0589 MAXILLOMANDIBULAR ADVANCEMENT VERSUS MULTI-LEVEL SURGERY FOR PATIENTS WITH SEVERE OBSTRUCTIVE SLEEP APNEA INTOLERANT OF CPAP - A META-ANALYSIS AND COST EFFECTIVENESS ANALYSIS

Abstract

Introduction: Obstructive sleep apnea (OSA) is associated with significant morbidity and mortality. Conventional OSA therapy entails lifelong positive airway pressure (CPAP), unfortunately adherence rates are poor. We explore the cost-effectiveness of maxillomandibular advancement (MMA) in those intolerant of CPAP. Methods: We compare the cost-effectiveness of MMA in those with severe OSA intolerant of CPAP compared to a no-treatment strategy, multilevel surgery (MLS), or a phased protocol (PP; MLS followed by MMA for those without surgical success) using a lifetime semi- Markov OSA model that accounts for observed increased cerebro/ cardiovascular events and motor-vehicle collisions. We perform a meta-analysis to determine surgical success rates in middle-aged men with severe OSA. Results: We identified 32 MMA studies (212 subjects) reporting short-term pooled success and cure of 73.7% and 16.7% for middle- aged men with severe OSA with prior MLS surgery and 87.4% and 31.0% for those without prior surgery. In middle-aged men with severe OSA, 42 MLS studies (569 subjects) report short-term success and cure of 64.6% and 12.8%. The annual surgical success decay-rate was 2.5% for MMA (from 10 long-term studies) and 8.6% for MLS (11 studies). Compared with the no-treatment strategy, MLS adds 0.93 quality adjusted life years (QALYs) for an increase of $17,544 (discounted 2016 dollars) with an incremental cost-effectiveness ratio (ICER) of $18,924/QALY for a 50-year-old severe OSA male intolerant to CPAP. Compared to MLS, MMA adds an additional 1.09 QALYs at an incremental increase of $25,945 (ICER $23,865/QALY). The MLS and MMA strategies dominate the PP strategy. Versus no-treatment, the MLS and MMA strategies are cost-effective over a wide range of parameter estimates. The cost-effectiveness of MMA versus MLS is sensitive to the cure and success rates of surgery as well as decay of these rates over time. PP is no longer dominated when MLS costs 88% (or >42%) or MMA success (or cure) rates <85% (or <23%). Conclusion: Both MLS and MMA appear cost-effective in middle- aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short and long-term surgical outcomes.