142 CHAPTER 6 DISCUSSION This interventional, RCT-based analysis of cost-effectiveness for treating drooling demonstrates that two-duct ligation is more expensive than BoNT-A injections after one treatment cycle. This is (to some extent) offset by the fact that two-duct ligation is a more effective procedure: both treatment success and wish for subsequent treatment favoured two-duct ligation, which suggests that, despite its higher initial costs, it might be a more cost-effective treatment when considered over multiple treatment cycles. The costs made during the follow-up visits were relatively similar, although this is also partly due to the trial protocol. Most children in the RCT visited an ear, nose, and throat consultant at the 8- and 32-week follow-up visits; however, in our routine clinical practice, patients who undergo BoNT-A injections will visit the rehabilitation physician preoperatively and follow-up is mainly coordinated by the speech and language therapists. This could have resulted in a slight overestimation of the costs after BoNT-A injection. More caregivers in the two-duct ligation group reported having to take off work or hire child minders to care for their child in the first days after the intervention, which was amajor driver of the difference in costs between the procedures. This difference is possibly linked to the larger invasiveness of the two-duct ligation procedure since the children in that group did experience more pain and discomfort than their peers in the BoNT-A group.10 The duration of the procedure was the other major driver of the difference in costs between the procedures, which was reflected by the decrease in the ICER in the sensitivity analysis. Wherever possible, general costs for health care resources were used. However, there were no general costs available for those associated with the interventions. Therefore, a micro-costing approach was used to calculate the costs made in the operation room. Owing to micro-costing, we have presented a better outlook on the total costs per intervention which might make our results more applicable to
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