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Your New Tonsillectomy Options
The latest methods reduce post-op pain and tissue damage by using less heat. Which is right for you?
Jay Klarsfeld
Publish Date: November 4, 2008   |  Tags:   ENT

Today's latest tonsillectomy treatment options employ various energy sources with the same goal in mind: to reduce the amount of heat involved and therefore cause less thermal injury to the surrounding tissue. Be it laser, microdebrider or cold ablation, each new method that has emerged over the past decade or so as an alternative to the traditional dissection methods comes with its own set of marketing claims, proponents, detractors and body of research showing that it's superior to all others. The truth is, in the hands of a capable and experienced surgeon, each can deliver positive results for our patients with minimal bleeding, tissue damage and post-op pain. The question for you then becomes, is it worth the investment?

With CMS's new payment system favoring ENT procedures, ASCs have seen the Medicare reimbursement payment for tonsillectomy increase from $630 last year to $921.41. In the ASC setting, the Medicare reimbursement rate for tonsillectomy is the same regardless of which method the surgeon uses. However, the equipment and disposables involved in some of the newer techniques are more expensive than the instruments used for cold knife and cautery. You'll want to do a thorough cost analysis before you invest in any new devices.

Hard costs
The hard costs — the price of the equipment and disposables you'll need for each treatment method — are the first and perhaps easiest part of the equation to tally. Each technique requires an up-front investment in the base power source for the device, plus the cost of the disposables — wands, blades, saline solution — you'll need for each individual case. Here's a quick look at the basics for each of the most common methods for tonsillectomy.

  • Electrocautery. In the cold dissection technique, the tonsils are cut away with a scalpel or snare, and bleeding in the tonsil bed is controlled with electrocautery. Electrocautery can also be used alone ("hot tonsillectomy") to cut and coagulate the tissue. Surgeons can use many techniques with this equipment to reduce thermal injury to the tissue and minimize pain.
  • Cold ablation. This technique uses a bipolar radiofrequency-powered wand in conjunction with saline solution to separate the tonsils from the tonsil bed at relatively low temperatures. It can be used for both total and partial (intracapsular) tonsillectomy.
  • Laser. The laser is used to completely or partially remove the tonsil tissue. A variety of delivery devices and fibers are available from several different manufactures.
  • Microdebrider. A powered, rotating instrument shaves away part or all of the tonsil tissue.
  • Thermal welding. Special forceps powered by pure thermal energy are used to cut out the tonsils and coagulate the remaining tissue. An alternative to electrocautery, this method passes no electricity through the tissue.
  • Ultrasonic dissection. The scalpel blade, vibrating at a high frequency, transfers ultrasonic energy to the tonsil tissue, removing the tonsils and sealing the tonsil bed at the same time.

Soft costs
A side-by-side comparison of the hard costs involved in, say, cold knife and cautery vs. cold ablation or microdebrider vs. laser will only tell you half the story. The second half involves the variable costs and potential benefits of the new technology. While the hard costs are easy to generate by asking for quotes from vendors and manufacturers, these "soft costs" are more nuanced and will require a bit more digging on your part. Some things to consider:

  • Purchase agreements. The list price for any item, be it equipment or disposables, should never be your endpoint. Always be prepared to negotiate everything, from the cost of the unit to discounts for volume on disposables and even the terms of payment or lease. You may be able to negotiate discounts or deals with the manufacturer whereby you get the base unit at no cost or on consignment and are only responsible for the price of disposables.
  • Other uses of the equipment. How much can the cost of the base unit be distributed among other procedures and specialties at your facility? The electrocautery unit, for example, is something that's used in a wide variety of outpatient procedures, which makes the initial investment more or less negligible. But if the microdebrider, laser or cold ablation system can also be used for more than just tonsillectomy, then the higher up-front costs associated with those techniques can be distributed across a variety of specialties and procedures, making them more cost-effective. Consult with the manufacturer to find out what other types of procedures might use the same technology, and ask your surgeons if they'd be willing to use the new device for those cases as well.
  • Maintenance. What kind of service contract will you need, and how much does that add to the overall cost?
  • Time and labor. How easy is it to set up, break down and operate the equipment? You'll want to know exactly how the equipment works, how many people are required to assist the surgeon during a procedure and what impact the new method will have on case times. Will the new device require more time to set up or additional staff in the OR? Or might it actually cut down on procedure and recovery times, letting you do faster room turnovers and send patients home more quickly? These variables can add huge pluses or minuses to your cost analysis.
  • Volume. How many docs do tonsillectomies at your facility, and how many of them are itching to use the new device? If it's just one out of five, you might not want to bother making that investment. But if that one doctor can bring in a lot of cases and makes a strong argument for the new device, it may be more detrimental to turn him down. Adding the new device might also bring new physicians to your center. Try getting all your physicians to participate in the trial — if you can get some more converts, that will boost the investment value.

Do your homework
Work closely with the equipment manufacturers and vendors to compile all the information you'll need to make an informed decision. However, the best way to evaluate the economics and feasibility of one of the newer tonsillectomy methods is to see it in action. Ask your vendor for references — is there a facility nearby that uses their device? If so, contact the facility and ask to come in and observe some cases from start to finish. Bring a checklist of the costs you're investigating and fill it out as you observe cases. Talk to the administrators, frontline staff and surgeons at the facility you visit.

When you get back to home base, compare your findings with what you know about the methods for tonsillectomy that are currently used at your facility. Of course, you'll also want your surgeons and staff to trial the new equipment themselves, which will give you a glimpse of how it may affect workflow and staffing on your own turf.

Be wary of claims that a new device will dramatically enhance your surgeons' ability to control bleeding and reduce tissue damage and post-op pain. These claims may well be true, but with a procedure as tried and true as tonsillectomy, the responsibility to control bleeding and minimize pain rests with the surgeon.

Your job is to focus on the quantifiable costs and benefits of investing in a new technology for tonsillectomy and to do a thorough analysis before rushing to purchase the hottest new device on the market.