Cost-effectiveness of corticosteroid nasal spray vs surgical therapy in patients with severe to extreme anatomical nasal obstruction

Abstract

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 Acost-efficiency frontier economic evaluationwas performed. The economic perspectivewas that of the health care third-party payer. Effectiveness datawere obtained fromNOSEscore questionnaires in 179 patients. An incremental cost-effectiveness ratiowas determined from the cost and efficacy data. Comparative treatment groupswere medical therapy with corticosteroid nasal spray vs surgical therapy for nasal airway obstruction. The studywas conducted between January 1, 2011, and December 30, 2013. The time horizon included 1, 2, and 5 years.Data analysiswas completed June 1, 2015. MAIN OUTCOMES AND MEASURES The primary outcomewas 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 100menand 79women evaluated (mean [SD] age, 37.9 [12.9] years), surgical repair of severe nasal airway obstruction cost $6537 and produced a total of 1.15QALYs at 1 year. Medical treatment involved a trial of corticosteroid nasal sprays, which cost $520and produced a total of 1.03QALYs. The surgical approachwas markedly more effective but at greater short-term cost. In cases of extreme nasal obstruction, medical treatment cost $520.73 with 1.004QALYs, demonstrating an incremental cost-effectiveness ratio (ICER) of $354 693 perQALY compared with no treatment. Conversely, surgical treatment cost $6536.64 and produced 1.136QALYs, with an ICER of $45 633 compared with medical therapy.At 5 years, the ICER decreased from $45 634 to $8110 perQALY for surgical treatment of extreme nasal obstruction. The medical treatment ICER decreased from $354 693 perQALY at 1 year to $273 704 perQALY at 5 years. An ICERwas performed and demonstrated a cost threshold of $50 554 perQALY for surgical treatment compared with $67 518 perQALY for medical treatment at 1 year for severe nasal obstruction. If the evaluation is extended to 5 years, surgical treatment cost $8984 perQALY compared with $52 571 perQALY for medical treatment. Owing to the improved effectiveness outcomes, greater cost savings per ICERwas 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.