Impact of a Streamlined Hypoglossal Nerve Stimulator Pathway on Cost and Time to Surgery

Introduction: Pilot data suggests that flexible laryngoscopy during awake volitional snore has good concordance with drug-induced sleep endoscopy (DISE) findings at the level of the velum. Our institution piloted a streamlined hypoglossal nerve stimulator (HGNS) pathway, where patients with anterior/posterior collapse pattern of the velum on volitional snore could undergo confirmatory DISE followed immediately by HGNS during the same surgical encounter. We hypothesized that the streamlined HGNS pathway would expedite time to surgery and reduce costs.

Methods: Data for patients undergoing HGNS implantation at an academic tertiary care center from 2016-2022 were retrospectively reviewed. The primary outcome was difference in costs between patients in the streamlined pathway (same day DISE-HGNS) versus traditional pathway (DISE and HGNS on different days). A secondary outcome was difference in time from initial clinic encounter with a sleep surgeon to HGNS implantation. Two-sided t-tests were used.

Results: There were 66 patients included in the analysis (11 streamlined, 55 traditional). The majority of patients had Medicare (59.1%) or Blue Cross Blue Shield (34.8%) based insurance plans. There was no significant difference in the total insurance payment [mean (SD): $64,383 (36,188) vs $41,986 (34,324); p = 0.055] or total patient payments [mean (SD): $485 (1,076) vs. $1,550 (9,655) p=0.718] between patients in the streamlined and traditional pathways, respectively. The hospital costs were significantly lower for patients in the streamlined compared to traditional pathway [mean (SD): $32,573 (1,076) vs $37,923 (7,978) p = 0.033]. In a subset analysis of 22 patients, patients in the streamlined pathway had surgery on average 88.4 days earlier than those in the traditional pathway relative to their first clinic visit with a sleep surgeon.

Conclusions: The streamlined HGNS pathway appears to significantly reduce hospital costs and may expedite surgery by nearly 3 months.