title: Making a case for high-volume robotic surgery centers: A cost-effectiveness analysis of transoral robotic surgery.
abstract: OBJECTIVE
  To evaluate the cost-effectiveness of transoral robotic surgery (TORS) compared to intensity-modulated radiotherapy (IMRT) for early stage (T1-2, N0, M0) oropharyngeal squamous cell carcinoma (OPSCC).
  
  
  METHODS
  A Markov decision tree model with a 5-year time horizon was developed. Comparative groups were: i) TORS with concurrent ipsilateral neck dissection +/- adjunctive IMRT, and ii) primary IMRT. Primary outcome was cost/quality adjusted life year (QALY). Perspective was the United States third party payer. Costs and effects were discounted at a rate of 3.5%. A threshold and probabilistic sensitivity analysis were performed.
  
  
  RESULTS
  TORS strategy cost $30,992 and provided 4.81 QALYs/patient. The IMRT strategy cost $26,033 and provided a total of 4.78 QALYs/patient. The incremental cost effectiveness ratio for TORS vs. IMRT in the reference case was $165,300/QALY. The probability that TORS is cost-effective compared to IMRT at a maximum willingness-to-pay threshold of $50,000/QALY is 42%.
  
  
  CONCLUSIONS
  An IMRT strategy for management of early stage OPSCC is more likely to be cost-effective compared to TORS. To improve the value of TORS for early stage OPSCC, consolidating TORS procedures to create high-volume centers of excellence may be a potential strategy to increase incremental effectiveness and reduce incremental costs. J. Surg. Oncol. 2015 111:155-163. © 2015 Wiley Periodicals, Inc.
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Luke
authors.initials: L
authors.lastname: Rudmik
authors.affiliation: Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Wenyi
authors.initials: W
authors.lastname: An
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Devon
authors.initials: D
authors.lastname: Livingstone
authors.affiliation: Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Wayne
authors.initials: W
authors.lastname: Matthews
authors.affiliation: D ivision of Otolaryngology-Head and Neck Surgery, Department of Surgery; University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Hadi
authors.initials: H
authors.lastname: Seikaly
authors.affiliation: Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Rufus
authors.initials: R
authors.lastname: Scrimger
authors.affiliation: Canada Research Chair, Health Services and Systems Research; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Deborah
authors.initials: D
authors.lastname: Marshall
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000191:economics* / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004469:Economics, Hospital; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D009055:Mouth; D057605:Natural Orifice Endoscopic Surgery / Q000191:economics / Q000295:instrumentation; D037981:Neck Dissection; D009367:Neoplasm Staging; D009959:Oropharyngeal Neoplasms / Q000191:economics* / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D019057:Quality-Adjusted Life Years; D018714:Radiotherapy, Adjuvant; D050397:Radiotherapy, Intensity-Modulated / Q000191:economics*; D065287:Robotic Surgical Procedures / Q000191:economics*; D014481:United States
keywords: cancer; cost-effectiveness; economic evaluation; oropharyngeal; oropharynx; radiation therapy; squamous cell carcinoma; transoral robotic surgery