients. Initial observation with serial imaging, reserving radiosurgery or microsurgery for patients exhibiting tumor growth, confers the greatest potential for optimized lifetime healthcare cost and QALY outcomes.
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Affiliation(s)
| | - Viengneesee Thao
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - Bijan J Borah
- Division of Health Care Policy Research, Department of Health Sciences Research
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | - James P Moriarty
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Jamie J Van Gompel
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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8
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Cost-effectiveness analysis of treatment for Koos 2 and 3 vestibular schwannomas: Wait & scan or radiosurgery. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Hear me out: rethinking internal auditory meatus magnetic resonance imaging in primary care. A cohort evaluation. The Journal of Laryngology & Otology 2021; 136:37-44. [PMID: 34412715 DOI: 10.1017/s0022215121002243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Imaging detects acoustic neuroma, a rare pathology associated with asymmetric sensorineural hearing loss and tinnitus, that is mostly managed conservatively. Scanning indication is debatable, without evaluation in primary care, despite the high burden of audiovestibular symptoms and commissioning of general practitioner imaging.
Method
Cohort evaluation of two years' internal auditory meatus magnetic resonance imaging in primary care.
Results
Of 200 scans requested by 77 general practitioners, only 33 per cent conformed to guideline indications. Most were referred to specialists, regardless of result. Only 10.5 per cent were appropriately imaged to rule out neuroma without specialist referral. One neuroma was detected (diagnostic yield 0.5 per cent) in a patient already referred. Incidental findings were shown in 44.5 per cent, triggering low-value cascades in 18 per cent. Whilst fewer than 1 in a 1000 imaged patients may improve through surgery, 1 in 5 can suffer negative imaging cascades.
Conclusion
Considering the bi-directional relationship between distress and audio-vestibular symptoms, anxiety-provoking imaging overuse should be minimised. In low-prevalence primary care, retrocochlear imaging could be limited to those with asymmetric sensorineural hearing loss. Alternatively, assessment and imaging could be shifted to audiologist-led settings, with a wider therapeutic offer, likely more beneficial and cost-effective than conventional surgical pathways.
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Perry A, Graffeo CS, Carlstrom LP, Hughes JD, Peris-Celda M, Cray NM, Pollock BE, Link MJ. Is There a Need for a 6-Month Postradiosurgery Magnetic Resonance Imaging in the Treatment of Vestibular Schwannoma? Neurosurgery 2020; 86:250-256. [PMID: 30980077 DOI: 10.1093/neuros/nyz052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/16/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a common treatment modality for vestibular schwannoma (VS), with a role in primary and recurrent/progressive algorithms. At our institution, routine magnetic resonance imaging (MRI) is obtained at 6 and 12 mo following SRS for VS. OBJECTIVE To analyze the safety and financial impact of eliminating the 6-mo post-SRS MRI in asymptomatic VS patients. METHODS A prospectively maintained SRS database was retrospectively reviewed for VS patients with 1 yr of post-treatment follow-up, 2005 to 2015. Decisions at 6-mo MRI were binarily categorized as routine follow-up vs clinical action-defined as a clinical visit, additional imaging, or an operation as a direct result of the 6-mo study. RESULTS A total of 296 patients met screening criteria, of whom 53 were excluded for incomplete follow-up and 8 for NF-2. Nine were reimaged prior to 6 mo due to clinical symptoms. Routine 6-mo post-SRS MRI was completed by 226 patients (76% of screened cohort), following from which zero instances of clinical action occurred. When scaled using national insurance database-derived financials-which estimated the mean per-study charge for MRI of the brain with and without contrast at $1767-the potential annualized national charge reduction was approximated as $1 611 504. CONCLUSION For clinically stable VS, 6-mo post-SRS MRI does not contribute significantly to management. We recommend omitting routine MRI before 12 mo, in patients without new or progressive neurological symptoms. If extrapolated nationally to the more than 100 active SRS centers, thousands of patients would be spared an inconvenient, nonindicated study, and national savings in health care dollars would be on the order of millions annually.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Joshua D Hughes
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Nealey M Cray
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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Schnurman Z, Golfinos JG, Epstein D, Friedmann DR, Roland JT, Kondziolka D. Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma. J Neurosurg 2019; 131:1395-1404. [PMID: 30497146 DOI: 10.3171/2018.5.jns18508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given rising scrutiny of healthcare expenditures, understanding intervention costs is increasingly important. This study aimed to compare and characterize costs for vestibular schwannoma (VS) management with microsurgery and radiosurgery to inform practice decisions and appraise cost reduction strategies. METHODS In conjunction with medical records, internal hospital financial data were used to evaluate costs. Total cost was divided into index costs (costs from arrival through discharge for initial intervention) and follow-up costs (through 36 months) for 317 patients with unilateral VSs undergoing initial management between June 2011 and December 2015. A retrospective matched cohort based on tumor size with 176 patients (88 undergoing each intervention) was created to objectively compare costs between microsurgery and radiosurgery. The full sample of 203 patients treated with resection and 114 patients who underwent radiosurgery was used to evaluate a broad range of outcomes and identify cost contributors within each intervention group. RESULTS Within the matched cohort, average index costs were significantly higher for microsurgery (100% by definition, because costs are presented as a percentage of the average index cost for the matched microsurgery group; 95% CI 93-107) compared to radiosurgery (38%, 95% CI 38-39). Microsurgery had higher average follow-up costs (1.6% per month, 95% CI 0.8%-2.4%) compared to radiosurgery (0.5% per month, 95% CI 0.4%-0.7%), largely due to costs incurred in the initial months after resection. A major contributor to total cost and cost variability for both resection and radiosurgery was the need for additional interventions in the follow-up period, which were necessary due to complications or persistent functional deficits. Although tumor size was not associated with increased total costs for radiosurgery, linear regression analysis demonstrated that, for patients who underwent microsurgery, each centimeter increase in tumor maximum diameter resulted in an estimated increase in total cost of 50.2% of the average index cost of microsurgery (95% CI 34.6%-65.7%) (p < 0.001, R2 = 0.17). There were no cost differences associated with the proportion of inpatient days in the ICU or with specific surgical approach for patients who underwent resection. CONCLUSIONS This study is the largest assessment to date based on internal cost data comparing VS management with microsurgery and radiosurgery. Both index and follow-up costs are significantly higher when tumors were managed with resection compared to radiosurgery. Larger tumors were associated with increased resection costs, highlighting the incremental costs associated with observation as the initial management.
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Affiliation(s)
| | | | | | - David R Friedmann
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York
| | - J Thomas Roland
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Medical Center, New York, New York
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12
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Patel VA, Dunklebarger M, Banerjee K, Shokri T, Zhan X, Isildak H. Surgical Management of Vestibular Schwannoma: Practice Pattern Analysis via NSQIP. Ann Otol Rhinol Laryngol 2019; 129:230-237. [DOI: 10.1177/0003489419882044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective:Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns.Methods:A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation.Results:A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( P < .001), ASA class ( P = .004), ethnicity ( P = .008), operative time ( P < .001), and reoperation ( P < .001) were found to be statistically significant between cohorts. Increased utilization of RS approach was consistent over the entire study period, with significantly more RS performed than either TL or MCF. Finally, a statistically significant difference with respect to general surgical complication rates was not noted between surgical approaches.Conclusions:There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.
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Affiliation(s)
- Vijay A. Patel
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | | | - Kalins Banerjee
- College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Tom Shokri
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Xiang Zhan
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Huseyin Isildak
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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13
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Twelve-year results of LINAC-based radiosurgery for vestibular schwannomas. Strahlenther Onkol 2019; 196:40-47. [DOI: 10.1007/s00066-019-01498-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
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Udawatta M, Kwan I, Preet K, Nguyen T, Ong V, Sheppard JP, Duong C, Romiyo P, Lee P, Tenn S, Kaprealian T, Gopen Q, Yang I. Hearing Preservation for Vestibular Schwannomas Treated with Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy. World Neurosurg 2019; 129:e303-e310. [PMID: 31132496 DOI: 10.1016/j.wneu.2019.05.133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Vestibular schwannomas (VS) are benign intracranial neoplasms arising from the eighth cranial nerve for which targeted radiation therapy (RT) has proved increasingly successful. However, long-term hearing and related cranial nerve outcomes have been disputed for the 3 current RT modalities. OBJECTIVE To determine differences in hearing preservation for patients treated with stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), or hypofractionated stereotactic radiotherapy (hypoFSRT) for VS. METHODS A retrospective electronic chart review was conducted for all patients with unilateral VS treated with primary RT at a single academic medical center between 2000 and 2017. The primary outcome measure was preservation of serviceable hearing status in the affected ear at last follow-up. Secondary outcomes included tinnitus, vertigo, and imbalance. RESULTS A total of 33 FSRT cases, 21 SRS cases, and 6 hypoFSRT cases were identified. Postoperative deterioration in serviceable hearing and tinnitus showed significant differences across cohorts. The SRS cohort had a higher baseline incidence of nonserviceable hearing and disequilibrium compared with other cohorts before RT (P = 0.001 and 0.022, respectively); no differences in baseline morbidity were observed for vertigo and tinnitus. The 5-year tumor control rate was 95.2%, 93.9%, and 100% with SRS, FSRT, and hypoFSRT, respectively. CONCLUSIONS Our series indicated an excellent tumor control rate in all the modalities. Our SRS cohort showed increased incidence and shorter time to hearing deterioration compared with the FSRT and hypoFSRT cohorts. The FSRT and hypoFSRT cohorts have shown comparable overall outcomes. Onset of post-RT tinnitus was observed only with FSRT.
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Affiliation(s)
- Methma Udawatta
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Isabelle Kwan
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Komal Preet
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Thien Nguyen
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Vera Ong
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Courtney Duong
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Tania Kaprealian
- Department of Neurosurgery, University of California, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, California, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, California, USA; Department of Head and Neck Surgery, University of California, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA; Los Angeles Biomedical Research Institute, University of California, Los Angeles, California, USA; Harbor-UCLA Medical Center, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA.
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15
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Scholte M, Hentschel MA, Hannink G, Kunst HPM, Steens SC, Rovers MM, Grutters JPC. In search of the most cost-effective monitoring strategy for vestibular schwannoma: A decision analytical modelling study. Clin Otolaryngol 2019; 44:525-533. [PMID: 30864276 PMCID: PMC6850121 DOI: 10.1111/coa.13326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 01/22/2023]
Abstract
Objectives To assess the cost‐effectiveness of frequently used monitoring strategies for vestibular schwannoma (VS). Design A state transition model was developed to compare six monitoring strategies for patients with VS: lifelong annual monitoring; annual monitoring for the first 10 years after diagnosis; scanning at 1‐5, 7, 9, 12, 15 years after diagnosis and subsequently every 5 years; a personalised monitoring strategy for small and large tumours; scanning at 1, 2 and 5 years after diagnosis and no monitoring. Input data were derived from literature and expert opinion. Quality‐adjusted life years (QALYs) and healthcare costs of each strategy were modelled over lifetime. Net monetary benefits (NMBs) were calculated to determine which strategy provided most value for money. Sensitivity analyses were performed to address uncertainty. Results Omitting monitoring is least effective with 18.23 (95% CI 16.84‐19.37) QALYs per patient, and lifelong annual monitoring is most effective with 18.66 (95% CI 17.42‐19.65) QALYs. Corresponding costs were €6526 (95% CI 5923‐7058) and €9429 (95% CI 9197‐9643) per patient, respectively. Lifelong annual monitoring provided the best value with a NMB of €363 765 (339 040‐383 697), but the overall probability of being most cost‐effective compared to the other strategies was still only 23%. Sensitivity analysis shows that there is large uncertainty in the effectiveness of all strategies, with largely overlapping 95% confidence intervals for all strategies. Conclusions Due to the largely overlapping 95% confidence intervals of all monitoring strategies for VS, it is unclear which monitoring strategy provides most value for money at this moment.
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Affiliation(s)
- Mirre Scholte
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mayke A Hentschel
- Department of Otolaryngology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus P M Kunst
- Department of Otolaryngology, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Otolaryngology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stefan C Steens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maroeska M Rovers
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Janneke P C Grutters
- Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.,Department for Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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17
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18
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Golfinos JG, Hill TC, Rokosh R, Choudhry O, Shinseki M, Mansouri A, Friedmann DR, Thomas Roland J, Kondziolka D. A matched cohort comparison of clinical outcomes following microsurgical resection or stereotactic radiosurgery for patients with small- and medium-sized vestibular schwannomas. J Neurosurg 2016; 125:1472-1482. [DOI: 10.3171/2015.12.jns151857] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
A randomized trial that compares clinical outcomes following microsurgery (MS) or stereotactic radiosurgery (SRS) for patients with small- and medium-sized vestibular schwannomas (VSs) is impractical, but would have important implications for clinical decision making. A matched cohort analysis was conducted to evaluate clinical outcomes in patients treated with MS or SRS.
METHODS
The records of 399 VS patients who were cared for by 2 neurosurgeons and 1 neurotologist between 2001 and 2014 were evaluated. From this data set, 3 retrospective matched cohorts were created to compare hearing preservation (21 matched pairs), facial nerve preservation (83 matched pairs), intervention-free survival, and complication rates (85 matched pairs) between cases managed with SRS and patients managed with MS. Cases were matched for age at surgery (± 10 years) and lesion size (± 0.1 cm). To compare hearing outcomes, cases were additionally matched for preoperative Class A hearing according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. To compare facial nerve (i.e., cranial nerve [CN] VII) outcomes, cases were additionally matched for preoperative House-Brackmann (HB) score. Investigators who were not involved with patient care reviewed the clinical and imaging records. The reported outcomes were as assessed at the time of the last follow-up, unless otherwise stated.
RESULTS
The preservation of preoperative Class A hearing status was achieved in 14.3% of MS cases compared with 42.9% of SRS cases (OR 4.5; p < 0.05) after an average follow-up interval of 43.7 months and 30.3 months, respectively. Serviceable hearing was preserved in 42.8% of MS cases compared with 85.7% of SRS cases (OR 8.0; p < 0.01). The rates of postoperative CN VII dysfunction were low for both groups, although significantly higher in the MS group (HB III–IV 11% vs 0% for SRS; OR 21.3; p < 0.01) at a median follow-up interval of 35.7 and 19.0 months for MS and SRS, respectively. There was no difference in the need for subsequent intervention (2 MS patients and 2 SRS patients).
CONCLUSIONS
At this high-volume center, VS resection or radiosurgery for tumors ≤ 2.8 cm in diameter was associated with low overall morbidity. The need for subsequent intervention was the same in both groups. SRS was associated with improved hearing and facial preservation rates and reduced morbidity, but with a shorter average follow-up period. Facial function was excellent in both groups. Since patients were not randomly selected for surgery, different clinical outcomes may be of different value to individual patients. Both anticipated medical outcomes and patient goals remain the drivers of treatment decisions.
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Affiliation(s)
| | | | | | | | | | | | - David R. Friedmann
- 2Otolaryngology, NYU Langone Medical Center, New York University, New York, New York
| | - J. Thomas Roland
- 2Otolaryngology, NYU Langone Medical Center, New York University, New York, New York
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19
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Zygourakis CC, Oh T, Sun MZ, Barani I, Kahn JG, Parsa AT. Surgery is cost-effective treatment for young patients with vestibular schwannomas: decision tree modeling of surgery, radiation, and observation. Neurosurg Focus 2016. [PMID: 26218621 DOI: 10.3171/2014.8.focus14435] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vestibular schwannomas (VSs) are managed in 3 ways: observation ("wait and scan"); Gamma Knife surgery (GKS); or microsurgery. Whereas there is considerable literature regarding which management approach is superior, there are only a few studies addressing the cost of treating VSs, and there are no cost-utility analyses in the US to date. METHODS In this study, the authors used the University of California at San Francisco medical record and hospital accounting databases to determine total hospital charges and costs for 33 patients who underwent open surgery, 42 patients who had GKS, and 12 patients who were observed between 2010 and 2013. The authors then performed decision-tree analysis to determine which treatment paradigm produces the highest quality-adjusted life years and to calculate the incremental cost-effectiveness ratio, depending on the patient's age at VS diagnosis. RESULTS The average total hospital cost over a 3-year period for surgically treated patients was $80,074 (± $49,678) versus $9737 (± $5522) for patients receiving radiosurgery and $1746 (± $2792) for patients who were observed. When modeling the most debilitating symptoms and worst outcomes of VSs (vertigo and death) at different ages at diagnosis, radiation is dominant to observation at all ages up to 70 years. Surgery is cost-effective when compared with radiation (incremental cost-effectiveness ratio < $150,000) at younger ages at diagnosis (< 45 years old). CONCLUSIONS In this model, surgery is a cost-effective alternative to radiation when VS is diagnosed in patients at < 45 years. For patients ≥ 45 years, radiation is the most cost-effective treatment option.
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Affiliation(s)
| | - Taemin Oh
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | | | - Igor Barani
- Radiation Oncology, University of California at San Francisco
| | - James G Kahn
- Department of Epidemiology and Biostatistics, Philip R Lee Institute for Health Policy Studies, University of California at San Francisco, California; and
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
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20
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Apicella G, Paolini M, Deantonio L, Masini L, Krengli M. Radiotherapy for vestibular schwannoma: Review of recent literature results. Rep Pract Oncol Radiother 2016; 21:399-406. [PMID: 27330427 DOI: 10.1016/j.rpor.2016.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/05/2015] [Accepted: 02/06/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The management of vestibular schwannoma is still a quite controversial issue and can include wait and see policy, surgery and radiotherapy, mainly with stereotactic technique. The purpose of this study is to review the results of recent clinical series treated by radiotherapy. MATERIALS AND METHODS Literature search was performed by Pubmed and Scopus by using the words "vestibular schwannoma, acoustic neuroma, radiotherapy, radiosurgery". RESULTS Management options of VS include wait and see, surgery and radiotherapy. In case of small lesions, literature data report local control rates higher than 90% after radiosurgery (SRS) similar those of surgical techniques. Recent literature reviews show favourable functional outcome by using SRS. Several literature data support the use of fractionated stereotactic radiotherapy (FSRT) in case of large inoperable lesions. CONCLUSION Radiotherapy plays a relevant role in the treatment of VS. In small-size lesions, SRS can guarantee similar local control and potentially better function outcome compared to surgery. In case of large and irregularly shaped lesions, FSRT can be the used when surgery is not feasible.
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Affiliation(s)
- Giuseppina Apicella
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy
| | - Marina Paolini
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy
| | - Letizia Deantonio
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy
| | - Laura Masini
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy
| | - Marco Krengli
- Radiotherapy Division, University Hospital "Maggiore della Carità", Novara, Italy; Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy; Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
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21
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Kim HJ, Park SH, Kim JS, Koo JW, Kim CY, Kim YH, Han JH. Bilaterally Abnormal Head Impulse Tests Indicate a Large Cerebellopontine Angle Tumor. J Clin Neurol 2016; 12:65-74. [PMID: 26754780 PMCID: PMC4712288 DOI: 10.3988/jcn.2016.12.1.65] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 09/11/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Tumors involving the cerebellopontine angle (CPA) pose a diagnostic challenge due to their diverse manifestations. Head impulse tests (HITs) have been used to evaluate vestibular function, but few studies have explored the head impulse gain of the vestibulo-ocular reflex (VOR) in patients with a vestibular schwannoma. This study tested whether the head impulse gain of the VOR is an indicator of the size of a unilateral CPA tumor. METHODS Twenty-eight patients (21 women; age=64±12 years, mean±SD) with a unilateral CPA tumor underwent a recording of the HITs using a magnetic search coil technique. Patients were classified into non-compressing (T1-T3) and compressing (T4) groups according to the Hannover classification. RESULTS Most (23/28, 82%) of the patients showed abnormal HITs for the semicircular canals on the lesion side. The bilateral abnormality in HITs was more common in the compressing group than the non-compressing group (80% vs. 8%, Pearson's chi-square test: p<0.001). The tumor size was inversely correlated with the head impulse gain of the VOR in either direction. CONCLUSIONS Bilaterally abnormal HITs indicate that a patient has a large unilateral CPA tumor. The abnormal HITs in the contralesional direction may be explained either by adaptation or by compression and resultant dysfunction of the cerebellar and brainstem structures. The serial evaluation of HITs may provide information on tumor growth, and thereby reduce the number of costly brain scans required when following up patients with CPA tumors.
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Affiliation(s)
- Hyo Jung Kim
- Department of Biomedical Laboratory Science, Kyungdong University, Goseong, Korea
| | - Seong Ho Park
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Ja Won Koo
- Department of Otolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chae Yong Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Hoon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Frew E, Harrison M, Rossello Roig M, Martin T. Providing an extended use of an otological-specific outcome instrument to derive cost-effectiveness estimates of treatment. Clin Otolaryngol 2015; 40:593-9. [DOI: 10.1111/coa.12424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2015] [Indexed: 11/26/2022]
Affiliation(s)
- E.J. Frew
- Health Economics Unit; School of Health and Population Sciences; University of Birmingham; Birmingham UK
| | - M. Harrison
- Faculty of Pharmaceutical Sciences; University of British Columbia; Vancouver BC Canada
- Centre for Health Evaluation and Outcome Sciences; St Paul's Hospital; Vancouver BC Canada
| | - M. Rossello Roig
- Health Economics Unit; School of Health and Population Sciences; University of Birmingham; Birmingham UK
| | - T.P.C. Martin
- ENT Department; Worcester Royal Hospital; Worcester UK
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