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Published on: December 6, 2016
Cost-effectiveness of polysomnography in the management of pediatric obstructive sleep apnea
Margaret Mitchell1, Jay A Werkhaven2
1Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, TN, USA.
Insights
Polysomnography (PSG) testing confirms obstructive sleep apnea (OSA) in children before adenotonsillectomy (T&A). Despite costs, PSG is crucial as symptom documentation alone has low specificity for diagnosing OSA in young children.
Area of Science:
- Pediatric Sleep Medicine
- Otolaryngology
- Health Economics
Background:
- Obstructive sleep apnea (OSA) diagnosis in young children often precedes surgical intervention like adenotonsillectomy (T&A).
- Polysomnography (PSG) is the gold standard for OSA diagnosis but incurs significant costs.
- The cost-effectiveness of PSG versus symptom-based evaluation for T&A is a critical consideration in pediatric care.
Purpose of the Study:
- To evaluate the cost-effectiveness of polysomnography (PSG) for diagnosing obstructive sleep apnea (OSA) in pediatric patients.
- To assess the role of symptom documentation as a screening tool for OSA in children undergoing evaluation for adenotonsillectomy (T&A).
- To analyze the association between PSG results and the likelihood of receiving T&A.
Main Methods:
- Retrospective cost analysis of pediatric patients (age 1-3 years) who underwent PSG between January 2015 and January 2016.
- Comparison of PSG results with symptom documentation for diagnosing OSA, using logistic regression analysis.
- Calculation of cost-effectiveness by comparing institutional costs of PSG and T&A procedures.
Main Results:
- 80% of pediatric patients tested positive for OSA via PSG.
- Children with positive PSG results were significantly more likely to undergo T&A compared to those with negative results.
- The cost of T&A was 17.7 times the cost of PSG, and symptom documentation showed low specificity for OSA diagnosis.
Conclusions:
- Positive PSG results are strongly associated with subsequent T&A, indicating its clinical utility despite costs.
- Symptom documentation alone is insufficient for accurate OSA diagnosis in this pediatric cohort.
- The study highlights the importance of PSG in guiding surgical decisions for T&A in young children with suspected OSA.
Objectives:
At our institution, younger children require polysomnography (PSG) testing to confirm obstructive sleep apnea (OSA hereafter) before surgical intervention by adenotonsillectomy (T&A). Given that sleep studies can be costly, we investigated the cost-effectiveness of PSG as well as the possible role for symptom documentation in evaluation for T&A.
Methods:
Pediatric patients age 1-3 years who received PSG testing between Jan. 2015 and Jan. 2016 who had not previously had T&A were identified for retrospective cost analysis. Cost data were obtained from institutional accountants. We defined a positive PSG as obstructive apnea-hypopnea index ≥1. Logistic regression analysis was used, and statistical significance was set a priori at p < 0.05. Sensitivities and specificities of symptom documentation screen for OSA were compared to gold standard, or PSG testing.
Results:
Of the 176 children who received polysomnography testing, 140 (80%) had a positive PSG indicative of OSA. Seventy-one (51%) children with OSA underwent T&A within 1 year of PSG, and 10 (7%) eventually received T&A after 1 year from PSG date. Of the children whose PSG results were negative (n = 36), 14 (39%) still underwent T&A within 1 year (n = 7, 19%) or later (n = 7, 19%). Children with positive sleep studies were significantly more likely to receive T&A within one year of PSG (p = 0.0006) and at any time after PSG (p = 0.04). Hospital costs for T&A varied widely while PSG costs were fairly consistent. Using average institutional costs of T&A and PSG, the total cost of a T&A was 17.7× the cost of PSG testing. Using number of recorded symptoms to diagnose OSA instead of PSG testing yielded low specificities.
Conclusion:
Fifty-eight percent of patients with OSA and 39% of patients without OSA had a T&A within 1 year or later, although positive PSG was significantly associated with a higher likelihood of receiving T&A. Given costs at this institution and current decision-making practices, 147 PSGs would need to be done to account for the cost of one T&A, which in our cohort would occur after approximately 305 days.
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