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The meaning clinical pathway of the operation for thyroid tumour and parotid tumour |
Ogawa T, Terada A, Yamada Y, Ijichi K, Hasegawa Y, Fujimoto Y |
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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 The study examined a clinical pathway (CP) for the management of operations for thyroid and parotid tumours. The CP employed standardised pre- and postoperative management, using a series of printed orders with instructions on such matters as treatment, examination, diet and mobility of the patients.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised hospitalised patients who underwent surgical operation for thyroid or parotid tumours. Those who were found to have metastases, or who suffered from aggravation of neurosis after operation, were excluded from the study.
Setting The setting was secondary care. The economic study was carried out at Aichi Cancer Center Hospital and Nagoya University, Japan.
Dates to which data relate The effectiveness data were derived from a single study conducted between December 1999 and October 2002. The resource use data related to the same period. The price year was not stated.
Source of effectiveness data The effectiveness data were derived from a single study.
Link between effectiveness and cost data The cost data for the single study were collected retrospectively from the same patient sample as that used in the effectiveness analysis.
Study sample Power calculations were not used to determine the sample size. The intervention (CP) group consisted of 46 thyroid tumour patients and 29 parotid tumour patients who underwent operation under CP care. The control group consisted of 26 thyroid tumour patients and 25 parotid tumour patients who underwent operation before the introduction of the CP.
Study design This was a cohort study with historical controls that was carried out in a single centre. The duration of follow-up was until hospital discharge. No loss to follow-up was reported.
Analysis of effectiveness The analysis of effectiveness was conducted on the basis of treatment completers. The outcomes assessed were:
the number of days using a drain tube,
the number of days before stitch removal, and
the lengths of total hospitalisation and postoperative hospitalisation.
In terms of the baseline characteristics, the CP and control groups did not differ in the duration of the operation and the amount of blood lost during the operation.
Effectiveness results For thyroid tumour patients, the average number of days using a drain tube was 2.8 days (standard deviation, SD=1.1) for the CP group and 3.5 days (SD=1.2) for the control group. The difference was statistically significant, (p=0.03). However, for parotid tumour patients, no significant difference was observed.
In terms of the number of days before stitch removal, no significant differences were observed between the groups for either thyroid or parotid tumour patients.
For thyroid tumour patients, total hospitalisation was 10.8 days (SD=3.5) for the CP group and 15.2 days (SD=4.7) for the control group, (p<0.0001). For parotid tumour patients, it was 12.0 days (SD=1.0) for the CP group and 22.0 days (SD=3.2) for the control group, (p=0.002). Postoperative hospitalisation was 6.5 days (SD=2.3) for CP thyroid tumour patients versus 8.5 days (SD=3.0) for the control group, (p=0.004), and 6.9 days (SD=0.8) for CP parotid tumour patients versus 13.1 days (SD=2.5) for the control group, (p=0.01).
Clinical conclusions The CP helps to reduce the number of days using a drain tube and postoperative and overall hospitalisation for patients.
Measure of benefits used in the economic analysis The authors did not develop a summary benefit measure in the economic analysis. As such a cost-consequences study was undertaken.
Direct costs The direct costs reported were the total costs in terms of Japanese health insurance points. Discounting was not carried out but was only marginally relevant (study period of 2 years or less). The unit costs and the resource quantities were not reported separately. The source for the resource use and cost data was not reported, but it was likely to have been actual data derived from the hospital itself. The price year was not stated.
Statistical analysis of costs The cost data were treated stochastically. Unpaired t-tests were used to examine differences in the costs between the CP and control groups.
Indirect Costs The indirect costs were not included.
Currency Japanese yen (Y) (health insurance points).
Sensitivity analysis No sensitivity analysis was carried out.
Estimated benefits used in the economic analysis Due to the cost-consequences approach adopted, see the 'Effectiveness Results' section.
Cost results For thyroid tumour patients, the total costs were 56,994 points (SD=15,296) for the CP group and 65,619 points (SD=18,083) for the control group. The difference was significant, (p=0.03).
For parotid tumour patients, the costs were 60,424 points (SD=3,217) for the CP group and 86,286 points (SD=12,801) for the control group. The difference was significant, (p=0.04).
Synthesis of costs and benefits The costs and benefits were not combined. The implementation of the CP led to a significant reduction in the length of hospitalisation, both for thyroid and parotid tumour patients, and a significant reduction in the number of days using a drain tube for thyroid tumour patients. At the same time, it led to a significant cost reduction for both types of patient. The general conclusion, therefore, was that the CP is a dominant strategy.
Authors' conclusions The implementation of a clinical pathway (CP) for thyroid and parotid tumours is beneficial as it enables a reduction in the length of hospitalisation and the medical costs, while maintaining the quality of operation and patient care.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator was clear. The intervention was adequately described in the paper, but the comparator was not described. This limits the validity of the analysis as the reader would be unable to determine if the study were relevant to their own setting.
Validity of estimate of measure of effectiveness The study design was appropriate for the study question, but this type of study is associated with potential bias and confounding. For example, other factors between the two study periods may partly explain the results and, in this sense, a prospective, randomised controlled study would have been a more reliable approach. However, the analysis of effectiveness was handled credibly and p-values were given for all results. It is unclear whether the patient sample was sufficiently large, as no power calculations were reported in the paper. Although the patients were reported to be comparable in several characteristics, the age of each group was not given. If the ages were significantly different, this could have impacted on the results.
Validity of estimate of measure of benefit The authors adopted a cost-consequences approach as all the outcomes were left disaggregated. This is likely to be a valid approach for this type of intervention. However, it does not permit cross-programme comparisons, as would be the case with a generic outcome such as quality-adjusted life years.
Validity of estimate of costs The cost data were presented in the form of insurance reimbursement points for the Japanese health care system. As such, the results are applicable to that setting. However, as the costs and the quantities were not reported separately and the price year was not given, in conjunction with the use of insurance points, the results cannot be generalised to other settings although the magnitude and direction of the cost data strongly favour the CP.
Other issues In terms of comparisons with similar work, the authors appropriately cited other studies that supported the results of their own study. The authors did not discuss the generalisability of their results but they would clearly be relevant to other hospitals in Japan. The limitations highlighted mean that the results have reduced applicability in other countries (although the general findings do not). The authors indicated their rationale for choosing the two cancers: the associated procedures have small variations in clinical outcomes. This means that changes in clinical benefit and cost are more closely associated with the CP (and its comparator).
Implications of the study The findings supported the use of the CP in terms of both the medical costs and patient outcomes. No recommendations were made for further research, but the authors pointed out the need to keep improving various aspects of the CP, such as choice of antibiotic, period of prescription and the selection of drain tubes.
Bibliographic details Ogawa T, Terada A, Yamada Y, Ijichi K, Hasegawa Y, Fujimoto Y. The meaning clinical pathway of the operation for thyroid tumour and parotid tumour. Practica Oto-Rhino-Laryngologica 2004; 97(6): 555-561 Indexing Status Subject indexing assigned by CRD MeSH Cost-Benefit Analysis; Critical Pathways; Drainage; Hospital Costs; Hospitalization; Medical Records; Parotid Neoplasms /prevention & Retrospective Studies; Thyroid Neoplasms /prevention & Thyroidectomy; control /surgery; control /surgery AccessionNumber 22004009002 Date bibliographic record published 28/02/2006 Date abstract record published 28/02/2006 |
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