Comparing the Cost-Effectiveness of Endoscopic and Microscopic Approaches to Transphenoidal Pituitary Surgery

Introduction: Endoscopic endonasal approach (EEA) has become increasingly popular for resection of pituitary tumors. However, microscopic transphenoidal surgery (MTS) remains a commonly utilized approach across the USA. The economic sustainability of new techniques and technologies is rarely evaluated in the neurosurgical skull base literature, and so, the aim of this study was to determine the cost-effectiveness of EEA compared with MTS.

Methods: A decision tree using TreeAgePro v.2013 was constructed to evaluate the cost-effectiveness of EEA versus MTS from a single-payer healthcare perspective. Comparative effectiveness data, such as resection rates, post-surgical complication rates, and SF-36 quality of life data, were obtained from previously published meta-analyses and outcomes studies. Cost components were based on 2012 Medicare reimbursement rates, taking into account covariates such as, complications, length-of-stay, and operative time. The base-case analysis adopted a 2-year follow-up period, which was varied from 1 to 10 years in a univariate sensitivity analysis. An annual discount rate of 3% was applied to both QALY and cost components.

Results: On average, EEA costs less and generates more QALYs than MTS for pituitary surgery. In our extrapolated model that assumed a cohort of 1,000 patients, EEA method saved $5.27 million and generated 7.4 additional QALYs over 2 years. The incremental cost-effectiveness ratio (ICER) is: -712,162 $/QALY. The QALY benefit increased to 18.3 when the model was assessed at 10 years, suggesting that EEA is even more favorable in the long-run. Sensitivity analysis demonstrated model susceptibility to operative time, procedure costs, and post-surgical QALYs.

Conclusions: EEA appears to be cost-effective when compared with MTS for pituitary surgery since the ICER falls below the commonly accepted 50,000 $/QALY benchmark. The negative ICER further indicates that EEA actually dominates MTS from a healthcare economic perspective.

Limitations: Our preliminary analysis did not account for sunk cost, such as equipment, facility training, and extra expertise/training. Furthermore, the available quality of life data for pituitary adenoma surgery is scarce and significantly outdated. Further research on the cost-effectiveness of both these modalities is warranted, preferably using prospectively collected data.