A DRG-based economic comparison of six topical hemostatic agents in thyroidectomy

Abstract Background The economic sustainability of topical hemostatic agents in thyroidectomy under diagnosis-related group (DRG) reimbursement is unclear. Using a model-based micro-costing approach, this study quantified their impact on hospital costs and contribution margins within the Italian National Health Service. Methods A micro-costing model was constructed using clinical and cost parameters from 1,800 thyroidectomies at a high-volume endocrine surgery unit. Seven strategies were compared as parallel cohorts with balanced baseline characteristics: no topical agent and six topical classes (oxidized cellulose, gelatin sponge, polysaccharide powder, fibrin sealant, collagen–fibrin patch, advanced pad). Costs were benchmarked against a mean DRG tariff of €3,350. Incremental costs per hematoma avoided (ICERs), contribution margins, and threshold analyses were computed; modeled clinical outcomes were reported descriptively, without inferential testing. Results The modeled incidence of cervical hematoma requiring reintervention was 1.4% (range 1.2–1.6% across strategies), reflecting the base-case assumption of comparable bleeding risk. Modeled mean postoperative length of stay ranged from 2.6 to 2.8 days. Mean device cost per case ranged from €24 (oxidized cellulose) to €235 (advanced pad), translating into incremental hemostasis-related costs of €25–235 versus no agent. Hemostasis-related expenditure rose from 48.4% of the DRG tariff in the no-agent group to 55.4% with advanced pads. ICERs for low-cost agents were €20,000–40,000 per hematoma avoided; high-cost agents consistently exceeded €100,000 and were often dominated. Threshold analysis showed that high-cost agents would require absolute hematoma reductions of 11–18 percentage points to break even — far exceeding the 1.5% baseline rate. Conclusions In DRG-funded thyroid surgery, when topical hemostatic agents are assumed to confer little or no reduction in bleeding complications, they increase costs without offsetting savings. High-cost products substantially erode contribution margins, supporting selective, risk-adapted use of low-cost adjuncts and economics-informed procurement policies.