title: A Cost-Effectiveness Analysis of Surgery for Middle-Aged Men with Severe Obstructive Sleep Apnea Intolerant of CPAP.
abstract: OBJECTIVE
  Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Conventional OSA therapy necessitates indefinite continuous positive airway pressure (CPAP). Although CPAP is an effective treatment modality, up to 50% of OSA patients are intolerant of CPAP. We explore whether surgical modalities developed for those intolerant of CPAP are cost-effective.
  
  
  METHODS
  We construct a lifetime semi-Markov model of OSA that accounts for observed increased risks of stroke, cardiovascular disease, and motor vehicle collisions for a 50-year-old male with untreated severe OSA. Using this model, we compare the cost-effectiveness of (1) no treatment, (2) CPAP only, and (3) CPAP followed by surgery (either palatopharyngeal reconstructive surgery [PPRS] or multilevel surgery [MLS]) for those intolerant to CPAP.
  
  
  RESULTS
  Compared with the CPAP only strategy, CPAP followed by PPRS (CPAP-PPRS) adds 0.265 quality adjusted life years (QALYs) for an increase of $2,767 (discounted 2010 dollars) and is highly cost effective with an incremental cost-effectiveness ratio (ICER) of $10,421/QALY for a 50-year-old male with severe OSA. Compared to a CPAP-PPRS strategy, the CPAP-MLS strategy adds 0.07 QALYs at an increase of $6,213 for an ICER of $84,199/QALY. The CPAP-PPRS strategy appears cost-effective over a wide range of parameter estimates.
  
  
  CONCLUSIONS
  Palatopharyngeal reconstructive surgery appears cost-effective in middle-aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short-term and long-term surgical outcomes.
  
  
  CONCLUSIONS
  A commentary on this article appears in this issue on page 509.
authors.affiliation: Stanford University, Management Science and Engineering Department, Stanford, CA.|Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA.
authors.forename: Kelvin B
authors.initials: KB
authors.lastname: Tan
authors.affiliation: Singapore General Hospital, Singapore.
authors.forename: Song Tar
authors.initials: ST
authors.lastname: Toh
authors.affiliation: Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA.
authors.forename: Christian
authors.initials: C
authors.lastname: Guilleminault
authors.affiliation: Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA.|Pulmonary, Critical Care and Sleep Section, VA Palo Alto Healthcare System, Palo Alto, CA.
authors.forename: Jon-Erik C
authors.initials: JE
authors.lastname: Holty
mesh_terms: D045422:Continuous Positive Airway Pressure; D003362:Cost-Benefit Analysis / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010159:Palate / Q000601:surgery; D010614:Pharynx / Q000601:surgery; D019057:Quality-Adjusted Life Years; D019651:Plastic Surgery Procedures / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D020181:Sleep Apnea, Obstructive / Q000601:surgery*; D015599:Trauma Severity Indices; D016896:Treatment Outcome
keywords: cost-effectiveness analysis; obstructive sleep apnea; sleep apnea surgery; sleep apnea syndromes