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A case controlled comparison of open and laparoscopic splenectomy in children |
Rescorla F J, Breitfeld P P, West K W, Williams D, Engum S A, Grosfeld J L |
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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 Open (OS) and laparoscopic splenectomy (LS) for hematologic disorders in children and adolescents.
Economic study type Cost-effectiveness analysis.
Study population Children and adolescents undergoing splenectomy for hematologic disorders.
Setting Secondary care. The economic study was conducted at the JW Riley Hospital for Children, Indianapolis, Indiana, USA.
Dates to which data relate Effectiveness data were collected between August 1994 and September 1997. Costs data appear to be related to the same period, although there is no clear statement on this and some of the costs have beenestimated by the authors.
Source of effectiveness data Effectiveness 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 analysis.
Study sample 82 consecutive children and adolescents were considered in the analysis. 50 patients underwent LS by lateral approach and 32 underwent OS through a left sub-costal incision. The groups were closely matched for age, weight and diagnosis. Mean age was 7.76 years for LS and 6.9 years for OS. Mean weight was 30.5kg for LS and 27.6kg for OS. Hematologic indications included hereditary spherocystosis in 43 children, sickle cell anaemia with sequestration in 13, immune thrombocytopenic purpura (ITP) in 14 and 12 with other disorders. Concomitant cholecystectomy for cholelithiasis was performed in 10 patients (20%) in the LS group and 6 (19%) in the OS group. Additional procedures were performed in 4 patients in the LS group: inguinal hernia repair, circumcision, incidental appendectomy and liver biopsy. No power calculations were reported in determining sample size.
Study design Retrospective case controlled study.
Analysis of effectiveness The analysis was based on the intention to treat principle. The main health outcomes used in the analysis were complication rate, mortality, operative time, postoperative intravenous narcotic, total narcotic dosage, length of hospital stay and response to splenectomy.
Effectiveness results There were no deaths or major complications in either group. No LS procedures required conversion to OS. Complications in the LS group consisted of ileus in 2 patients and atelectasis in 1. Two patients in the LS group required nasogastric tube insertion for management of postoperative ileus and 6 in the OS group had nasogastric tube in place for 24 hours after the procedure. Operative time was longer in the LS group (115 versus 83 minutes, p=0.002), and the mean estimated blood loss was 54.4 mL for LS and 49.0 mL for OS (p=0.233). There was less need for postoperative intravenous narcotic (51% versus 100%, p<0.0001) with LS, lower total narcotic doses (0.239 versus 0.480 mg/kg morphine, p=0.006), and shorter length of hospital stay at 1.4 (+/- 0.97) days versus 2.5 (+/- 1.43) days for OS, (p=0.001). There were no readmissions within 30 days of operation in either group. The response to splenectomy for ITP and hereditary spherocystosis was 100% in both groups.
Clinical conclusions LS is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration and shorter length of stay.
Measure of benefits used in the economic analysis The authors did not provide a summary measure of benefit. As such a cost-consequences analysis was performed and the health benefits are associated with the health outcomes reported above.
Direct costs Total average hospital charges were considered, excluding physicians' fees, namely operative time, transfusion requirements, use of nasogastric tube decompression, postoperative narcotic requirement, and length of hospital stay. The surgeons' fees were identical for both procedures and the anaesthesiologists' fee was estimated to be approximately $100 higher for the LS group, although the actual numbers were not available. Cost dates were not stated. Also, the costing methodology was not clearly presented, so it is hard to see exactly what cost items were included in the total hospital charges. Discounting was not applied due to the short period of analysis (less than 1 year).
Statistical analysis of costs Statistical analysis of costs was performed using the Wilcoxon rank-sum test.
Estimated benefits used in the economic analysis As no summary benefit measure was provided the reader is referred to the effectiveness results reported above.
Cost results The average total hospital charges were $5,713 for LS alone versus $6,564 for OS alone (p=0.117, NS). For splenectomy and cholecystectomy the total charges were $9,342 for OS and $6,244 for LS, (p=0.09, NS).
Synthesis of costs and benefits A synthesis of costs and benefits was not applicable due to the cost-consequences approach adopted.
Authors' conclusions LS is a safe and effective procedure in children with hematologic disorders resulting in longer operative times, less narcotic administration, shorter length of stay and lower hospital total charges.
CRD COMMENTARY - Selection of comparators The reason for the choice of the comparators (OS versus LS) is clear, as both procedures are widely used in the authors' setting. You, as a database user, should consider if the same applies to your own setting.
Validity of estimate of measure of benefit The authors did not provide a summary measure of benefit and, hence, conducted a cost-consequences analysis. The validity of estimates of effectiveness will be less reliable than those derived from an experimental design using randomisation in order to reduce potential confounders. At baseline there were some obvious differences between samples such as the number of males in each group, the differing numbers in each sample and in some aspects of hematologic conditions.The retrospective approach is also less reliable than a prospective design.
Validity of estimate of costs It is hard to assess whether the estimate of costs is valid, because the charges presented are not completely itemised and it is not clear what cost items were considered in the final cost calculation. The use of charges does not reflect opportunity costs which limits the generalisability of the cost results. Extensive comparisons were made with other studies on the same topic and nearly all the studies analysed revealed an increase in operating time and a decrease in length of stay for LS versus OS.
Other issues Aspects such as the impact on the lifestyle of the patients could have been considered in this study. For example, the impact on return to school and on parents' return to work.
Implications of the study The authors suggest that LS is a reasonable alternative to OS when performed by experienced surgeons in an expeditious fashion. The caveats are that the spleen must be removed without any intraperitoneal spill of splenic tissue, and surgeons must carefully search for the presence of accessory spleens.
Bibliographic details Rescorla F J, Breitfeld P P, West K W, Williams D, Engum S A, Grosfeld J L. A case controlled comparison of open and laparoscopic splenectomy in children. Surgery 1998; 124(4): 670-676 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Adult; Child; Child, Preschool; Female; Hematologic Diseases /therapy; Hospital Charges; Humans; Infant; Laparoscopy /economics; Length of Stay; Male; Postoperative Complications; Retrospective Studies; Splenectomy /economics /methods AccessionNumber 21998001539 Date bibliographic record published 31/03/2000 Date abstract record published 31/03/2000 |
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