Dataset Information

Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate.

ABSTRACT: To assess the impact of the rate of spontaneous resolution of congenital nasolacrimal duct obstruction on the relative cost-effectiveness of deferred nasolacrimal duct probing in a surgical facility (DFPS) compared with an immediate office-based probing surgery (IOPS).Data from the literature, Medicare 2009 fee schedule, and consensus assumptions were combined to populate a model of outcomes of 2 treatment strategies: immediate office-based probing (IOPS) and deferred facility-based probing (DFPS) (deferred for 6 months). Sensitivity analyses were conducted, varying the 6-month spontaneous resolution rate from 50% to 90%. Additional factors varied during analyses included surgical cost and each procedure's probability of success. Outcomes measured were overall cost of treatment, chance of cure, and months of symptoms avoided by 18 months of life.Under the base case, assuming a 75% spontaneous resolution rate during 6 months prior to deferred probing, IOPS is more expensive ($771 vs $641) and slightly less effective (93.0% vs 97.5%) than DFPS, although IOPS costs only $44 per month of symptoms avoided. At spontaneous resolution rates between 50% and 68%, IOPS costs less than DFPS (from $2 to $342 less), although it also is slightly less effective (from 2.0% to 3.8% less). At a 90% spontaneous resolution rate, IOPS costs $169 per month of symptoms avoided. As the rate of spontaneous resolution falls, the cost per additional success for DFPS increases to $16 709 at a 50% spontaneous resolution rate.The relative cost-effectiveness of these strategies for treatment of nasolacrimal duct obstruction depends on the spontaneous resolution rate after diagnosis.

SUBMITTER: Frick KD

PROVIDER: S-EPMC3156092 | biostudies-literature | 2011 May

REPOSITORIES: biostudies-literature

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Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate.

Frick Kevin D KD Hariharan Luxme L Repka Michael X MX Chandler Danielle D Melia B Michele BM Beck Roy W RW

Archives of ophthalmology (Chicago, Ill. : 1960) 20110501 5

<h4>Objective</h4>To assess the impact of the rate of spontaneous resolution of congenital nasolacrimal duct obstruction on the relative cost-effectiveness of deferred nasolacrimal duct probing in a surgical facility (DFPS) compared with an immediate office-based probing surgery (IOPS).<h4>Methods</h4>Data from the literature, Medicare 2009 fee schedule, and consensus assumptions were combined to populate a model of outcomes of 2 treatment strategies: immediate office-based probing (IOPS) and de ...[more]

PMID: 21555614

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Project description:To compare the cost-effectiveness of 2 approaches for treating unilateral nasolacrimal duct obstruction (NLDO).One hundred sixty-three infants aged 6 to less than 10 months with unilateral NLDO were randomly assigned to receive immediate office-based nasolacrimal duct probing (n = 82) or 6 months of observation/nonsurgical management (n = 81) followed by probing in a facility for persistent symptoms.Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) on masked examination at age 18 months. Cost of treatment between randomization and age 18 months included costs for all surgical procedures and medications.In the observation/deferred facility-probing group, NLDO resolved within 6 months without surgery in 44 of the 67 patients (66%; 95% CI, 54% to 76%) who completed the 6-month visit. Twenty-two (27%) of the 81 patients in the observation/deferred facility-probing group underwent surgery, 4 of whom were operated on within the initial 6 months. At age 18 months, 69 of 75 patients (92%) in the immediate office-probing group were treatment successes, compared with 58 of 71 observation/deferred facility-probing group patients (82%) (10% difference in success; 95% CI, -1% to 21%). The mean cost of treatment was $562 in the immediate office-probing group compared with $701 in the observation/deferred facility-probing group (difference, -$139; 95% CI, -$377 to $94). The immediate office-probing group experienced 3.0 fewer months of symptoms (95% CI, -1.8 to -4.0).The immediate office-probing approach is likely more cost-effective than observation followed by deferred facility probing if needed. Adoption of the immediate office-probing approach would result in probing in approximately two-thirds of infants whose obstruction would have resolved within 6 months of nonsurgical management, but would largely avoid the need for probing under general anesthesia.Although unilateral NLDO often resolves without surgery, immediate office probing is an effective and potentially cost-saving treatment option.clinicaltrials.gov Identifier: NCT00780741.

Project description:Importance:Although the overall rate of spontaneous resolution in congenital nasolacrimal duct obstruction (CNLDO) and efficacy of probing have been documented in the literature, the optimal timing of intervention has not been established. Objective:To report new findings regarding spontaneous resolution in a large cohort of children with CNLDO. Design, Setting, and Participants:The medical records of 1998 consecutive infants diagnosed with CNLDO from January 1, 1995, through December 31, 2004, while residing in Olmsted County, Minnesota, were retrospectively reviewed. Data were analyzed between January 1, 2015, and January 2017. Main Outcomes and Measures:Rate of spontaneous resolution over time and by sex. Results:The cohort, diagnosed at a median age of 1.2 months (interquartile range, 0.4-3.6), was 48% girls (n = 959) and 89% white (n = 1626; 173 were unreported). Among the 1998 cases, 1669 (83.5%) spontaneously resolved, 289 (14.5%) underwent treatment, and the remaining 40 (2.0%) were lost to follow-up. Of the 1958 infants followed up, CNLDO in 925 (47.3%) spontaneously resolved by age 3 months, in 1300 (66.4%) by 6 months, in 1472 (75.7%) by 9 months, and in 1516 (78.4%) by 12 months. The rate of resolution was 35% faster (95% CI, 23%-47%; P?<?.001) at less than 1 month vs 3 months, 43% faster (95% CI, 27%-64%; P?<?.001) at 3 months vs 6 months, 39% faster (95% CI, 16%-64%; P?<?.001) at 6 months vs 9 months, and 1% slower at 9 months vs 12 months (hazard ratio, 0.99; 95% CI, 0.80-1.22; P?=?.78). Congenital nasolacrimal duct obstruction resolved in boys 0.5 months (95% CI, 0.2-0.8; P?<?.001) faster than girls (median, 2.9 vs 3.4 months), and unilateral obstructions resolved 0.2 months (95% CI, 0.1-0.4; P?=?.002) faster than bilateral (median, 3.1 vs 3.3 months) ones. Children probed at 15 months or older had decreased odds of resolution after probing (odds ratio, 0.11; 95% CI, 0.01-0.89; P?=?.04) compared with children probed at age 12 to 14 months. Conclusions and Relevance:Based on this large cohort of children with CNLDO, probing between age 9 and 15 months may be reasonable given that the rate of spontaneous resolution plateaued after 9 months and initial probing success declined after 15 months. This time frame supports both an earlier and narrower range of ages for intervention compared with the current practice of probing after age 1 year.

Dataset Information

Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate.

Publications

Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate.

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