Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate.

OBJECTIVE To assess the impact of the rate of spontaneous resolution of congenital nasolacrimal duct obstruction on the relative cost-effectiveness of deferred nasolacrimal duct probing in a surgical facility (DFPS) compared with an immediate office-based probing surgery (IOPS). METHODS Data from the literature, Medicare 2009 fee schedule, and consensus assumptions were combined to populate a model of outcomes of 2 treatment strategies: immediate office-based probing (IOPS) and deferred facility-based probing (DFPS) (deferred for 6 months). Sensitivity analyses were conducted, varying the 6-month spontaneous resolution rate from 50% to 90%. Additional factors varied during analyses included surgical cost and each procedure's probability of success. Outcomes measured were overall cost of treatment, chance of cure, and months of symptoms avoided by 18 months of life. RESULTS Under the base case, assuming a 75% spontaneous resolution rate during 6 months prior to deferred probing, IOPS is more expensive ($771 vs $641) and slightly less effective (93.0% vs 97.5%) than DFPS, although IOPS costs only $44 per month of symptoms avoided. At spontaneous resolution rates between 50% and 68%, IOPS costs less than DFPS (from $2 to $342 less), although it also is slightly less effective (from 2.0% to 3.8% less). At a 90% spontaneous resolution rate, IOPS costs $169 per month of symptoms avoided. As the rate of spontaneous resolution falls, the cost per additional success for DFPS increases to $16 709 at a 50% spontaneous resolution rate. CONCLUSION The relative cost-effectiveness of these strategies for treatment of nasolacrimal duct obstruction depends on the spontaneous resolution rate after diagnosis.