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Economic Implications of Diagnostic Strategies for CSF Rhinorrhea Contact 1. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence- based review with recommendations. Int Forum Allergy Rhinol. 2016;6:8– 16. 2. Reddy M, Baugnon K. Imaging of Cerebrospinal Fluid Rhinorrhea and Otorrhea. Radiol Clin North Am. 2017 Jan;55(1):167-187. 3. Le C, Strong EB, Luu Q. Management of Anterior Skull Base Cerebrospinal Fluid Leaks. J Neurol Surg B Skull Base. 2016 Oct;77(5):404-11. References Diagnostic and localizing strategies for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely. Recent reviews have established sensitivities and specificities for diagnostic modalities. To date, no study has investigated the cost implication of using a certain order of tests to arrive at a diagnosis and ultimately treatment. Background Methods The use of High-Resolution Computed Tomography (HRCT) followed by exploration in the operating room if preliminary HRCT was negative was found to be the least costly means of diagnosing and localizing a patient with a high index of suspicion for CSF leak (expected cost $1579). The next least costly algorithm was CT-Cisternogram (CTC) followed by visualization in the operating room (expected cost $1897). Sensitivity analyses generally supported HRCT to be the optimal strategy over a wide range of parameter values. Results Our model suggests primary use of HRCT for localization is the lowest cost approach to localize CSF leaks in patients with confirmed CSF rhinorrhea. These results differ from previously published algorithms with respect to CTC. Considering the additional risks and discomfort associated with intrathecal contrast and lumbar puncture, we recommend HRCT as the first line to localize an assist in treating CSF rhinorrhea. A decision tree analysis of diagnostic algorithms for CSF rhinorrhea localization was performed. The primary outcome measured was cost, with estimated study costs from the Centers for Medicare and Medicaid. The model was parameterized using the best available current literature; a systematic review was performed of studies published from 1990 to 2017 to estimate the sensitivity, specificity, and accuracy of four localization modalities for CSF rhinorrhea. One-way sensitivity analyses were performed via TreeAge Pro software. Figure 2 Decision tree for diagnosis of CSF leaks with sensitivities and pricing Christopher Pool, MD Division of Otolaryngology- Head and Neck Surgery Pennsylvania State University Milton S. Hershey Medical Center 500 University Dr., Hershey, PA, 17033 Email: [email protected] Phone: (717)-531-6822 Christopher Pool MD, Vijay Patel MD, Amber Schilling PharmD, Christopher Hollenbeak PhD, Neerav Goyal MD MPH Department of Surgery, Division of Otolaryngology – Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA Decision Tree Model for Cost of Localizing Clinically Suspicious CSF Leaks Sensitivity of Each Model Parameters to Cost of Localization Conclusion A A B C D B A Cost Based on Localization Success of High-Resolution Computed Tomography Figure 1 Magnetic Resonance Cisternography demonstrating a right-sided CSF leak Figure 3 Sensitivity Analysis for Probability of HRCT Success Cost of CSF localization (Y-axis) as a function of probability of localization success for HRCT (X-axis). As probability of success of HRCT increases above 54%, the expected cost of localizing a CSF leak using HRCT becomes the least costly method relative to all other methods. Notice that even at extremely low success probabilities for HRCT, HRCT is less costly than MR- Cisternography. Figure 4 Tornado Diagram for Probability of Successful Localization for Each Modality Cost of CSF leak localization with relation to the success of detection modalities. The wider the bar, the greater the change in the cost workup algorithm as the success of each test changes. As shown, the model is most sensitive to changes in the success rate of RNC.

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EconomicImplicationsofDiagnosticStrategiesforCSFRhinorrhea

Contact1. OakleyGM,AltJA,SchlosserRJ,HarveyRJ,OrlandiRR.Diagnosisofcerebrospinalfluidrhinorrhea:anevidence- basedreviewwithrecommendations.IntForumAllergyRhinol.2016;6:8–

16.2. ReddyM,BaugnonK. ImagingofCerebrospinalFluidRhinorrheaandOtorrhea.RadiolClinNorthAm.2017Jan;55(1):167-187.3. LeC,StrongEB,LuuQ.ManagementofAnteriorSkullBaseCerebrospinalFluidLeaks.JNeurolSurgB Skull Base.2016Oct;77(5):404-11.

References

Diagnostic and localizing strategies for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely. Recent reviews have established sensitivities and specificities for diagnostic modalities. To date, no study has investigated the cost implication of using a certain order of tests to arrive at a diagnosis and ultimately treatment.

Background

Methods

The use of High-Resolution Computed Tomography (HRCT) followed by exploration in the operating room if preliminary HRCT was negative was found to be the least costly means of diagnosing and localizing a patient with a high index of suspicion for CSF leak (expected cost $1579). The next least costly algorithm was CT-Cisternogram (CTC) followed by visualization in the operating room (expected cost $1897). Sensitivity analyses generally supported HRCT to be the optimal strategy over a wide range of parameter values.

Results

Our model suggests primary use of HRCT for localization is the lowest cost approach to localize CSF leaks in patients with confirmed CSF rhinorrhea. These results differ from previously published algorithms with respect to CTC. Considering the additional risks and discomfort associated with intrathecal contrast and lumbar puncture, we recommend HRCT as the first line to localize an assist in treating CSF rhinorrhea.

A decision tree analysis of diagnostic algorithms for CSF rhinorrhea localization was performed. The primary outcome measured was cost, with estimated study costs from the Centers for Medicare and Medicaid. The model was parameterized using the best available current literature; a systematic review was performed of studies published from 1990 to 2017 to estimate the sensitivity, specificity, and accuracy of four localization modalities for CSF rhinorrhea. One-way sensitivity analyses were performed via TreeAge Pro software.

Figure2 DecisiontreefordiagnosisofCSFleakswithsensitivitiesandpricing

ChristopherPool,MDDivisionofOtolaryngology- HeadandNeckSurgeryPennsylvaniaStateUniversityMiltonS.HersheyMedicalCenter500UniversityDr.,Hershey,PA,17033Email:[email protected]:(717)-531-6822

Christopher Pool MD, Vijay Patel MD, Amber Schilling PharmD, Christopher Hollenbeak PhD, Neerav Goyal MD MPHDepartment of Surgery, Division of Otolaryngology – Head and Neck Surgery, The Pennsylvania State University,

College of Medicine, Hershey, PA, USA

DecisionTreeModelforCostofLocalizingClinicallySuspiciousCSFLeaks

SensitivityofEachModelParameterstoCostofLocalization

Conclusion

B C D

CostBasedonLocalizationSuccessofHigh-ResolutionComputedTomography

Figure1MagneticResonanceCisternographydemonstratingaright-sidedCSFleak

Figure3 SensitivityAnalysisforProbabilityofHRCTSuccessCostofCSFlocalization(Y-axis)asafunctionofprobabilityof

localizationsuccessforHRCT(X-axis).AsprobabilityofsuccessofHRCTincreasesabove54%,theexpectedcostoflocalizingaCSFleakusingHRCTbecomestheleastcostlymethodrelativetoallothermethods.Noticethatevenatextremelylowsuccess

probabilitiesforHRCT,HRCTislesscostlythanMR-Cisternography.

Figure4 TornadoDiagramforProbabilityofSuccessfulLocalizationforEachModality

CostofCSFleaklocalizationwithrelationtothesuccessofdetectionmodalities.Thewiderthebar,thegreaterthechangeinthecostworkupalgorithmasthesuccessof

eachtestchanges.Asshown,themodelismostsensitivetochangesinthesuccessrateofRNC.

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