Cost of closure: Comparing success and spending of fat graft myringoplasties with and without hyaluronic acid

Abstract

Introduction

Myringoplasties are common pediatric procedures used to surgically close a perforated tympanic membrane. While a wide variety of graft materials are available to surgeons, the cost effectiveness of these different techniques is not well studied.

Objectives

To compare the cost effectiveness of the fat graft myringoplasty (FGM) with the hyaluronic acid fat graft myringoplasty (HAFGM).

Methods

Retrospective chart review of patients ages 31 days to 18 years who had undergone either FGM or HAFGM from 2006 to 2016.

Results

We identified 85 patients who had undergone FGM and 51 patients who had undergone HAFGM. The two groups were statistically similar in age (CI -0.51, 1.9; p = 0.23), sex (CI 0.3, 1.4; p = 0.27), and history of prior tympanostomy tube placement (CI -0.07, 0.07; p = 0.69). Both groups had a similar number of total comorbidities (40.0% of patients in the FGM group and 27.5% of patients in the HAFGM; CI -0.04, 0.29; p = 0.19). The FGM and the HAFGM procedure did not have statistically significant differences in perforation closure rates, 82.4% and 92.2% respectively (CI 0.81, 7.3; p = 0.13). In comparing the total surgeons’ cost of closing a tympanic membrane deficit, the FGM incurred a greater cost per perforation. The cost/tympanic membrane perforation closure for the FGM totaled $3011.88 per deficit, whereas the HAFGM totaled $2742.98.

Conclusion

As financial stewardship becomes more important for medical decision making, it is imperative that providers consider cost and outcomes data together when comparing similar treatment options. The FGM and the HAFGM have statistically similar rates of success in closing tympanic membrane perforations. In this study, the FGM cohort consumed more health care dollars per perforation secondary to the need for revision surgeries. As such, this study offers that the additional use of a hyaluronic disc does not increase overall cost to the healthcare system when performing a fat graft myringoplasty over a large cohort of patients.

Introduction

Myringoplasties are very common surgical procedures used to repair tympanic membrane perforations. While most perforations heal spontaneously within 6–12 months in the pediatric population, many perforations go on to become chronic defects within the tympanic membrane [1]. Chronic perforations occur in 2–16% of patients with pressure equalization (PE) tube placement and can also be the result of chronic suppurative otitis media, cholesteatomas, trauma, and significant negative pressure changes [2]. Tympanic membrane perforations carry long-term risks of conductive hearing loss, speech impairment, middle ear disease, water contamination, infection, and otorrhea, all of which can be improved with myringoplasty procedures. Tympanostomy tube placement occurs approximately 500,000 times annually in children. As such, it is the most common ambulatory procedure performed in children. Conservatively, 2% of patients with tubes will acquire perforations. Therefore, the success of myringoplasty procedures can have a significant public health impact within our pediatric population as there could potentially be 10,000 myringoplasties performed annually [3,4].

In performing a myringoplasty, several different kinds of graft materials are available to surgeons, including fat grafts with and without hyaluronic acid, cartilage grafts, temporalis fascia grafts, paper patches, gelfoam, and gelfilm. Procedure technique, complexity, outcome, and cost vary between these different myringoplasty options. Our study focused on fat graft myringoplasty (FGM) and hyaluronic acid fat graft myringoplasty (HAFGM). Both procedures require removal of a small portion of adipose tissue from the postauricular area or lobule to create a fat scaffolding within the tympanic membrane defect. In HAFGM, a hyaluronic acid disc is applied over the fat graft. Fat grafts provide a revascularization matrix to facilitate the healing tympanic membrane. In HAFGM, the hyaluronic acid promotes epithelial cell migration into the fat graft and it also prevents perforation at the margins of the fat graft [5].

Within the last ten years, HAFGM have been cited as being more efficacious than FGM. Despite studies reporting increased success rate of HAFGM, it has been suggested that fat alone can be an appropriate choice for smaller, uncomplicated perforations due to its cost effectiveness [6,7]. Overall, the reported success rates of HAFGM and FGM are 86–92% and 57.1–87%, respectively [[8], [9], [10], [11], [12], [13], [14]]. While repeated HAFGM or FGM may be performed after unsuccessful closure with similar success rates, many providers advance to a more invasive tympanoplasty procedure. This has implications on the overall cost to repair a tympanic membrane deficit [15].

Revision surgery after failed HAFGM or FGM incur significant cost to the family and the health care system. As such, a more expensive technique that limits the need for revision surgery may be beneficial when examining the cost of caring for a cohort of patients. With financial stewardship gaining increasing importance, it is necessary for providers to be familiar with the cost of the surgical procedures they recommend and perform. This includes the current cost and potential chance of downstream cost due to failed procedures. Our study sought to provide a cost vs. benefit analysis of HAFGM when compared with FGM.