Pilot study of FLT-PET/CT uptake in ovarian cancer patients with biologic correlates

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Background: New imaging modalities for ovarian cancer disease burden are needed. Positron emission tomography (PET) with [F-18] fluorodeoxyglucose (FDG) has shown promise for early prediction of outcome and response to therapy when compared to CT alone. Recent studies have suggested that 3’-fluoro-3’ [F-18] deoxythymidine (FLT) has a higher specificity than FDG. The objective of this study was to correlate FLT tracer uptake with different in vitro quantitation of cellular proliferation. Methods: Patients with suspected or know ovarian cancer and an elevated Ca 125 were recruited for this trial. These patients were injected with 5 mCi of [F-18]FLT intravenously as a slow bolus. After an uptake period of 60 minutes, patients were scanned for approximately 36 minutes by CT and then PET, and images were co- registered. Standardized uptake values (SUV) of both hot and cold areas were obtained and these lesions were biopsied at the time of surgery. Tissue was divided and used for Ki-67 proliferation index staining to determine mitotic index, RNA isolation for rt-PCR for thymidine kinase-1 (TK1) levels, and grown ex vivo for cell proliferation analysis. Univariate analysis was preformed using the student's t-test. Results: PET positive lesions were found to have a significantly increased mitotic index when compared to control lesions (0.134 vs. 0.004, p<0.001). There were no significant differences in relative TK1 levels or ex vivo cell proliferation ability between PET positive and control lesions in the initial four patients. Conclusions: Increased mitotic index by Ki-67 staining correlates with increased FLT activity by PET scan, but not TK1 levels or DNA content. We will continue to explore this modality as compared to FDG-PET in patients with ovarian cancer.

No significant financial relationships to disclose.

Are today's junior doctors confident in managing patients with minor injury?

OBJECTIVES

To assess the confidence of junior doctors in managing minor injuries, compared with other common acute conditions.

METHOD

A questionnaire designed to elicit areas of confidence and subjective competence was distributed to junior doctors working in the emergency department in December 2004.

RESULTS

Junior doctors felt most competent and confident working with medical trolley patients and least competent working with patients with minor injury. A lack of teaching and experience in handling minor injuries (which are seen by nurse practitioners in a separate unit during the day) was highlighted.

CONCLUSIONS

Nurse-led minor injury units may have an effect on junior doctors' experience and confidence in minor injury care. Further effort needs to be made to increase the training of junior doctors in minor injury care.

CD70 (TNFSF7) is expressed at high prevalence in renal cell carcinomas and is rapidly internalised on antibody binding

In order to identify potential markers of renal cancer, the plasma membrane protein content of renal cell carcinoma (RCC)-derived cell lines was annotated using a proteomics process. One unusual protein identified at high levels in A498 and 786-O cells was CD70 (TNFSF7), a type II transmembrane receptor normally expressed on a subset of B, T and NK cells, where it plays a costimulatory role in immune cell activation. Immunohistochemical analysis of CD70 expression in multiple carcinoma types demonstrated strong CD70 staining in RCC tissues. Metastatic tissues from eight of 11 patients with clear cell RCC were positive for CD70 expression. Immunocytochemical analysis demonstrated that binding of an anti-CD70 antibody to CD70 endogenously expressed on the surface of A498 and 786-O cell lines resulted in the rapid internalisation of the antibody-receptor complex. Coincubation of the internalising anti-CD70 antibody with a saporin-conjugated secondary antibody before addition to A498 cells resulted in 50% cell killing. These data indicate that CD70 represents a potential target antigen for toxin-conjugated therapeutic antibody treatment of RCC.

The evolution of the emergency care practitioner role in England: experiences and impact

BACKGROUND

The emergency care practitioner (ECP) is a generic practitioner who combines extended nursing and paramedic skills. The "new" role emerged out of changing workforce initiatives intended to improve staff career opportunities in the National Health Service and ensure that patients' health needs are assessed appropriately.

OBJECTIVE

To describe the development of ECP Schemes in 17 sites, identify criteria contributing to a successful operational framework, analyse routinely collected data and provide a preliminary estimate of costs.

METHODS

There were three methods used: (a) a quantitative survey, comprising a questionnaire to project leaders in 17 sites, and analysis of data collected routinely; (b) qualitative interpretation based on telephone interviews in six sites; and (c) an economic costing study.

RESULTS

Of 17 sites, 14 (82.5%) responded to the questionnaire. Most ECPs (77.4%) had trained as paramedics. Skills and competencies have been extended through educational programmes, training, and assessment. Routine data indicate that 54% of patient contacts with the ECP service did not require a referral to another health professional or use of emergency transport. In a subset of six sites, factors contributing to a successful operational framework were strategic visions crossing traditional organisational boundaries and appropriately skilled workforce integrating flexibly with existing services. Issues across all schemes were patient safety, appropriate clinical governance, and supervision and workforce issues. On the data available, the mean cost per ECP patient contact is 24.00 pounds sterling, which is less than an ED contact of 55.00 pounds sterling.

CONCLUSION

Indications are that the ECP schemes are moving forward in line with original objectives and could be having a significant impact on the emergency services workload.

Should desperate volunteers be included in randomised controlled trials?

Randomised controlled trials (RCTs) sometimes recruit participants who are desperate to receive the experimental treatment. This paper defends the practice against three arguments that suggest it is unethical first, desperate volunteers are not in equipoise. Second clinicians, entering patients onto trials are disavowing their therapeutic obligation to deliver the best treatment; they are following trial protocols rather than delivering individualised care. Research is not treatment; its ethical justification is different. Consent is crucial. Third, desperate volunteers do not give proper consent: effectively, they are coerced. This paper responds by advocating a notion of equipoise based on expert knowledge and widely shared values. Where such collective, expert equipoise exists there is a prima facie case for an RCT. Next the paper argues that trial entry does not involve clinicians disavowing their therapeutic obligation; individualised care based on insufficient evidence is not in patients best interest. Finally, it argues that where equipoise exists it is acceptable to limit access to experimental agents; desperate volunteers are not coerced because their desperation does not translate into a right to receive what they desire.

Improving the quality of consent to randomised controlled trials by using continuous consent and clinician training in the consent process

OBJECTIVE

To assess whether continuous consent, a process in which information is given to research participants at different stages in a trial, and clinician training in that process were effective when used by clinicians while gaining consent to the Total Body Hypothermia (TOBY) trial. The TOBY trial is a randomised controlled trial (RCT) investigating the use of whole-body cooling for neonates with evidence of perinatal asphyxia. Obtaining valid informed consent for the TOBY trial is difficult, but is a good test of the effectiveness of continuous consent.

METHODS

Semistructured interviews were conducted with 30 sets of parents who consented to the TOBY trial and with 10 clinicians who sought it by the continuous consent process. Analysis was focused on the validity of parental consent based on the consent components of competence, information, understanding and voluntariness.

RESULTS

No marked problems with consent validity at the point of signature were observed in 19 of 27 (70%) couples. Problems were found mainly to lie with the competence and understanding of the parents: mothers, particularly, had problems with competence in the early stages of consent. Problems in understanding were primarily to do with side effects. Problems in both competence and understanding were observed to reduce markedly, particularly for mothers, in the post-signature phase, when further discussion took place. Randomisation was generally understood but unpopular. Information was not always given by clinicians in stages during the short period available before parents gave consent. Most clinicians, however, were able to give follow-up information.

DISCUSSION

Consent validity was found to compare favourably with similar trials examined in the Euricon study.

CONCLUSION

Adopting the elements of the continuous consent process and clinician training in RCTs should be considered by researchers, particularly when they have concerns about the quality of consent they are likely to obtain by using a conventional process.

Pressure relieving support surfaces: a randomised evaluation

OBJECTIVES

To determine differences between alternating pressure overlays and alternating pressure replacement mattresses with respect to the development of new pressure ulcers, healing of existing pressure ulcers, patient acceptability and cost-effectiveness of the different pressure-relieving surfaces. Also to investigate the specific additional impact of pressure ulcers on patients' well-being.

DESIGN

A multicentre, randomised, controlled, open, fixed sample, parallel-group trial with equal randomisation was undertaken. The trial used remote, concealed allocation and intention-to-treat (ITT) analysis. The main trial design was supplemented with a qualitative study involving a purposive sample of 20-30 patients who developed pressure ulcers, to assess the impact of the pressure ulcers on their well-being. In addition, a focus group interview was carried out with clinical research nurses, who participated in the PRESSURE (Pressure RElieving Support SUrfaces: a Randomised Evaluation) Trial, to explore the experiences of their role and observations of pressure area care.

SETTING

The study took place in 11 hospital-based research centres within six NHS trusts in England.

PARTICIPANTS

Acute and elective patients aged 55 years or older and admitted to vascular, orthopaedic, medical or care of the elderly wards in the previous 24 hours were investigated.

INTERVENTIONS

Patients were randomised to either an alternating pressure overlay or an alternating pressure mattress replacement, with mattress specifications clearly defined to enable the inclusion of centres using products from different manufacturers, and to exclude hybrid mattress systems (which either combine foam or constant low pressure with alternating pressure in one mattress, or can be used as either an overlay or a replacement mattress).

MAIN OUTCOME MEASURES

Development of a new pressure ulcer (grade < or =2, i.e. partial-thickness wound involving epidermis/dermis only) on any skin site. Also healing of existing pressures ulcers, patient acceptability and cost-effectiveness.

RESULTS

In total, 6155 patients were assessed for eligibility to the trial and 1972 were randomised: 990 to the alternating pressure overlay (989 after one postrandomisation exclusion) and 982 to the alternating pressure mattress replacement. ITT analysis found no statistically significant difference in the proportions of patients developing a new pressure ulcer of grade 2 or above [10.7% overlay patients, 10.3% mattress replacement patients, a difference of 0.4%, 95% confidence interval (CI) -2.3 to 3.1%, p = 0.75]. When logistic regression analysis was used to adjust for minimisation factors and prespecified baseline covariates, there was no difference between the mattresses with respect to the odds of ulceration (odds ratio 0.94, 95% CI 0.68 to 1.29). There was no evidence of a difference between the mattress groups with respect to time to healing (p = 0.86). The Kaplan-Meier estimate of the median time to healing was 20 days for each intervention. More patients allocated overlays requested mattress changes due to dissatisfaction (23.3%) than mattress replacement patients (18.9%, p = 0.02) and more than one-third of patients reporting difficulties associated with movement in bed and getting into or out of bed. There is a higher probability (64%) that alternating mattress replacements are cost-saving; they were associated with lower overall costs (74.50 pounds sterling per patient on average, mainly due to reduced length of stay) and greater benefits (a delay in time to ulceration of 10.64 days on average). Patients' accounts highlighted that the development of a pressure ulcer could be pivotal in the trajectory from illness to recovery, by preventing full recovery or causing varied impacts on their quality of life.

CONCLUSIONS

There is no difference between alternating pressure mattress replacements and overlays in terms of the proportion of patients developing new pressure ulcers; however, alternating pressure mattress replacements are more likely to be cost-saving. The results suggest that when renewing alternating pressure surfaces or ordering equipment within a rental contract, mattress replacements should be specified; however, overlays are acceptable if no replacement mattress is available. Similarly, patient preferences can be supported, without any great increase in risk, if individual patients request an overlay rather than a replacement mattress. Further research could include a randomised controlled trial comparing alternating pressure mattress replacements and high-specification foam mattresses in patients at moderate to high risk; an accurate costing study to understand better how much pressure ulcers cost health and social services in the UK; and trials in higher risk groups of patients. Also future trials should measure time to ulceration as the primary end-point, since this is more informative economically and possibly also from a patient and clinical perspective.

Effectiveness of measures to reduce emergency department waiting times: a natural experiment

OBJECTIVES

To determine what measures were introduced by emergency departments in response to the national monitoring week in March 2003, and which, if any, of these were most effective in reducing waiting times.

METHODS

A postal survey of all emergency departments in England was undertaken to gather data on measures taken. Department waiting times before, during, and after monitoring week were determined from data held by the Department of Health and linked to the survey data for analysis.

RESULTS

A total of 111/198 responses (56%) were received. Departments had taken a wide range of measures to improve waiting times. The commonest were additional senior doctor hours (39%), creation of a "four hour monitor" role (37%), improved access to emergency beds (36%), additional non-clinical staff hours (33%), additional junior doctor hours (32%), additional nursing hours (29%), and triage by senior staff (28%). In 35 departments (32%) no changes were made at all to usual practice. The biggest influence on improved performance during monitoring week was the number of measures that a department took, rather than any specific measure, although there was weak evidence that additional junior medical and non-clinical staff time may have contributed more than other measures.

CONCLUSIONS

Improved waiting time performance may depend, at least in the short term, more on the amount of effort expended than on introducing a single effective change. In addition, those measures most likely to be helpful are likely also to require additional resources.

Targets and moving goal posts: changes in waiting times in a UK emergency department

OBJECTIVES

To describe changes in the case mix, demographics, waiting times (WTs; time from arrival in the emergency department (ED) until seen by a clinician) and treatment times (TTs; time from seeing a clinician until leaving the ED) of adult patients presenting to the EDs in Sheffield, UK, between 1993 and 2003.

DESIGN

A retrospective analysis of routinely collected data.

RESULTS

Of a total of 252,156 patients included in the study, the proportion of attendees aged 16-29 years decreased from 38.7% in 1993 to 28.8% in 2003 (rate of change (b) = -1.10% per year, 95% CI -1.20% to -0.82%, p < 0.001) whereas the proportion aged 80-99 years increased from 6.2% to 10.4% (b = 0.37% per year, 95% CI 0.29% to 0.45%, p < 0.001). The proportion of "minors" (patients not arriving by ambulance and subsequently discharged) fell from 71.1% in 1993 to 60.8% in 2003 (b = -1.04% per year, 95% CI -1.36% to -0.73%, p < 0.001). WTs increased from a median of 21 minutes in 1993 to 48 minutes in 2003 (b = 3.5 min per year, 95% CI 2.23 min to 4.77 min, p < 0.001). The median TT for minors was unchanged but that for majors (patients arriving by ambulance and admitted to hospital from the ED) increased from 55 to 205 minutes (b = 11.55 min per year, 95% CI 6.54 min to 16.55 mins, p = 0.01).

CONCLUSION

The demographics, case mix, and waiting times of patients presenting to EDs in Sheffield changed considerably over an 11 year period. There is evidence that the service for minor case patients improved slightly at the end of the period studied, but this is possibly at the expense of a deteriorating experience for major case patients.

Brief report on the experience of using proxy consent for incapacitated adults

The Medicines for Human Use (Clinical Trials) Regulations 2004, which came into force in the UK in May 2004, cover the conduct of clinical trials on medicinal products. They allow a legal representative (a person not connected with the conduct of the trial) to consent to the participation of incompetent adults in medical research. Currently, very little is known about how such representatives will make their decisions. We have experience with proxy consent for older adults in a large, national trial. From 2445 potentially eligible but incapacitated patients, proxy, relative assent resulted in trial participation of only 87 (3.6%) patients. The reasons for this were that a large number of incapacitated patients had no relative available for assent (2286), but also a high proportion of relatives approached refused to provide assent (72/159, 45.3%). In comparison, 17.7% of patients declined participation in the trial.Proxy consent allowed only a small increase in trial recruitment of incapacitated patients. The fact that a greater proportion of relatives than patients refused to provide assent implies that they were more cautious than the patients themselves, or perhaps used different criteria, when making their decision. In future research involving incapacitated older patients there is likely to be heavy reliance on proxy consent provision by legal representatives. Our findings imply that consent decisions of legal representatives will not necessarily reflect those of patients themselves.

Has the assessment of isolated ankle injuries altered since 1993?

BACKGROUND

Performance of emergency departments in England and Wales has declined in recent years. Data from the authors' department has shown that junior doctors now see fewer patients and spend longer over their assessment than was the case previously. This study aimed to determine how the assessment of patients with isolated ankle injuries changed over an 11 year period.

METHODS

A retrospective case note review was conducted. Data regarding the duration of assessment, clinical information recorded, investigations, and treatments were retrieved.

RESULTS

During the period studied 13 555 patients presented with isolated ankle injuries; case notes of 550 of these patients were reviewed in the present study. Linear regression demonstrated that the median length of time from arrival in the department until seen by a clinician increased (b = 3.0 min/year, 95% CI 0.7 to 5.2, p = 0.015), but the median length of time from seeing a clinician until leaving the department was unchanged (b = 0.6 min/year, 95% CI -1.3 to 2.5, p = 0.475). More clinical information was being recorded, but the proportion of patients having radiographs of the ankle (b = 0.24% per year, 95% CI -1.40% to 1.87%, p = 0.751) or in whom a fracture was diagnosed (b = -0.20% per year, 95% CI -1.59% to 1.19% per year, p = 0.752) remained unchanged.

CONCLUSION

It appears from this study that the duration of assessment of patients with minor injuries is not changing although this result should be interpreted cautiously.

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis

BACKGROUND

Numerous studies have evaluated the accuracy of D-dimer in diagnosing suspected deep vein thrombosis (DVT), but results are conflicting.

AIM

To overview estimates of the diagnostic accuracy of D-dimer and identify causes of variation.

DESIGN

Systematic review, meta-analysis and meta-regression.

METHODS

We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, citation lists, and contacted manufacturers. We selected studies that compared D-dimer to a reference standard in patients with suspected DVT. Data were analysed by random effects meta-analysis and meta-regression.

RESULTS

We included 97 studies reporting 198 assays in 99 different patient groups. Overall estimated sensitivity and specificity of D-dimer were 90.5% and 54.7%, but both estimates were subject to significant heterogeneity (p < 0.001). Meta-regression identified that some heterogeneity was explained by study setting, exclusion criteria, whether recruitment was consecutive or the study prospective, whether D-dimer and the reference standard were measured blind, and whether the D-dimer threshold was determined a priori. Sensitivity and specificity also varied between ELISA (94% and 45% respectively), latex (89% and 55%) and whole blood agglutination assays (87% and 68%). Sensitivity was higher for proximal than distal DVT. Specificity was dependent upon whether clinical probability of DVT was high (specificity 51%), intermediate (67%) or low (78%).

DISCUSSION

D-dimer has good sensitivity, but poor specificity, for DVT. Estimates are subject to substantial heterogeneity from various sources. D-dimer specificity appears to be strongly dependent upon the pre-test clinical probability of DVT.

Can additional experienced staff reduce emergency medical admissions?

BACKGROUND

Increases in emergency medical admissions are placing a strain upon hospitals throughout the world. The aim of the study was to evaluate the effect of a new post, the "A&E physician", upon emergency medical admissions to a hospital.

METHODS

For six months the A&E physician workload was audited and a randomised controlled comparison undertaken. Days were randomised to "A&E physician present" or "A&E physician absent". The A&E physician recorded details of all patients referred for medical admission, any intervention made, and their disposal from A&E. Routine hospital data compared the mean daily number of medical admissions, non-medical admissions, and referrals to other hospitals.

RESULTS

124 days were randomised: 59 to A&E physician present, 65 to A&E physician absent. The A&E physician received 581 referrals and intervened in the management of 142 (24%). Of these, 80 were discharged home, apparently saving 1.4 admissions per day. However, randomised comparison showed that presence of the A&E physician was associated with a reduction of only 0.7 medical admissions per day (95% CI -1.7 to 3.2, p = 0.561), and an increase of 1.1 non-medical admissions (95% CI -0.2 to 2.3, p = 0.09) and 0.3 transfers to other hospitals per day (95% CI zero to 0.6, p = 0.09). Overall, hospital admissions were increased by 0.9 per day when the A&E physician was present (95% CI -1.8 to 3.6, p = 0.5).

CONCLUSION

Despite receiving many referrals and discharging a substantial proportion of these patients home, the A&E physician did not significantly change emergency medical admissions and may have increased admissions to other specialties.

Involving South Asian patients in clinical trials

OBJECTIVES

To investigate how South Asian patients conceptualise the notion of clinical trials and to identify key processes that impact on trial participation and the extent to which communication difficulties, perceptions of risk and attitudes to authority influence these decisions. Also to identify whether 'South Asian' patients are homogeneous in these issues, and which factors differ between different South Asian subgroups and finally how professionals regard the involvement of South Asian patients and their views on strategies to increase participation.

DATA SOURCES

A review of the literature on minority ethnic participation in clinical trials was followed by three qualitative interview studies. Interviews were taped and transcribed (and translated if required) and subjected to framework analysis. Face-to-face interviews were conducted with 25 health professionals; 60 South Asian lay people who had not taken part in a trial and 15 South Asian trial participants.

RESULTS

Motivations for trial participation were identified as follows: to help society, to improve own health or that of family and friends, out of obligation to the doctor and to increase scientific knowledge. Deterrents were concerns about drug side-effects, busy lifestyles, language, previous bad experiences, mistrust and feelings of not belonging to British society. There was no evidence of antipathy amongst South Asians to the concept of clinical trials and, overall, the younger respondents were more knowledgeable than the older ones. Problems are more likely to be associated with service delivery. Lack of being approached was a common response. Lay-reported factors that might affect South Asian participation in clinical trials include age, language, social class, feeling of not belonging/mistrust, culture and religion. Awareness of clinical trials varied between each group. There are more similarities than differences in attitudes towards clinical trial participation between the South Asian and the general population. Important decisions, such as participation in clinical trials, are likely to be made by those family members who are fluent in English and younger. Social class appears to be more important than ethnicity, and older South Asian people and those from working class backgrounds appear to be more mistrustful. Approachable patients (of the same gender, social class and fluent in English) tend to be 'cherry picked' to clinical trials. This practice was justified because of a lack of time and resources and inadequate support. South Asian patients might be systematically excluded from trials owing to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. Other characteristics such as gender, age, educational level and social class can also affect trial inclusion.

CONCLUSIONS

Effective strategies for South Asian recruitment to clinical trials include: using multi-recruitment strategies; defining the demographic and social profiles of the population to be included; using focus groups to identify any potential barriers; consulting representative community members to provide assistance in the study; ensuring eligibility criteria are set as wide as possible; developing educational and recruitment approaches to attract ethnic minority health professionals; ensuring health professionals are adequately trained in culturally and ethnically orientated service provision; determining the most effective mass media to use in study promotion and recruitment; and targeting inner-city, single-handed practices likely to have high ethnic minority populations. Future research should consider: responses when invited to participate; the role of methodological and organisational barriers to recruitment; the complexities of recruitment from a health professional perspective; developing culturally sensitive research methods; the magnitude of the problem of under-recruitment; strategies to encourage inner-city, single-handed GP participation; and other factors affecting trial inclusion, such as age, gender, educational level and socio-cultural background.

EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy

OBJECTIVES

To test the null hypothesis of no significant difference between laparoscopic hysterectomy (LH), abdominal hysterectomy (AH) and vaginal hysterectomy (VH) with regard to each of the outcome measures of the trial, and also to assess the cost-effectiveness of the alternatives.

DESIGN

Patients were allocated to either the vaginal or abdominal trial by the individual surgeon according to their usual clinical practice. After allocation patients were then randomised to receive either LH or the default procedure in an unbalanced 2:1 manner.

SETTING

Forty-three surgeons from 28 centres throughout the UK and two centres in South Africa took part in the study.

PARTICIPANTS

Patients with gynaecological symptoms that, in the opinion of the gynaecologist and the patient, justified hysterectomy.

INTERVENTIONS

Of 1380 patients recruited to the study, 876 were included in the AH trial and 504 in the VH trial. In the AH trial, 584 patients had a laparoscopic type of hysterectomy (designated ALH) and 292 had a standard AH. In the VH trial 336 had a VLH and 168 had a standard VH. A cost--utility analysis was undertaken based on a 1-year time horizon. Quality-adjusted life years (QALYs) were estimated using the EQ-5D.

RESULTS

Compared with AH, LH was associated with a higher rate of major complications, less postoperative pain and shorter hospital stay, but took longer to perform. Securing the ovarian pedicles with laparoscopic sutures was used in only 7% of cases but was associated with 25% of the complications. At the 6 weeks postoperative point, ALH was associated with a significantly better physical component of the SF-12 (QoL questionnaire), better body image scale scores and a significantly increased frequency of sexual intercourse than AH. These differences were not observed at either 4 or 12 months after surgery. There were no significant differences in any measured outcome between LH and VH except that VLH took longer to perform and was associated with a higher rate of detecting unexpected pathology. Compared with VH, VLH had a higher mean cost per patient of GBP401 and higher mean QALYs of 0.0015, resulting in an incremental cost per QALY gained of GBP267,333. The probability that VLH is cost-effective was less than 50% for a large range of willingness to pay values for an additional QALY. Compared with AH, ALH had a higher mean cost per patient of GBP186 and higher mean QALYs of 0.007, resulting in an incremental cost per QALY gained of GBP26,571.

CONCLUSIONS

ALH is associated with a significantly higher risk of major complications and takes longer to perform than AH. ALH is, however, associated with less pain, quicker recovery and better short-term QoL after surgery than AH. The cost-effectiveness of ALH is finely balanced and is also influenced by the choice of reusable versus disposable equipment. Individual surgeons must decide between patient-orientated benefits and the risk of severe complications. VLH was not cost-effective relative to VH. Recommendations for future research include the application and relevance of QoL measures following hysterectomy, and long-term follow-up; patient preferences; reducing complication rates; improving gynaecological surgical training; surgeon effect in surgery trials; care pathways for hysterectomy; additional pathology identification in LH and meta-analysis/further trial of VH versus LH.