Four strategies for the management of esophageal coins in children

Objective. To compare clinical outcomes and costs under 4 strategies for th e management of esophageal coins in children. Methods. We developed a decision analysis model of 4 possible strategies fo r managing esophageal coins: 1) endoscopic removal under general anesthesia ; 2) esophageal bougienage, 3) an outpatient 12- to 24-hour observation per iod to allow spontaneous coin passage; and 4) an inpatient observation peri od. Probabilities of success and complication rates for endoscopy and esoph ageal bougienage were obtained from published data. The probability of spon taneous coin passage was derived from chart review data at our institution. Costs were calculated from charges using a cost-to-charge ratio of .72. Hy pothetical patients included in the model were those with a single esophage al coin presenting within 24 hours of ingestion, with no respiratory compro mise on presentation and with no previous history of esophageal disease. St rategy-specific outcomes were overall complication rate and total cost in d ollars per patient. Sensitivity analyses were performed to account for vari ations in the data. Results. The esophageal bougienage strategy resulted in no complications an d a total cost per patient of $382, which represents a marginal advantage o f $2915 per patient compared with the endoscopic removal strategy. On sensi tivity analysis over the range of success and complication rates of bougien age, this strategy maintained a considerable decrease in both overall compl ications and total cost per patient compared with all other strategies. Bot h outpatient and inpatient observation strategies had overall complication rates of 4.2% compared with the complication rate of 5.8% for the endoscopy strategy. The total cost per patient under these strategies was $2439 for the outpatient and $3141 for the inpatient strategy, representing a margina l advantage of $858 and $156 per patient, respectively, compared with the e ndoscopy strategy. Both observation strategies maintained a lower overall c omplication rate compared with endoscopy in the sensitivity analysis. The o utpatient observation strategy maintained a marginal advantage of $645 to $ 1257 per patient compared with endoscopy; however, the inpatient observatio n strategy total cost per patient surpassed that of endoscopy at a spontane ous passage rate <23%. Conclusions. Given the high success and low complication rates reported for esophageal bougienage, substantial savings in overall complications and co sts would be expected with the use of this procedure. With spontaneous pass age rates >23%, either an outpatient or an inpatient observation strategy w ould reduce costs and complications, compared with endoscopic removal of al l esophageal coins.