|
The use of caudal epidural anesthesia in clubfoot surgery |
Foulk D A, Boakes J, Rab G T, Schulman S |
|
|
Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of supplemental caudal anaesthesia, on an outpatient basis, for the surgical release of clubfeet in children.
Economic study type Cost-effectiveness analysis.
Study population Children undergoing complete subtalar release for resistant, idiopathic clubfoot. Group 1 consisted of 27 children (17 male, 10 female) with a mean age 9.0 months, and Group 2 consisted of 31 children (20 male, 11 female) with a mean age 9.6 months. Patients were excluded if they presented with nonidiopathic clubfeet, suffered from recurrent clubfeet, had undergone non-standard operations (such as Lichtblau osteotomy), or were older than 30 months.
Setting Hospital, University of California, USA.
Dates to which data relate Effectiveness and resource use data were collected during the period 1987 - 1992. The price year used was not stated.
Source of effectiveness data Data were derived from a single study.
Link between effectiveness and cost data Costing was undertaken retrospectively on the same patient sample as that used in the effectiveness study.
Study sample The sample consisted of two sequential groups of children undergoing surgery at the host institution. No power calculations were used to determine the sample size. Group 1 consisted of 27 patients with 39 clubfoot releases (all with general anaesthesia only, and all during the period 1987-1990), and Group 2 consisted of 31 patients with 41 clubfoot releases (all with general anaesthesia, supplemented with caudal epidural anaesthesia, 30 patients being operated on between Jan 1990 and May 1992).81% of group 2 were operated on as outpatients (discharged on the day of surgery).
Study design Case series from a single centre. The duration of follow-up was not stated, although it continued beyond hospital discharge.
Analysis of effectiveness It was not stated whether the analysis was based on intention to treat or on treatment completers only. Groups 1 and 2 were shown to be well matched by age, sex, weight and ASA status. Health outcomes used included anaesthetic time required, occurrence of anaesthetic complications, the use of intraoperative narcotics, recovery room time, the need for recovery room narcotics, the occurrence of postoperative wound complications, the need for overnight stay (for the outpatient group), and parent satisfaction.
Effectiveness results Intraoperative narcotics were used in 17 of 27 patients in group 1, and 8 of 24 preincision caudal patients in group 2, (p<0.05).25 of 31 patients in group 2 were discharged on the same day as surgery after it had been established that the following requirements had been met:oral non-opioid analgesics were determined to be adequate by parents' assessment, no medical contraindication was found, parents were willing to care for the child at home and no significant travel was involved for the family. All other outcomes showed no significant difference between the two groups (p<0.05). No postoperative wound complications occurred in either group, other than one minor complication in Group 2 (without untoward sequelae). There were no anaesthetic complications in either group.
Clinical conclusions The supplementation of general anaesthesia with caudal epidural anaesthesia in children undergoing surgery for clubfoot was found to be safe and effective. It reduced the requirements for intraoperative narcotics and was not associated with major complications. It was considered to reduce pain in the recovery room and facilitate successful comforting of children by parents in the immediate postoperative period.
Measure of benefits used in the economic analysis Since the effectiveness study showed no difference in clinical benefits between groups, the economic analysis was based on the difference in costs only.
Direct costs Both inpatient and outpatient charges were included in the analysis. Quantities of resource use were not analysed separately from the costs. Bills were examined to look at bed charges and to put these into the context of the overall bill for the procedure. No monetary figures were reported and nor was the price year used in the calculations stated.
Sensitivity analysis No sensitivity analysis was performed.
Estimated benefits used in the economic analysis Cost results Cost results were expressed only as a percentage reduction in hospital bed charges between the two groups. There was a 30% reduction in hospital bed charges in the outpatient group relative to the inpatient group. However, the authors reported that, when all charges were evaluated, this reduction represented only 3% of the overall bill.
Synthesis of costs and benefits Authors' conclusions The early discharge allowed by the supplemental use of caudal epidural anaesthesia in these patients is preferred by parents, and may be shown to be cost saving in other settings. The cost savings shown here were minor but may be due to the billing patterns being strongly oriented toward reimbursement by procedure.
CRD Commentary As with many studies of this type the numbers are low. The main problem with this study is that it lacks any formal economic analysis. If a prospective full economic evaluation were to be carried out it would probably be shown to be cost-effective. The unit costs should be shown, a sensitivity analysis should be carried out, and a rating scale used to measure pain relief objectively. The costs of drugs, their administration, side effects, and the staff involved should also have been included.
Implications of the study Further studies are needed in order to validated the economic cost and benefits associated with use of supplemental caudal epidural anaesthesia in clubfoot surgery for children.
Bibliographic details Foulk D A, Boakes J, Rab G T, Schulman S. The use of caudal epidural anesthesia in clubfoot surgery. Journal of Pediatric Orthopaedics 1995; 15(5): 604-607 Indexing Status Subject indexing assigned by NLM MeSH Analgesics, Opioid; Anesthesia, Caudal; Anesthesia, General; Child, Preschool; Clubfoot /surgery; Female; Hospitalization; Humans; Infant; Male; Treatment Outcome AccessionNumber 21995000978 Date bibliographic record published 31/03/1999 Date abstract record published 31/03/1999 |
|
|
|