For children with mild/moderate throat infection symptoms, tonsillectomy (removing the tonsils) may be more costly but not necessarily better than watchful waiting, according to an article in Archives of Otolaryngology-Head & Neck Surgery (JAMA/Archives), November issue.
The authors explain that the removal of the tonsils (tonsillectomy), with or without adenoidectomy (removing the adenoids), is one of the most common surgical procedures performed on children. The frequency of tonsillectomies varies greatly from country-to-country. In 1998 115 per 10,000 Dutch children, 65 per 10,000 British children and 50 per 10,000 American children had an adenotonsillectomy (both adenoids and tonsils removed) – suggesting that in each country the indications for surgery are different.
Erik Buskens, M.D., Ph.D., University Medical Center Utrecht, Utrecht, the Netherlands, and team carried out a clinical trial with 300 children aged 2-8. They had all been recommended for adenotonsillectomy during 2000-2003. 151 children were randomly assigned to undergo surgery within six weeks, while the other 149 were assigned to watchful waiting. Watchful waiting means the patient is monitored closely and additional interventions are done as required. The parents kept diaries in which they logged data on their children’s upper respiratory tract symptoms, their daily temperatures, and recorded any costs associated with their care. There were follow-up visits after 3, 6, 12, 19 and 24 months.
During the 24 month period, the annual costs for the watchful waiting children were about $500 (€551, at 2002 exchange rate), while for the children who had had surgery the costs were $730 (€803) – 46% higher. The children who had undergone surgery experienced fewer fevers and throat infections. The researchers worked out that “The incremental costs per episode of fever, throat infection and respiratory tract infection avoided were €1,136 ($1,033), €1,187 ($1,079) and €465 ($423), respectively.”
The authors added “Overall, the balance between costs and effects in this population seemed unfavorable for adenotonsillectomy, with incremental cost-effectiveness ratios in excess of €465 ($423) per disease episode averted. Note that this estimate includes societal costs such as parental leave of absence associated with their child’s illness. Had these costs been left out of the equation, the figures would be even somewhat less favorable. With time, the child’s immune system matures and the difference in adverse episodes disappears. Thus, the initial cost increment in the adenotonsillectomy group will never be counterbalanced by a continued positive health effect.”
The researchers stressed that the cost effectiveness balance might be even less favorable in other countries – in the Netherlands, a relatively inexpensive procedure is used for adenotonsillectomy. It is possible, say the authors, that there may be children for whom surgery is cost-effective. Further research is needed to find out whether this is the case.
“Adenotonsillectomy or Watchful Waiting in Patients With Mild to Moderate Symptoms of Throat Infections or Adenotonsillar Hypertrophy – A Randomized Comparison of Costs and Effects”
Erik Buskens, MD, PhD; Birgit van Staaij, MD, PhD; Jet van den Akker, MD, PhD; Arno W. Hoes, MD, PhD; Anne G. M. Schilder, MD, PhD
Arch Otolaryngol Head Neck Surg. 2007;133(11):1083-1088.
Written by – Christian Nordqvist