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Original Investigation |

Cost-effectiveness of Corticosteroid Nasal Spray vs Surgical Therapy in Patients With Severe to Extreme Anatomical Nasal Obstruction

Virginia P. Teti, MD1; Seden Akdagli, MD1; Sam P. Most, MD1
[+] Author Affiliations
1Division of Facial Plastic & Reconstructive Surgery, School of Medicine, Stanford University, Stanford, California
JAMA Facial Plast Surg. 2016;18(3):165-170. doi:10.1001/jamafacial.2015.2039.
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Importance  Health insurance companies commonly require a trial of corticosteroid nasal spray prior to authorizing nasal surgery, even in patients with severe to extreme anatomical nasal obstruction, despite lack of data supporting such medical therapy.

Objectives  To provide a model for the comparative analysis of medical vs surgical treatment for nasal obstruction to help maximize health care benefit per dollar spent and to explore the cost-effectiveness of corticosteroid nasal spray in patients with severe to extreme nasal airway obstruction on Nasal Obstruction Symptom Evaluation (NOSE) scores.

Design, Setting, and Participants  A cost-efficiency frontier economic evaluation was performed. The economic perspective was that of the health care third-party payer. Effectiveness data were obtained from NOSE score questionnaires in 179 patients. An incremental cost-effectiveness ratio was determined from the cost and efficacy data. Comparative treatment groups were medical therapy with corticosteroid nasal spray vs surgical therapy for nasal airway obstruction. The study was conducted between January 1, 2011, and December 30, 2013. The time horizon included 1, 2, and 5 years. Data analysis was completed June 1, 2015.

Main Outcomes and Measures  The primary outcome was cost per quality-adjusted life-year (QALY). A modified Markov decision tree model was used. Costs were obtained from the Medicare 2015 physician fee schedule, and the mean was determined (owing to geographic disparity) along with wholesale and generic pharmaceutical pricing.

Results  Among 100 men and 79 women evaluated (mean [SD] age, 37.9 [12.9] years), surgical repair of severe nasal airway obstruction cost $6537 and produced a total of 1.15 QALYs at 1 year. Medical treatment involved a trial of corticosteroid nasal sprays, which cost $520 and produced a total of 1.03 QALYs. The surgical approach was markedly more effective but at greater short-term cost. In cases of extreme nasal obstruction, medical treatment cost $520.73 with 1.004 QALYs, demonstrating an incremental cost-effectiveness ratio (ICER) of $354 693 per QALY compared with no treatment. Conversely, surgical treatment cost $6536.64 and produced 1.136 QALYs, with an ICER of $45 633 compared with medical therapy. At 5 years, the ICER decreased from $45 634 to $8110 per QALY for surgical treatment of extreme nasal obstruction. The medical treatment ICER decreased from $354 693 per QALY at 1 year to $273 704 per QALY at 5 years. An ICER was performed and demonstrated a cost threshold of $50 554 per QALY for surgical treatment compared with $67 518 per QALY for medical treatment at 1 year for severe nasal obstruction. If the evaluation is extended to 5 years, surgical treatment cost $8984 per QALY compared with $52 571 per QALY for medical treatment. Owing to the improved effectiveness outcomes, greater cost savings per ICER was demonstrated in patients with extreme nasal obstruction.

Conclusions and Relevance  Surgical treatment for patients with severe to extreme anatomical nasal obstruction demonstrates increased short-term expense but is cost-effective in the long term. These data suggest that treatment with corticosteroid nasal spray in patients with documented severe to extreme anatomical nasal obstruction is unnecessary and results in a delay in treatment.

Level of Evidence  NA.

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Figure 1.
Distribution of 179 Patients With Nasal Obstruction by Severity Class

Analysis using χ2 testing revealed a significant change in distribution when comparing pretreatment (baseline) with postsurgical Nasal Obstruction Symptom Evaluation severity scores (P < .01); no significant change was noted when comparing pretreatment with scores after the use of corticosteroid nasal spray (P = .40).

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Figure 2.
Cost-Efficiency Frontier Model Based on Severity of Treatment

Triangles and circles represent surgical or medical treatment, respectively, for patients with varying severity of nasal obstruction. Note that, although cost is higher for surgical therapy, the benefit is substantial compared with medical therapy. Benefit increases with the severity of the patients’ preoperative severity score. NOSE indicates Nasal Obstruction Symptom Evaluation.

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