|
Thoracoscopic surgery for diagnosis of interstitial pneumonia special reference to medicoeconomical effect |
Kuda T, Nagamine N, Oshiro J, Matsubara S, Tamashiro M, Sakuda H, Kamada Y, Kuniyoshi Y, Koja K |
|
|
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 Thoracoscopic surgery (TS) and open thoracotomy for the diagnosis of interstitial pneumonia.
Economic study type Cost-effectiveness analysis.
Study population Hospitalised patients with interstitial pneumonia.
Setting University hospital. The economic study was conducted in Okinawa, Japan.
Dates to which data relate The effectiveness data come from studies conducted between 1991 and 1993 for open thoracotomy and between 1994 and 1996 for thoracoscopic surgery.1996 cost data were used.
Source of effectiveness data The effectiveness data come from a single study.
Link between effectiveness and cost data The cost data were derived retrospectively from the same sample which formed the clinical study.
Study sample 8 patients (3 male/5 female) who had open thoracotomy and 8 patients (2 male/6 female) who had thoracoscopic surgery formed the study sample. The average age for open thoracotomy was 55.1 years (range: 23 - 72), and for thoracoscopic surgery was 59.9 years (range: 43 - 70). The study sample was chosen from all patients who had had a diagnosis of interstitial pneumonia during the period of study (1991-1993 for open thoracotomy and 1994-1996 for thoracoscopic surgery). No power calculations were used to determine the sample size.
Study design The study was a non-randomized trial with historical controls at a single centre. The period of follow-up was until hospital discharge. No loss to follow-up occurred.
Analysis of effectiveness The analysis of effectiveness was based on intention to treat. The outcomes assessed were operating time, intraoperative blood loss, duration of postoperative chest drainage and postoperative hospital stay. Patients differed in the kind of diagnosis for interstitial pneumonia. In terms of patient clinicopathalogical profiles, among the patients who had open thoracotomy, 1 was classified as having Lymphocytic Interstitial Pneumonia (LIP), 4 as having Usual Interstitial Pneumonia (UIP), 3 as having a combination of UIP and Bronchiolitis Obliterans Organizing Pneumonia (BOOP) and 1 as having Non-Classifiable Interstitial Pneumonia (NCIP). Among the patients who had thoracoscopic surgery, 2 were diagnosed as having UIP, 1 as having BOOP, 2 as having NCIP, 2 as having Diffuse Alveolar Damage (DAD) and 1 as having a combination of BOOP and DAD. The samples were therefore not similar due to a greater incidence of UIP in the open group which had been reduced due to subsequent advances in diagnostic imaging processes that were available in the later study period covering TS.
Effectiveness results For the open and TS groups the results were:
intraoperative blood loss, 66g (+/- 58) and 7.5g (+/- 2.7), (p<0.05);
duration of postoperative chest drainage, 2.8 days (+/- 1.0) and 1.5 days (+/- 0.8), (p<0.05);
postoperative hospital stay, 8.6 days (+/- 5.0) and 3.3 days (+/-2.8), (p<0.05).
There were no significant differences in the operating time between the two surgical techniques: 110 minutes (+/- 14) for open and 90 minutes (+/- 42) for TS.
Clinical conclusions Thoracoscopic surgery leads to less surgical stress with less intraoperative blood loss, shorter duration of postoperative chest drainage and shorter postoperative hospital stay and therefore is superior to open thoracotomy.
Measure of benefits used in the economic analysis The authors did not develop a summary benefit measure. As such the benefits are assumed to be equal to the effectiveness results reported above.
Direct costs Direct costs were derived from Japanese social insurance as derived from published Ministry of Public Welfare (points) health charts and included total surgical costs. Discounting was not applied because the period of analysis was less than one year. Costs and quantities were not reported separately. The perspective adopted was that of the third-party payer.1996 cost data were used.
Statistical analysis of costs Undertaken but no details of specific tests were recorded.
Sensitivity analysis No sensitivity analysis was reported.
Estimated benefits used in the economic analysis The estimated benefits are shown in the effectiveness results recorded above.
Cost results The average total social insurance costs was 32,266 points for open thoracotomy and 21,615 points for thoracoscopic surgery. The costs for thoracoscopic surgery were significantly less than those for open thoracotomy (p<.05).
Synthesis of costs and benefits Costs and benefits were not combined. Asintraoperative blood loss, duration of postoperative chest drainage,duration of postoperative hospital stay and total direct costs were significantly less with thoracoscopic surgery than with open thoracotomy, thoracoscopic surgery was shown to be the dominant strategy.
Authors' conclusions Thoracoscopic surgery for the diagnosis of interstitial pneumonia is superior to open thoracotomy in terms of clinical outcomes, surgical stress and cost.
CRD COMMENTARY - Selection of comparators The rationale for the choice of comparator is clear. TS is becoming a preferred intervention but needed to be shown to be more cost-effective than the more traditional, open procedure which was the only presented modality covered by the Japanese social insurance system.
Validity of estimate of measure of benefit No summary benefit measure was provided and as such the study was an analysis of costs and outcomes. The introduction of new diagnostic imaging procedures between the two study periods introduced a confounding variable with respect to UIP classifications, which were not as prevalent in the later TS procedure. The small sample size, which was not validated by a power calculation, generates some doubt as to the validity of the results even though they would appear to have been well founded. The use of historical controls is associated with well-recognised sources of bias which may have had an influence on the results.
Validity of estimate of costs Costs and quantities were not reported separately which makes the issue of generalisability difficult to judge. Additionally, the authors adopted the perspective of a third party payer which will have greater applicability to social insurance systems rather than the UK National Health Service.
Other issues The study was conducted with the specific aim of demonstrating the cost-effectiveness of TS in achieving cover for this procedure within the Japanese health care system. The results, because of the limitations identified above, may need to be validated by a randomized controlled trial if this is ethically feasible in the context in question.
Bibliographic details Kuda T, Nagamine N, Oshiro J, Matsubara S, Tamashiro M, Sakuda H, Kamada Y, Kuniyoshi Y, Koja K. Thoracoscopic surgery for diagnosis of interstitial pneumonia special reference to medicoeconomical effect. Journal of the Japanese Association for Thoracic Surgery 1998; 46(4): 344-346 Indexing Status Subject indexing assigned by NLM MeSH Adult; Aged; Costs and Cost Analysis; Endoscopy /economics; English Abstract; Female; Humans; Length of Stay; Lung Diseases, Interstitial /diagnosis /surgery; Male; Middle Aged; Pneumonectomy /economics; Thoracoscopy; Thoracotomy /economics AccessionNumber 21998006727 Date bibliographic record published 30/04/1999 Date abstract record published 30/04/1999 |
|
|
|