Cost and Efficiency of Drug‐Induced Sleep Endoscopy: Endoscopy Suite Versus Outpatient Surgery Center

ABSTRACT

Objective

Drug‐induced sleep endoscopy (DISE) is used to identify airway obstruction patterns in patients with obstructive sleep apnea (OSA). This procedure is typically performed in either the traditional operating room (OR) or an outpatient surgery center (SC). There is limited data regarding the cost and efficiency of DISE in the endoscopy suite (ES). This study compares the cost, efficiency, and safety of DISE performed in the ES compared to the SC.

Methods

This retrospective review included patients who underwent DISE between July 2023 and April 2024 at a single tertiary care center. Consecutive patients with CPAP‐intolerant OSA undergoing DISE in the ES or SC were included. Patient demographics, sleep studies, procedure‐related costs, procedure duration characteristics, and anesthesia documentation were analyzed.

Results

Eighty‐four patients (36 ES, 48 SC) were included. Patient sex, age, BMI, and preoperative AHI/REI were similar in both cohorts (p > 0.05). DISE in the ES significantly reduced total facility time (48 min, p < 0.0001), time in procedure room (6.6 min, p < 0.0001), DISE procedure time (1.7 min, p = 0.0034), total recovery time (30.4 min, p < 0.0001), and procedure room turnover time (7.1 min, p = 0.0012). Costs for ES procedures were 39.35% lower, specifically in costs associated with anesthesia, operating room, and recovery room (all comparisons, p < 0.001). No complications occurred in either group.

Conclusions

Performing DISE in the ES increases efficiency and reduces costs compared to the outpatient SC while maintaining safety for patients with CPAP‐intolerant OSA.

Level of Evidence

3

Performing Drug‐Induced Sleep Endoscopy in the Endoscopy Suite (ES) increases efficiency and reduces costs compared to the outpatient surgery center (SC) while maintaining safety for patients with CPAP‐intolerant Obstructive Sleep Apnea. Total facility time was reduced by 48 min and costs were 39.35% lower in the ES group, with all comparisons showing highly significant differences (p < 0.0001).

1. Introduction

Obstructive sleep apnea (OSA) is characterized by intermittent episodes of upper airway obstruction resulting in disruption of airflow during sleep and is a pervasive disorder impacting 936 million adults globally [1, 2]. Untreated OSA is associated with significant adverse health outcomes including hypertension, cardiovascular disease, cardiac arrhythmias, and stroke [3]. Quality of life can be profoundly diminished in patients with OSA through exacerbations of daytime sleepiness and fatigue that severely limit daily functioning [4]. Continuous positive airway pressure (CPAP) is widely recognized as an efficacious first‐line therapy for OSA yet is poorly tolerated by patients due to discomfort associated with its use [5]. Multiple factors ultimately contribute to poor tolerance and suboptimal adherence rates for CPAP therapy for OSA [6].

Treatment modalities such as uvulopalatopharyngoplasty (UPPP), oral appliances, maxillomandibular advancement (MMA), and hypoglossal nerve stimulation (HGNS) therapy are potential options for select CPAP‐intolerant patients with moderate‐to‐severe OSA [7, 8]. With the advent of novel treatments, drug‐induced sleep endoscopy (DISE) has become a critical diagnostic tool for the evaluation of surgical candidacy in these patients [9]. This procedure is performed under sedation anesthesia, allowing for endoscopic examination of the upper airway for obstruction at specific sites (velum, oropharynx, tongue base and epiglottis) as well as patterns of airway collapse in patients with OSA [10].

As the utilization of DISE becomes increasingly prevalent in clinical practice for OSA, optimizing its efficiency and cost‐effectiveness is paramount. Recent quality improvement efforts have identified endoscopy suites (ES) as an underutilized resource that may serve as a potential target for optimizing the efficiency of outpatient procedures [11]. Patients with OSA routinely undergo common procedures within endoscopy suites such as colonoscopy and esophagogastroduodenoscopy, which are often safely performed in this setting [12]. The purpose of the present study is to investigate variability in efficiency and cost between performing DISE in a specialized ES compared to an outpatient surgery center (SC) operating room. We hypothesize that conducting DISE in the ES will enhance operational efficiency and reduce overall procedural costs while remaining safe for patients with OSA.

2. Methods

2.1. Study Approval and Data Collection

The present study is a single‐center retrospective analysis of patients with OSA undergoing DISE for evaluation of surgical candidacy between July 2023 and April 2024. The study obtained approval from the Institutional Review Board at Thomas Jefferson University (Control #20E.1181). Consecutive patients who underwent DISE without any additional procedures in either the ES or outpatient SC for evaluation of CPAP‐intolerant OSA were included in the study. Demographic data including patient age, sex, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status classification (measurement of comorbidities) were collected. Key measurements such as the Apnea‐Hypopnea Index (AHI), Respiratory Event Index (REI), and oxygen desaturation nadir from type 1 polysomnographic and type 3 home sleep studies included in the preoperative note were recorded. The procedural summary of each patient's DISE was reviewed on the electronic medical record, from which operational metrics including total facility time, time in the procedure room (defined as time in room to time out of room), DISE procedure time (defined as the time from nasal scope insertion to scope removal), total recovery time, and procedure room turnover time were collected. Beyond temporal characteristics, anesthesia documentation was evaluated for the recorded number of desaturations, oxygenation status, mean arterial pressure (MAP), and propofol amount received during the DISE procedure. Anesthesia‐related operative complications were also collected. Cost‐based data was also collected and provided to our group by our institutional finance department. Cost data was provided on a per‐patient basis and included the total cost of admission and procedure, as well as charges stratified into the following categories: Pharmacy, Operating Room, Anesthesia, and Recovery Room as previously reported [13]. Endoscopy suites and operating rooms within our institutional enterprise are each billed on a per 15‐min basis.

2.2. Procedure and Anesthetic Protocol

The procedural and anesthetic protocols for patients undergoing DISE are independent of the procedure taking place in the ES or SC. Scheduling of DISEs in the ES and SC is based on room availability, and patients are not preferentially scheduled in either setting. Our institutional protocols limit any patient with an Anesthesia Society of America physical status classification (ASA) greater than three from the outpatient ES or SC after preoperative anesthesia evaluation. Thus, every patient had an ASA classification of three or less. However, we cannot account for the unconscious bias of the attending surgeon's decision making which may direct patients with multiple or more severe medical comorbidities to the operating room over the endoscopy suite. Following arrival in either location, patient intravenous access is obtained in the preoperative holding area. No sedative medications are administered in the preoperative area, however oxymetazoline is generally provided to promote nasal decongestion. Procedures are carried out under sedation with propofol unless a patient allergy is specified. A core group of Certified Registered Nurse Anesthetists and Anesthesiologists familiar with DISE are our typical Anesthesia caregivers. Anesthesia is administered directly or under an attending anesthesiologist's direct oversight. We typically use a continuous infusion of propofol supplemented by bolus to achieve a level of sedation where the respiratory drive is maintained but the patient does not react to the insertion of the camera into the nose. Bispectral index monitoring is generally not utilized at our institution, as patients are monitored hemodynamically and based on their reaction to the procedure as described previously [14]. We strive for a depth of anesthesia where respiratory drive is maintained but the patient is not reactive to verbal stimuli or insertion of the scope into the nose, and there is no evidence of coughing or swallowing. The infusion is typically started when the patient enters the room. If the above signs of inadequate sedation occur, a propofol bolus is given or the continuous infusion is titrated up as needed. Supplemental oxygen is administered on an as‐needed basis dependent on oxygen saturation level. Following appropriate sedation administration, anatomic sites including the velum, oropharynx, tongue base, and epiglottis are evaluated for the magnitude of airway collapse under direct visualization with nasopharyngoscopy. Visualization of these sites was repeated using CPAP with nasal masks at a starting pressure of 5 cm H₂O with incremental pressure increases to 15 cm H₂O to determine opening pressures. Sedation is then weaned, and the procedure is completed with patients traveling to the recovery area.

2.3. Statistical Analysis

Categorical variables were assessed using Fisher's exact tests while continuous variables were assessed using unmatched parametric t‐tests or nonparametric Mann–Whitney tests depending on the distribution of data. Normality was analyzed using Shapiro–Wilk tests. All statistical analyses were conducted using GraphPad Prism (Version 10.4.1) and statistical significance was defined as p < 0.05.

2.4. Results

Eighty‐four patients who underwent DISE in either the ES (n = 36) or SC (n = 48) were investigated. In the ES and SC groups, respectively, there were no statistically significant differences in mean patient age (56.2 vs. 57.9 years), BMI (29.7 vs. 30.8 kg/m²), preoperative AHI/REI (32.4 vs. 33.8), preoperative oxygen desaturation nadir (78.3% vs. 78.7%) the proportion of males (69.4% vs. 60.4%), or distribution of ASA physical status classification (p > 0.05). These data are summarized in Table 1.

TABLE 1.

Patient demographics and sleep study characteristics.

	Endoscopy suite (n = 36)	Surgery center (n = 48)	p
Age (at time of DISE)	56.2 ± 11.7	57.9 ± 14.3	0.55
Sex
Male	25 (69.4)	29 (60.4)	0.49
Female	11 (30.6)	19 (39.6)
BMI	29.7 ± 4.0	30.8 ± 3.8	0.21
Preoperative AHI/REI	32.4 ± 15.7	33.8 ± 16.7	0.74
Preoperative O2 nadir	78.3 ± 8.4	78.7 ± 8.3	0.87
ASA Status
2	7 (19.4)	16 (33.3)	0.21
3	29 (80.6)	32 (66.7)

Note: Data are mean ± standard deviation or number (percentage).

Abbreviations: AHI, apnea‐hypopnea index; ASA, American Society of Anesthesiologists; DISE, drug‐induced sleep endoscopy; O₂, oxygen; REI, respiratory event index.

Compared to the SC cohort, ES patients experienced significant temporal reductions in average total facility time by 48 min (p < 0.0001), time in the procedure room by 6.6 min (p < 0.0001), DISE procedure time by 1.7 min (p = 0.0034) and total recovery time by 30.4 min (p < 0.0001). Procedure room turnover time between consecutive DISE cases was significantly reduced in patients undergoing their procedure in the ES vs. SC (21.1 vs. 28.2 min, p = 0.0012). A summary of these data can be found in Table 2.

TABLE 2.

Operational efficiency metrics.

	Endoscopy suite (n = 36)	Surgery center (n = 48)	p
Total facility time (min)	140.0 ± 43.5	188.3 ± 41.5	< 0.0001
Total recovery time (min)	58.6 ± 18.4	89.0 ± 25.4	< 0.0001
DISE procedure time (min)	6.89 ± 2.34	8.58 ± 3.14	0.0034
Time in procedure room (min)	15.3 ± 4.17	21.9 ± 5.23	< 0.0001
Procedure room turnover time (min)	21.1 ± 16.0	28.2 ± 18.1	0.0012

Note: Data are mean ± standard deviation. Statistically significant results are in bold.

Abbreviation: DISE, drug‐induced sleep endoscopy.

An assessment of intraoperative monitoring by anesthesia demonstrated significant differences for the ES and SC groups, respectively, with regard to mean oxygen desaturations (SpO₂ < 88%) (1.52 vs. 3.17, p = 0.0077), minimum O₂ saturation (84.9% vs. 80.4%, p = 0.0096), and minimum MAP (87.0 vs. 80.8, p = 0.015). The maximum MAP did not differ between groups (p > 0.05). These data are present in Table 3. There was no significant difference in mean amount of propofol received for sedation in the ES vs. SC cohorts (227.6 vs. 257.3 mg, p = 0.30). There were no instances of intubation, cardiopulmonary compromise, unplanned readmission, or cancellation of the procedure related to patient safety in either cohort. These data are summarized in Table 3.

TABLE 3.

Intraoperative anesthesia care and complications.

	Endoscopy suite (n = 36)	Surgery center (n = 48)	p
Oxygen desaturations	1.52 ± 2.17	3.17 ± 3.20	0.0077
Minimum O2%	84.9 ± 12.9	80.4 ± 10.4	0.0096
Minimum MAP	87.0 ± 12.4	80.8 ± 10.3	0.015
Maximum MAP	106.7 ± 17.0	106.3 ± 20.7	0.77
Propofol Received (mg)	227.6 ± 106.6	257.3 ± 120.0	0.30

Note: Data are mean ± standard deviation. Statistically significant results are in bold.

Abbreviations: mg, milligrams; O₂, oxygen.

Evaluation of patient financial data demonstrated significant differences in both total and categorized costs for DISE in the ES and SC settings. The mean total cost was reduced in the ES cohort as compared to the SC cohort ($510.70 vs. $842.10, p < 0.0001). Regarding mean categorized costs, the ES cohort was associated with lessened charges compared to the SC cohort for Anesthesia ($54.62 vs. $77.21, p < 0.0001), Operating Room ($81.11 vs. $269.40, p < 0.0001), and Recovery Room ($109.70 vs. $375.90, p < 0.0001) categories. Pharmacy costs were more expensive for the ES group on average ($51.04 vs. $36.08, p = 0.0008). These data are visually summarized in Figure 1.

FIGURE 1.

Total and categorized DISE costs by location of procedure. Data are mean ± standard deviation total (A), pharmacy (B), anesthesia (C), operating room (D), and recovery (E) charges dependent on procedure location. p < 0.05 was considered statistically significant. DISE, drug‐induced sleep endoscopy. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

2.5. Discussion

Drug‐induced sleep endoscopy can be efficiently and safely performed in the endoscopy suite in a cost‐effective manner. Several factors may potentially contribute to the differences seen in the two settings studied here for the performance of DISE. Endoscopy suites often have pre‐established workflows and an organizational structure optimal for short procedures. It is conceivable that this specialization lends itself to enhanced efficiency and a reduction in the time needed to prepare patients for the procedure, turnover the room, and safely transition patients through the post‐anesthesia care unit [15]. Additionally, from a hospital systems science perspective, the operational framework of ES's facilitates a systematic patient care journey from pre‐procedure to post‐procedure recovery. Complementing these infrastructural benefits of the ES, this outpatient procedure setting is often staffed by healthcare providers with specific training and experience in endoscopic procedures, which may contribute to a reduction in procedural times and improved patient throughput [11]. Lastly, operating rooms in surgery centers usually accrue greater overhead costs resulting in the need for a wider range of equipment, greater need for sterilization, and use by larger surgical teams [16]. When compared to the SC, the specialized ES thus incurs lower overall costs, which translate to greater cumulative cost reductions in this procedural setting.

While we demonstrate statistically significant differences in intraoperative anesthesia parameters, specifically fewer oxygen desaturations, higher minimum oxygen saturation, and higher minimum MAP in the ES as compared to the SC, their clinical relevance should be interpreted with caution. Both settings demonstrated an excellent safety profile, with no instances of emergent intubation, cardiopulmonary compromise, unplanned readmission, or procedure cancellation related to patient safety. In addition, in our cohort, the procedure was performed by experienced teams in both settings. To investigate the reasoning for these findings, the mean amount of propofol (milligrams) was recorded for each cohort. There was no significant difference in the amount of propofol received in the ES versus SC groups, respectively (227.6 vs. 257.3 mg). However, on average there was a higher mean propofol amount in the SC group, and we cannot definitively say it did not contribute to these vital sign differences. Furthermore, although not represented by ASA status, the observed differences in oxygen saturation parameters may in part be explained by institutional practices directing patients with more significant comorbidities to the SC, thereby reserving the ES for healthier patients. Additionally, although both practice settings employ experienced anesthesia teams, providers do not typically overlap and mainly practice at one of the two locations. Thus, it is conceivable that the SC providers may be more comfortable with a deeper level of sedation, potentially contributing to the demonstrated differences in vital signs and procedure time. In an effort to assess if potential differences in sedation level during DISE impact OSA patient outcomes, we plan to analyze the success of eventual surgical recommendations based on DISE performed at both locations. Regardless, our conclusion supports previously reported findings that DISE is an exceedingly safe procedure irrespective of practice setting [17]. Thus, decisions regarding the procedural setting can be guided by considerations of efficiency rather than safety concerns.

The financial implications of performing DISE in the ES are significant. We demonstrate that DISE procedures occurring in the ES incurred significantly lower overall costs compared to those in the SC. DISE conducted in the ES was 39.35% less expensive than in the SC, supporting previously reported findings regarding the reduced expenses faced by patients and the healthcare system when DISE procedures are relocated to the ES [18]. Our investigation expands upon Ghazizadeh et al.'s work by providing a more detailed financial analysis of DISE procedures based on setting, itemizing total costs into individual components including anesthesia care, operating room, recovery room, and pharmacy‐related costs. We discovered significant reductions in costs related to anesthesia care, direct operating room expenses, and recovery room charges in the ES. While we observed a relative increase in mean pharmacy‐related costs in the ES, this increase is marginal ($51.04 vs. $36.08) relative to the greater overall cost savings of the operating room ($81.11 vs. $269.40) and recovery room ($109.70 vs. $375.90) on average.

Considering the short duration of these procedures, seemingly small reductions in actual procedural times and room turnover times between patients may accumulate to allow for additional procedures to be performed per day. When compounded over weeks, this improvement in efficiency could conceivably improve patient throughput and enhance overall productivity on a larger scale. Furthermore, the increased patient throughput and thus more procedures completed within the same period of time may also improve patient access to care and patient satisfaction by reducing wait times. Future investigations should explore the direct implications of improved turnover time on survey‐based patient satisfaction metrics. As a quality improvement‐based initiative, it would be valuable to understand whether patients prefer the ES or the outpatient SC. Lastly, a significant proportion of the time savings observed in the ES group occurred in the recovery room. Modeling workflows established in other surgical fields, developing and implementing a standardized post‐procedure DISE protocol, alongside training recovery room staff in practices aligned with the ES, may further enhance cost efficiency and value in the SC [19].

Additionally, investigating the relative accessibility and availability of ES and SC across diverse geographical areas and urban versus rural practice settings is crucial. Our study distinctly expands upon Ghazizadeh et al.'s prior investigation by making a comparison between the outpatient SC to the ES rather than to an operating room at a tertiary medical center. With the rapid evolution of surgical treatment options for OSA and therefore the increasing adoption and utility of DISE, ensuring the accessibility of the endoscopy procedure across diverse practice settings is imperative. While not assessed in this study, further research should also seek to evaluate long‐term patient outcomes following DISE in the ES versus SC to compare and evaluate potential correlations between procedural environments and treatment success rates. These future directions for further investigation can contribute to a greater understanding of the role of DISE in enhancing patient care, reducing costs, and optimizing operational efficiency.

The utility of the endoscopy suite for otolaryngology‐based procedures may feasibly expand beyond DISE to include other endoscopic procedures and procedures requiring local or sedation anesthesia. Several laryngology procedures, including injection laryngoplasty and esophageal dilation, and non‐laryngology procedures such as temporal artery biopsy for temporal arteritis workup have been increasingly performed in the office setting or in the operating room under sedation anesthesia [20, 21, 22]. The decision of anesthesia type often depends on the specific patient and comfort of the provider with the endoscopy suite providing another considerable option for carrying out these relatively short procedures. This is an important area of future study to improve efficiency and cost‐effectiveness of additional procedures within otolaryngology.

The present study is one of the few in the literature to evaluate metrics for operational efficiency for DISE procedures. However, our investigation is not without limitations. The present study evaluated the operational metrics of a single institution, which may reduce the generalizability of our findings to other settings with different patient populations or specific nuances in procedural practices. Financial data provided to us as part of this study included categorized costs with regard to Pharmacy, Operating Room, Anesthesia, and Recovery Room charges; however, specific itemized costs beyond the category total were not available to our team. Additionally, the DISE procedures investigated in the present study were all conducted by two sleep surgeons board‐certified in Otolaryngology and Sleep Medicine. Considering the relatively short time necessary to conduct a DISE procedure, variability of skill and comfort level between providers may lend itself to an additional reduction in the generalizability of our findings. Furthermore, there may have been variability between the anesthesiologists and nursing staff present within and between cases that was unaccounted for. Future studies may seek to further control for these variables by standardizing the personnel involved in the study or perhaps stratifying results based on different sleep surgeon or anesthesia provider experience levels. Lastly, expanding the model of the present study to be a prospective, multi‐institutional investigation may mitigate some of these limitations.

2.6. Conclusions

In summary, DISE procedures used for the evaluation of alternative treatment options for patients with OSA can be performed with increased efficiency and reduced cost in the ES as compared to the outpatient SC without compromising patient safety. Where appropriate, our findings support the adoption and utilization of endoscopy suites for DISE at other institutions that may seek to optimize resource utilization and efficiency in the clinical management of OSA.

Conflicts of Interest

Maurits Boon reports grants from Inspire Medical Systems, during the conduct of the study; and grants and personal fees for consultancy from Inspire Medical Systems, outside the submitted work. Colin Huntley reports research support from Inspire, Nyxoah, and consulting relationship with Inspire, Nyxoah, and Avivomed, outside the submitted work.

Sina E. M., Corr A., Estephan L. E., Hunt P., Boon M., and Huntley C., “Cost and Efficiency of Drug‐Induced Sleep Endoscopy: Endoscopy Suite Versus Outpatient Surgery Center,” The Laryngoscope 135, no. 10 (2025): 3938–3943, 10.1002/lary.32183.