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Management of penetrating colon trauma: a cost-utility analysis |
Brasel K J, Borgstrom D C, Weigelt J A |
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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 Management strategies in penetrating colon injuries.
Study population Patients with traumatic colon injuries.
Setting Hospital. The study was carried out at the Regions Hospital, University of Minnesota, St Paul, Minnesota, USA.
Dates to which data relate Effectiveness data were collected from studies previously published between 1980 and 1996. Resource use and cost data were collected from a 1996 source. The price year was 1996.
Source of effectiveness data Effectiveness data were derived from a literature review.
Modelling A decision tree was used to determine the cost-utility of the three management strategies.
Outcomes assessed in the review The review assessed the following outcomes: complication rate stratified by management method and injury severity, abscess rate, complication rate from colostomy closure, colostomy closure rate, and mortality rate.
Study designs and other criteria for inclusion in the review Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Summary statistics from each study.
Number of primary studies included 12 studies were included in the review.
Methods of combining primary studies Meta-analysis based on weighted averages.
Investigation of differences between primary studies Results of the review The complication rate after primary repair was 0.41 (range: 0.1 - 0.7) for severe injury and 0.18 (range: 0.05 - 0.3) for non-severe injury. The complication rate after resection and anastomosis was 0.43 (range: 0.4 - 0.7) for severe injury and 0.23 (range: 0.07 - 0.3) for non-severe injury. The complication rate after colostomy was 0.45 (range: 0.25 - 0.88) for severe injury and 0.22 (range: 0.1 - 0.5) for non-severe injury. The rate of intra-abdominal abscess formation was 30% of the total complication rate. The complication rate from colostomy closure was 0.15 (range: 0.05 - 0.25). The colostomy closure rate was 0.9. The mortality rate after colon injury was 9% for patients with intra-abdominal abscess. These data were used as the effectiveness and outcome parameters for the model.
Measure of benefits used in the economic analysis Quality-adjusted life years (QALYs) were used as the primary measure of benefits. A visual analog scale was used to assess temporary colostomy disutility. The scale was administered to 18 healthy volunteers aged 14 to 35 years with demographic profiles similar to those of the index trauma population. All surviving patients were assumed to have a 50-year life expectancy after injury.
Direct costs Costs related to colostomy supplies were discounted at an annual discount rate of 5%. Quantities and costs were reported separately. Direct costs for each procedure were calculated by identifying all components necessary for peri-operative care. The quantity/cost boundary adopted was that of the hospital. The estimation of quantities and costs was based on actual data. Professional fees were collected from the Department of Surgery, St Paul-Ramsey Medical Center, St Paul, Minnesota. True resource costs were used for 60% of items included in the analysis. Remaining costs were estimated with the use of a cost-to-charge ratio, which was specific to the hospital. The price year was 1996.
Statistical analysis of costs Sensitivity analysis One-way and two-way sensitivity analyses were conducted on all assumptions, probabilities, and outcome assignments through the reported ranges.
Estimated benefits used in the economic analysis Colostomy, resection and primary repair yielded 48.39, 48.96, and 49.19 QALYs, respectively, for non-severe injuries. Colostomy, resection and primary repair yielded 47.37, 48.06, and 48.15 QALYs, respectively, for severe injuries.
Cost results Total costs for treating non-severe injuries were $22,016 for colostomy, $12,396 for resection, and $11,279 for primary repair. Total costs for treating severe injuries were $26,947 for colostomy, $16,865 for resection, and $16,418 for primary repair.
Synthesis of costs and benefits Primary repair and resection and anastomosis dominated colostomy (higher quality of life at lower cost). Sensitivity analysis did not alter these conclusions.
Authors' conclusions Simple suture or resection and anastomosis at the time of initial exploration is the dominant management strategy for penetrating colon trauma.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparators was clear. You, as a user of this database, should verify whether these health technologies are relevant to your setting.
Validity of estimate of measure of benefit A relevant measure of benefits was used. Utility values for specified outcomes were assigned by healthy volunteers. Alternatively, patients or physicians could have assigned utility values. Utility values were assigned by only 18 healthy volunteers. More details about the meta-analysis of the effectiveness estimates derived from the literature could have been provided. The authors did not consider non-infectious or non-abdominal infectious complications (and associated mortality).
Validity of estimate of costs Only direct costs were included. Indirect costs falling to patients or their family were not considered. For 40% of cost items, the authors used an institution specific cost-to-charge ratio. Cost results are therefore likely to be specific. The robustness of the cost estimates was examined in the sensitivity analysis.
Other issues The results are specific to colon repair after trauma and presume a previously healthy trauma patient who does not have continuing life-threatening haemorrhage. An extensive sensitivity analysis was conducted to compensate for the uncertainty surrounding the effectiveness estimates. The generalisability of the results to other settings or countries was not discussed. No comparisons with other relevant studies were made.
Implications of the study This study suggest that simple suture or resection and anastomosis at the time of initial exploration is the dominant management strategy for penetrating colon trauma when quality of life issues as well as costs are considered.
Bibliographic details Brasel K J, Borgstrom D C, Weigelt J A. Management of penetrating colon trauma: a cost-utility analysis. Surgery 1999; 125(5): 471-479 Other publications of related interest 1. MacRae H M, McLeod R S. Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis. Diseases of the Colon and Rectum 1998;41(2):180-189.
2. Lustosa S A S, Matos D, Atallah A N, Castro A A. Mechanical versus manual suturing for anastomosis of the colon (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software.
3. Le T H, Timmcke A E, Gathright B, Hicks T C, Opelka F G, Beck D E. Outpatient bowel preparation for elective colon resection. Southern Medical Journal 1997;90(5):526-530.
Indexing Status Subject indexing assigned by NLM MeSH Colon /injuries /surgery; Costs and Cost Analysis; Health Care Costs; Humans; Quality of Life; Wounds, Penetrating /mortality /psychology /surgery AccessionNumber 21999000970 Date bibliographic record published 30/04/2000 Date abstract record published 30/04/2000 |
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