Cost-effectiveness of two types of dysphagia care in head and neck cancer: A preliminary report.

Abstract

We conducted a prospective, preliminary study to compare the cost-effectiveness of two different instrument-based techniques for diagnosing and managing dysphagia in 30 consecutive hospitalized patients with head and neck cancer. The two techniques are videofluoroscopy via modified barium swallow (MBS) and videoendoscopy via flexible endoscopic evaluation of swallowing with sensory testing (FEESST). Medicare was the primary insurer of all patients. Fifteen of these patients had their dysphagia diagnosed and managed by MBS and the other 15 by FEESST. Cost-effectiveness was assessed by determining the average Medicare reimbursement for each procedure. We found that the mean reimbursements were $451.01 ([+ or -] $50.55) for MBS and $321.23 ([+ or -] $3.01) for FEESST. The mean reimbursement for FEESST was significantly lower than that for MBS (p[less than]0.0001; Mann-Whitney U test). We conclude that FEESST appears to be more cost-effective than MBS for the inpatient management of dysphagia in patients with hea d and neck cancer.

Introduction

Swallowing problems are ubiquitous in patients with head and neck cancer, and they pose special challenges for rehabilitation teams. The growing interest in the diagnosis and management of dysphagia by clinicians is being matched by the United States government, which is now addressing the entire issue of swallowing problems in the elderly. [1] As investigators around the country assemble studies in an effort to determine the efficacy of one diagnostic technique over another, the issue of the relative and absolute costs of these procedures invariably enters the discussion. A fundamental element of determining the cost-effectiveness of any procedure is an analysis of the reimbursement it generates.

Two of the most common instrument-based examinations that guide the dietary and behavioral management of patients with dysphagia are fluoroscopy and endoscopy. Behavioral management refers to the postural changes (e.g., head turns and chin tucks) and other measures (e.g., throat-clearing, small bites and sips, and alternation of solid and liquid food consistencies) that are implemented to assure that a swallow will not lead to aspiration. Studies have shown that the information gleaned from fluoroscopic and endoscopic examinations with respect to laryngeal penetration and aspiration is similar. [2-6] Laryngeal penetration is defined as the passage of material into the larynx but not below the true vocal folds. Aspiration is defined as the passage of material below the level of the true vocal folds and into the trachea.

A recent study compared pneumonia outcomes among noncancer patients with dysphagia who were diagnosed and managed on the basis of the results of randomly assigned fluoroscopy or endoscopy. [7] That study found no significant difference between the two groups of patients. The type of endoscopy used in that study was flexible endoscopic evaluation of swallowing with sensory testing (FEESST). FEESST differs from traditional endoscopic evaluations in that it assesses airway protection capacity prior to food administration. Airway protection is tested by delivering air-pulse stimuli through a port in the flexible endoscope in order to elicit the laryngeal adductor reflex, a superior laryngeal nerve-mediated airway-protective reflex. [8,9] The type of fluoroscopy used in that study was a modified barium swallow (MBS) procedure. During MBS, the patient swallows doses of barium of various viscosities while the swallowing process is observed fluoroscopically by a radiologist and a speech language pathologist (SLP).

When data and outcomes are not significantly different between one diagnostic test and another, other considerations, such as cost-effectiveness, become quite important. The purpose of this preliminary study was to determine cost-effectiveness on the basis of comparisons of Medicare reimbursements for MBS and FEES ST in hospitalized head and neck cancer patients.

Patients and methods

Thirty consecutive hospitalized head and neck cancer patients in an urban tertiary care medical center were studied prospectively. Each had a complaint of dysphagia, and each underwent either MBS or FEES ST between Dec. 1, 1998, and Nov. 30, 1999. Dysphagia was defined as any subjective or objective complaint of (1) difficulty swallowing solid or liquid food, (2) coughing while taking food by mouth, (3) choking, or (4) difficulty handling secretions. The primary insurer for each patient in this study was Medicare.

The decision to administer either MBS or FEESST had been randomly determined to depend on which day of the week the dysphagia consult request was called in to the Department of Otolaryngology--Head and Neck Surgery. Patients whose consults were requested on a Monday or Thursday were assigned to the FEESST group, and patients whose consults were requested on a Tuesday, Wednesday, or Friday were assigned to the MBS group. The same team of SLPs carried out all testing in collaboration with the principal investigator (J.E.A.). All SLPs in this study were trained in both MBS and FEESST, and they had similar amounts of didactic and clinical experience ([greater than or equal to]2 yr).

Two outcomes measures were addressed in this preliminary study. One was the number of personnel required to carry out a procedure. The other was the amount of Medicare reimbursement based on the inpatient Current Procedural Terminology (CPT) codes published by Medicare. [10] The CPT code we used for MBS was 74230. At our institution, 74230 is submitted only for the radiologist and the radiology technician; the SLP charge is billed separately by the hospital and is derived from what is considered to be the reasonable and customary charge for SLP evaluations in the community. There is no difference between inpatient and outpatient reimbursement for MBS.

There is a difference between in- and outpatient reimbursement for FEESST. Because we were studying hospitalized patients, we used only inpatient reimbursement data for our analysis. Three CPT codes were used for FEESST, as permitted by Empire Medicare. [11] The FEESST codes we used were 31575 (flexible laryngoscopy), 9252059 (laryngeal function studies), and 92525 (swallowing evaluation). The evaluation and management code we used to submit the charge for the otolaryngologist who carried out the procedure was either 99252 (initial inpatient consult) or 99263 (followup inpatient consult).

The protocols for MBS and FEESST have been described in detail elsewhere. [7] The Mann-Whitney U test was used to analyze the difference in total reimbursements between MBS and FEESST.

Results

MBS group. Eleven men and four women, aged 62 to 78 years (mean: 70.7 [+ or -] 4.4), were administered MBS (table 1). Eight had cancer of the larynx, five had cancer of the tongue, and one each had cancer of the palate and pharynx.

Three persons--a radiologist, a radiology technician, and an SLP--were required to administer the procedure. At our institution, the amount of the CPT code 74230 reimbursement is $102.34. [12] The SLP portion of the evaluation--which included patient positioning, dietary and behavioral management, and report-writing--was reimbursed at an average of $348.67 ([+ or -]$50.55). The average total reimbursement for MBS, then, was $451.01 ([+ or -]$50.55).

FEESST group. Eleven men and four women, aged 50 to 80 years (mean: 69.8 [+ or -] 10.0), underwent FEESST (table 2). Seven patients had laryngeal cancer, four had glottic cancer, two had thyroid cancer, and one each had nasopharyngeal and tonsillar cancer.

Two persons--an otolaryngologist and an SLP--were needed to administer the procedure. For patients who were being seen for the first time by the otolaryngologist, we used the initial inpatient consultation code (99252). For patients who had been seen previously by the otolaryngologist, we used the followup inpatient consult code (99263). Charging on the basis of the three FEESST CPT codes (31575, 92520-59, and 92525) plus the initial consult code resulted in a mean reimbursement of $230.84 plus $91.85, for a total of $322.69. Charging on the basis of the FEESST codes plus the followup consult code resulted in a mean reimbursement of $230.84 plus $84.57, for a total of $315.41. The reason for the difference is that reimbursement for an initial inpatient consult is $7.28 higher than that for a followup inpatient consult. Overall, the average total reimbursement for FEES ST was $321.23 ([+ or -]$3.01).

Comparison. The average total reimbursement for FEESST was significantly lower than that for MBS (p[less than]0.0001, Mann-Whitney U test). More specifically, the three FEESST CPT codes plus 99252 (initial consult) resulted in a reimbursement of $230.84 plus $91.85, for a total of $322.69. Followup FEESST, using the FEESST codes plus 99263, resulted in a reimbursement of $315.41.

In summary, Medicare reimbursement for the initial inpatient FEESST was 28% less than that for MBS ($322.69 vs $451.01); put another way, MBS generated 40% more reimbursement than did initial inpatient FEES ST.

Discussion

To assess comprehensively the economic impact of a particular diagnostic test requires a variety of analyses, in addition to an analysis of the number of personnel required and individual procedure reimbursement. The salaries of ancillary personnel (including those who transport patients), the salaries of professionals, and the costs of equipment and overhead are also integral to a complete economic study of the actual and relative costs of running an instrument-based dysphagia program. Finally, the costs associated with disease entities that are likely to be prevented as a result of instrument-based diagnosis and management must be factored in as well, and more work in this area lies ahead. Nevertheless, we have developed a starting point from which some of these issues can be studied.

The cost-effectiveness of FEESST compared with MBS in the diagnosis and management of dysphagia in patients with head and neck cancer can be more fully appreciated if one extrapolates the expected savings we found to the nation as a whole. Approximately 30,200 new cases of head and neck cancer were diagnosed in the United States during 2000. [13] Conservatively, 60% of such patients--roughly 18,000--have some type of swallowing problem that requires an evaluation. [14] If the average FEESST reimbursement is $130 less than the average MBS reimbursement, the immediate savings to Medicare would be $2.3 million per year. Even though it is quite difficult to calculate the number of swallowing evaluations that would be required on an annual basis for currently surviving head and neck cancer patients, the cost-effectiveness of endoscopy cannot be denied.

The advantages of FEESST over MBS extend to areas beyond direct reimbursement. For example, our study demonstrated that MBS requires the services of three persons: a radiologist, a radiology technician, and an SLP. In addition, patients had to be transported to and from the radiology suite, which required the services of hospital transport personnel. MBS also requires the use of disposable supplies such as x-ray film and barium. In all, it appears likely that even the additional $130 reimbursement does not adequately compensate hospitals and providers for the expense of the additional personnel and material required. Finally, MBS exposes the patient to radiation.

In contradistinction, FEESST is performed at the bedside by an otolaryngologist and an SLP, and transportation of the patient off the floor is not required. FEESST requires no disposable supplies other than rubber gloves. Finally, of course, there is no radiation exposure. Further study of the economics of dysphagia appears to be warranted.

References

(1.) An Evidence Report on the Diagnosis and Treatment of Dysphagia/Swallowing Problems in the Elderly. Rockville, Md.: Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), U.S. Department of Health and Human Services, 1999.

(2.) Langmore SE, Schatz K, Olson N. Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Ann Otol Rhinol Laryngol 1991;100:678-81.

(3.) Ekberg O, Nylander G. Cineradiography of the pharyngeal stage of deglutition in 250 patients with dysphagia. Br J Radiol 1982;55:258-62.

(4.) Crary MA, Baron J. Endoscopic and fluoroscopic evaluations of swallowing: Comparison of observed and inferred findings [abstract]. Dysphagia 1997;12:108.

(5.) Wu CH, Hsiao TY, Chen JC, et al. Evaluation of swallowing safety with fiberoptic endoscope: Comparison with videofluoroscopic technique. Laryngoscope 1997;107:396-401.

(6.) Kaye GM, Zorowitz RD, Baredes S. Role of flexible laryngoscopy in evaluating aspiration. Ann Otol Rhinol Laryngol 1997;106:705-9.

(7.) Aviv JE. Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope 2000;110:563-74.

(8.) Aviv JE, Martin JH, Sacco RL, et al. Supraglottic and pharyngeal sensory abnormalities in stroke patients with dysphagia. Ann Otol Rhinol Laryngol 1996;105:92-7.

(9.) Ludlow CL, Van Pelt F, Koda J. Characteristics of late responses to superior laryngeal nerve stimulation in humans. Ann Otol Rhinol Laryngol 1992;101:127-34.

(10.) Current Procedural Terminology, 2000. Chicago: American Medical Association, 2000.

(11.) Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) Policy. The Medicare News Brief. Washington, D.C.: Health Care Financing Administration. Issue no. MNB-98-3, March 1998:25-8.

(12.) 2000 Enrollment Package, Medicare Part B, area 01, Manhattan. Washington, D.C.: Health Care Financing Administration, 2000.

(13.) Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000;50:7-33.

(14.) Epstein JB, Emerton S, Kolbinson DA, et at, Quality of life and oral function following radiotherapy for head and neck cancer. Head Neck 1999;21:1-11.

Table 1. Characteristics of MB' patients
Patient  Sex  Age  Site of cancer
1        M    66   Larynx
2        M    69   Larynx
3        M    70   Larynx
4        M    76   Larynx
5        M    70   Larynx
6        M    66   Palate
7        F    78   Larynx
8        F    76   Tongue
9        M    71   Larynx
10       M    70   Tongue
11       F    75   Tongue
12       M    74   Tongue
13       M    69   Larynx
14       M    68   Pharynx
15       F    62   Tongue
(*)Modified barium swallow.
Table 2. Characteristics of FEESST *
patients
Patient  Sex  Age  Site of cancer  Encounter
   1      F   80    Nasopharynx     Initial
   2      M   64       Larynx       Initial
   3      M   66      Thyroid      Followup
   4      M   52       Tongue       Initial
   5      M   62       Larynx       Initial
   6      M   62       Larynx       Initial
   7      F   69      Thyroid       Initial
   8      F   75       Tonsil       Initial
   9      M   76       Larynx       Initial
  10      F   80       Tongue      Followup
  11      M   79       Larynx       Initial
  12      M   50       Larynx       Initial
  13      M   78       Tongue       Initial
  14      M   78       Larynx       Initial
  15      M   76       Tongue      Followup
(*)Flexible endoscopic evaluation of
swallowing with sensory testing.