title: Economic evaluation of surgical insertion of ventilation tubes for the management of persistent bilateral otitis media with effusion in children.
abstract: BACKGROUND
  The surgical insertion of Ventilation Tubes (VTs) for the management of persistent bilateral Otitis Media with Effusion (OME) in children remains a contentious issue due to the varying opinions regarding the risks and benefits of this procedure. The aim of this study was to evaluate the economic impact of VTs insertion for the management of persistent bilateral OME in children, providing an additional perspective on the management of one of the commonest medical conditions of childhood.
  
  
  METHODS
  A decision-tree model was constructed to assess the cost-effectiveness of VTs strategy compared with the Hearing Aids (HAs) alone and HAs plus VTs strategies. The model used data from published sources, and assumed a 2-year time horizon and UK NHS perspective for costs. Outcomes were computed as Quality-Adjusted Life-Years (QALYs) by attaching a utility value to the total potential gains in Hearing Level in decibels (dBHL) over 12 and 24 months. Modelling uncertainty in the specification of decision-tree probabilities and QALYs was performed through Monte Carlo simulation. Expected Value of Perfect Information (EVPI) and partial EVPI (EVPPI) analyses were conducted to estimate the potential value of future research and uncertainty associated with the key parameters.
  
  
  RESULTS
  The VTs strategy was more effective and less costly when compared with the HAs plus VTs strategy, while the incremental cost-effectiveness ratio for the VTs strategy compared with the HAs strategy was £ 5,086 per QALY gained. At the willingness-to-pay threshold of £ 20,000 per QALY, the probability that the VTs strategy is likely to be more cost-effective was 0.58. The EVPI value at population level of around £ 9.5 million at the willingness-to-pay threshold of £ 20,000 indicated that future research in this area is potentially worthwhile, while the EVPPI analysis indicated considerable uncertainty surrounding the parameters used for computing the QALYs for which more precise estimates would be most valuable.
  
  
  CONCLUSIONS
  The VTs strategy is a cost-effective option when compared with the HAs alone and HAs plus VTs strategies, but the need for additional information from future study is evident to inform this surgical treatment choice. Future studies of surgical and non-surgical treatment of OME in childhood should evaluate the economic impact of pertinent interventions to provide greater context.
authors.affiliation: Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK. syed.mohiuddin@manchester.ac.uk.
authors.forename: Syed
authors.initials: S
authors.lastname: Mohiuddin
authors.forename: Anne
authors.initials: A
authors.lastname: Schilder
authors.forename: Iain
authors.initials: I
authors.lastname: Bruce
mesh_terms: D002648:Child; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D019468:Disease Management; D004739:England; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D008876:Middle Ear Ventilation / Q000191:economics*; D009010:Monte Carlo Method; D010034:Otitis Media with Effusion / Q000601:surgery*; D019057:Quality-Adjusted Life Years; D013222:State Medicine