Discussion:
To our knowledge, this research was the first comprehensive study on the cost-effectiveness of DCT and inpatient method in south of Iran.
Among all four clinical outcomes, DCT was considered as the most cost effective option. Mahdavan et al. studied on a total of 5400 tonsillectomies in children aged 7.4 months to 15 years with a mean age of 6.2 years and they observed no significant difference in bleeding after tonsillectomy between day case and hospitalized patients(17). Other studies, also support this (15, 16, 17). Al-Sobaki et al (2014) showed that the pediatric patients who had day case surgery had no complications during the first 24 hours after surgery. Also, the cost of hospitalization for children was $ 1971, while it was less than half ($ 870) for DCT method. These figures reveal that pediatric tonsillectomy is performed as an economically justified DCT procedure and it is recommended for selected patients if it meets their criteria(18). The result of the above mentioned study supports the result of the present study. Also, consistent with the results of this study, a study in Germany (2017) showed that outpatient surgery saves potentially about \euro 213500,000 annually. However, inconsistent with the results of the current study, tonsillectomy is not recommended as an outpatient surgery in Germany due to economic reasons and medical quality(13). Jain et al (2004) studied on 269 patients in the United Kingdom. The average hospital cost per patient was £ 768 for DCT and £ 1430 for admission which means that DCT was about 46% cheaper(19). This is in line with the results of the current study. In a retrospective study by Paquette et al. on 4040 patients, the average cost of hospital was $ 12978 while it was $ 6391 for a day case surgery center. In other words, the average patient cost for day case surgery center was approximately $ 50 cheaper. Besides, the patients treated in day case surgery center were younger and had fewer concurrent diseases than those treated in hospital (21) which seems to be confirmed by the results of the present study.
ICER compared with many parameters was not much sensitive and confirms the robustness of the study results. Moreover, ICER was more sensitive to the effectiveness of inpatient and DCT but less sensitive to other parameters. For instance, for the outcome of patient pain score, although the parameter of inpatient effectiveness had 20% increase on the parameter by the most effect on ICER and it increased ICER to almost 800 dollars PPP, however, the new amount of ICER is still lower than threshold and DCT is dominant and more cost-effective. This has happened also for the incidence of bleeding and re-operation; because by increasing ICER to 1000 dollars, again due to being lower than threshold, DCT is considered dominant. Regarding the outcome of incidence of blood transfusion, DCT is the superior option confidently; because it turned ICER from positive to negative
Economic considerations regarding the safety of day case surgery in tonsillectomy can have a major impact at national level. Supporting this method is completely reasonable and has benefits for both patients and insurance companies. This method reduces waiting time for selective surgery, implements a reservation system, and introduces the treatment centers for patients which require significant changes in the manner of surgery.
This study had some strengths like: considering the total costs, including direct medical and non-medical costs as well as indirect costs. One of the limitations of this study was lack of access to information of other hospitals in Iran.
Conclusion : It can be concluded that DCT is a cost-effective option and a superior strategy for our country, Iran, and can be suggested as a better alternative for a wide range of patients after tonsillectomy. According to the result of our study, supporting day case surgery for tonsillectomy cases can significantly reduce the financial burden.

Declarations

The authors declare that they have no competing interests.
Funding
Not applicable.