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
- Consent for publication
Not applicable
- Availability of data and materials
Datasets are available from the corresponding author on reasonable
request.
- Competing interests
The authors declare that they have no competing interests.
Funding