The use of micro-costing in economic analyses of surgical interventions: a systematic review

A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND

Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions.

METHODS

We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters.

RESULTS

For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery.

CONCLUSION

Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes

Importance

With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies.

Objective

To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies.

Design, Setting, and Participants

This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons.

Exposures

Robotic-assisted or video-assisted lung lobectomy.

Main Outcomes and Measures

The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator.

Results

The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process.

Conclusions and Relevance

In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

Cost-benefit ratio of modern medical education using micro-costing: a model calculation using the example of an innovative breast brachytherapy workshop

BACKGROUND AND PURPOSE

Radiation oncology is an essential component of therapeutic oncology and necessitates well-trained personnel. Multicatheter brachytherapy (MCBT) is one radiotherapeutic option for early-stage breast cancer treatment. However, specialized hands-on training for MCBT is not currently included in the curriculum for residents. A recently developed hands-on brachytherapy workshop has demonstrated promising results in enhancing knowledge and practical skills. Nevertheless, these simulation-based teaching formats necessitate more time and financial resources. Our analyses include computational models for the implementation and delivery of this workshop and can serve as a basis for similar educational initiatives.

METHODS

This study aimed to assess the cost-effectiveness of a previously developed and evaluated breast brachytherapy simulation workshop. Using a micro-costing approach, we estimated costs at a detailed level by considering supplies, soft- and hardware, and personnel time for each task. This method also allows for a comprehensive evaluation of the costs associated with implementing new medical techniques. The workshop costs were divided into two categories: development and workshop execution. The cost analysis was conducted on a per-participant basis, and the impact on knowledge improvement was measured using a questionnaire.

RESULTS

The total workshop costs were determined by considering the initial workshop setup expenses including the development and conceptualization of the course with all involved collaborators, as well as the costs incurred for each individual course. The workshop was found to be financially efficient, with a per-participant cost of € 39, considering the industrial sponsorship provided for brachytherapy equipment. In addition, we assessed the workshop's efficacy by analyzing participant feedback using Likert scale evaluations. The findings indicated a notable enhancement in both theoretical and practical skills among the participants. Moreover, the cost-to-benefit ratio (CBFR) analysis demonstrated a CBFR of € 13.53 for each Likert point increment.

CONCLUSION

The hands-on brachytherapy workshop proved to be a valuable and approximately cost-effective educational program, leading to a significant enhancement in the knowledge and skills of the participants. Without the support of industrial sponsorship, the costs would have been unattainable.

Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study

BACKGROUND

Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVES

Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime.

METHOD

We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values.

RESULTS

Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI -  £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI -  0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained.

CONCLUSION

TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Costs of endovascular and open repair of thoracic aortic aneurysms

BACKGROUND

Repair of thoracic aortic aneurysms with either endovascular repair (TEVAR) or open surgical repair (OSR) represents major surgery, is costly and associated with significant complications. The aim of this study was to establish accurate costs of delivering TEVAR and OSR in a cohort of UK NHS patients suitable for open and endovascular treatment for the whole treatment pathway from admission and to discharge and 12-month follow-up.

METHODS

A prospective study of UK NHS patients from 30 NHS vascular/cardiothoracic units in England aged ≥18, with distal arch/descending thoracic aortic aneurysms (CTAA) was undertaken. A multicentre prospective cost analysis of patients (recruited March 2014-July 2018, follow-up until July 2019) undergoing TEVAR or OSR was performed. Patients deemed suitable for open or endovascular repair were included in this study. A micro-costing approach was adopted.

RESULTS

Some 115 patients having undergone TEVAR and 35 patients with OSR were identified. The mean (s.d.) cost of a TEVAR procedure was higher £26 536 (£9877) versus OSR £17 239 (£8043). Postoperative costs until discharge were lower for TEVAR £7484 (£7848) versus OSR £28 636 (£23 083). Therefore, total NHS costs from admission to discharge were lower for TEVAR £34 020 (£14 301), versus OSR £45 875 (£43 023). However, mean NHS costs for 12 months following the procedure were slightly higher for the TEVAR £5206 (£11 585) versus OSR £5039 (£11 994).

CONCLUSIONS

Surgical procedure costs were higher for TEVAR due to device costs. Total in-hospital costs were higher for OSR due to longer hospital and critical care stay. Follow-up costs over 12 months were slightly higher for TEVAR due to hospital readmissions.

Cost-utility analysis of ferric derisomaltose versus ferric carboxymaltose in patients with inflammatory bowel disease and iron deficiency anemia in England

AIMS

Anemia is the most common extraintestinal complication of inflammatory bowel disease (IBD), with approximately half of cases caused by iron deficiency (ID). Intravenous iron is the preferred ID anemia (IDA) treatment where oral iron is contraindicated, ineffective or not tolerated, or where ID correction is urgent. The objective was to evaluate the cost-utility of ferric derisomaltose (FDI) versus ferric carboxymaltose (FCM) in patients with IBD and IDA in England, in whom IV iron treatment is preferred.

MATERIALS AND METHODS

A patient-level simulation model was developed, capturing quality of life (QoL) differences based on SF-36v2 data from the PHOSPHARE-IBD randomized controlled trial, monitoring and incidence of post-infusion hypophosphatemia, and number of iron infusions required. Analyses were conducted over a five-year time horizon from the Department of Health and Social Care (DHSC) perspective, with healthcare provider and societal perspectives adopted in separate analyses. Future costs and effects were discounted at 3.5% per annum and one-way and probabilistic sensitivity analyses were performed.

RESULTS

FDI increased quality-adjusted life expectancy by 0.075 QALYs versus FCM from 2.57 QALYs to 2.65 QALYs per patient. Patients receiving FDI required 1.63 fewer iron infusions over the five-year time horizon, driving infusion-related cost savings of GBP 496 per patient (GBP 2,188 versus GBP 1,692) from the DHSC perspective. Costs of monitoring and treating hypophosphatemia after FCM were GBP 226, yielding total savings of GBP 722 per patient (GBP 2,414 versus GBP 1,692) over the five-year time horizon. FDI also led to reduced costs versus FCM in the societal and provider analyses and was therefore the dominant intervention across all three perspectives.

LIMITATIONS

The analysis did not capture patient adherence, hypophosphatemic osteomalacia, or fractures.

CONCLUSIONS

Results showed that FDI improved patient QoL and reduced direct healthcare expenditure versus FCM in patients with IBD and IDA in England.

Cost impact analysis of enhanced recovery after minimally invasive gynecologic oncology surgery

OBJECTIVE

The implementation of a peri-operative care program based on enhanced recovery after surgery principles for minimally invasive gynecologic oncology surgery led to an improvement in same day discharge from 29% to 75% at our center. This study aimed to determine the program's economic impact.

METHODS

Our initial enhanced recovery quality improvement program enrolled consecutive patients undergoing minimally invasive hysterectomy at a single center during a 12-month period and compared them to a pre-intervention cohort. The primary outcome was overall costs. The secondary outcomes were surgical and post-operative visit costs. The surgical visit costs included pre-operative and operating room, post-operative stay, pharmacy, and interventions costs. The 30-day post-operative visit costs included clinic and emergency room, and readmission costs. The costs for every visit were collected from the case-cost department and expressed in 2020 Canadian dollars (CAD).

RESULTS

A total of 96 and 101 patients were included in the pre- and post-intervention groups, respectively. The median total cost per patient for post-intervention was $7252 compared with $8381 pre-intervention (p=0.02), resulting in a $1129 cost reduction per patient. The total cost for the program implementation was $134 per patient for a total cost of $13 106. The median post-operative stay cost was $816 post-intervention compared with $1278 pre-intervention (p<0.05). Statistically significant savings for the post-intervention group were also found for operative visit, operating room costs, and pharmacy (p<0.05). On multivariate analysis, surgical approach was the only factor associated with operating room costs, whereas both surgical approach and group (pre- vs post-intervention) impacted the total and post-operative stay costs (p<0.05).

CONCLUSION

In addition to increasing the same day discharge rate after minimally invasive gynecologic oncology surgery, an enhanced recovery-based peri-operative care program led to significant reductions in cost.

Colonoscopic-assisted laparoscopic wedge resection versus segmental colon resection for benign colonic polyps: a comparative cost analysis

AIM

The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR.

METHOD

A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period.

RESULTS

Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001).

CONCLUSION

Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

Cost-effectiveness analysis of pressure-controlled intermittent coronary sinus occlusion in elective percutaneous coronary intervention

OBJECTIVES

Percutaneous coronary intervention (PCI) represents the standard treatment for ST-elevated myocardial infarction, nevertheless, mortality and heart failures are frequent. Pressure-controlled intermittent coronary sinus occlusion (PiCSO) might reduce infarct size showing better patients' outcomes. We evaluated the cost-effectiveness of PCI+PiCSO compared to PCI from the National Healthcare Service (NHS) perspective in Italy.

METHODS

A Markov model was developed to estimate life years (LYs), quality-adjusted life years (QALYs) and costs. A micro-costing analysis has been performed to inform the cost of PCI+PiCSO procedure. Sensitivity analyses were performed to test the robustness of the model results.

RESULTS

Considering a willingness-to-pay threshold of 50,000€/QALY for the ICUR and a cost for PCI+PiCSO procedure of 14,654€, the innovative strategy may be cost-effective compared to PCI alone from the Italian NHS perspective, showing an ICUR of 17,530€/QALY (ICER 14,631€/LY) over a lifetime horizon; the probabilistic sensitivity analysis showed that PCI+PiCSO is cost-effective in 78.8% of simulations.Considering the above mentioned willingness-to-pay threshold, PCI+PiCSO strategy would be cost-effective over a lifetime horizon considering a cost for PCI+PiCSO procedure lower than 28,160€.

CONCLUSION

PCI+PiCSO procedure may be considered a cost-effective technology that allows reducing cardiac events, while improving patients' life expectancy and quality of life.

Estimating the Health Care Expenditure to Manage and Care for Type 2 Diabetes in Nepal: A Patient Perspective

Background. This study aimed to estimate the health care expenditure for managing type 2 diabetes (T2D) in the community setting of Nepal. Methods. This is a baseline cross-sectional study of a heath behavior intervention that was conducted between September 2021 and February 2022 among patients with T2D (N = 481) in the Kavrepalanchok and Nuwakot districts of Nepal. Bottom-up and micro-costing approaches were used to estimate the health care costs and were stratified according to residential status and the presence of comorbid conditions. A generalized linear model with a log-link and gamma distribution was applied for modeling the continuous right-skewed costs, and 95% confidence intervals were obtained from 10,000 bootstrapping resampling techniques. Results. Over 6 months the mean health care resource cost to manage T2D was US $22.87 per patient: 61% included the direct medical cost (US $14.01), 15% included the direct nonmedical cost (US $3.43), and 24% was associated with productivity losses (US $5.44). The mean health care resource cost per patient living in an urban community (US $24.65) was about US $4.95 higher than patients living in the rural community (US $19.69). The health care costs per patient with comorbid conditions was US $22.93 and was US $22.81 for those without comorbidities. Patients living in rural areas had 16% lower health care expenses compared with their urban counterparts. Conclusion. T2D imposes a substantial financial burden on both the health care system and individuals. There is a need to establish high-value care treatment strategies for the management of T2D to reduce the high health care expenses.

Highlights

More than 60% of health care expenses comprise the direct medical cost, 15% direct nonmedical cost, and 24% patient productivity losses. The costs of diagnosis, hospitalization, and recommended foods were the main drivers of health care costs for managing type 2 diabetes.Health care expenses among patients living in urban communities and patients with comorbid conditions was higher compared with those in rural communities and those with without comorbidities.The results of this study are expected to help integrate diabetes care within the existing primary health care systems, thereby reducing health care expenses and improving the quality of diabetes care in Nepal.

The healthcare system costs of hip fracture care in South Africa

Despite rapidly ageing populations, data on healthcare costs associated with hip fracture in Sub-Saharan Africa are limited. We estimated high direct medical costs for managing hip fracture within the public healthcare system in SA. These findings should support policy decisions on budgeting and planning of hip fracture services.

PURPOSE

We estimated direct healthcare costs of hip fracture (HF) management in the South African (SA) public healthcare system.

METHODS

We conducted a micro-costing study to estimate costs per patient treated for HF in five regional public sector hospitals in KwaZulu-Natal (KZN), SA. Two hundred consecutive, consenting patients presenting with a fragility HF were prospectively enrolled. Resources used including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by unit costs, estimated from the KZN Department of Health hospital fees manual 2019/2020, in local currency (South African Rand, ZAR), and converted to 2020 US$ prices. Generalized linear models estimated total covariate-adjusted costs and cost predictors.

RESULTS

The mean unadjusted cost for HF management was US$6935 (95% CI; US$6401-7620) [ZAR114,179 (95% CI; ZAR105,468-125,335)]. The major cost driver was orthopaedics/surgical ward costs US$5904 (95% CI; 5408-6535), contributing to 85% of total cost. The covariate-adjusted cost for HF management was US$6922 (95% CI; US$6743-7118) [ZAR113,976 (95% CI; ZAR111,031-117,197)]. After covariate adjustment, total costs were higher in patients operated under general anaesthesia [US$7251 (95% CI; US$6506-7901)] compared to surgery under spinal anaesthesia US$6880 (95% CI; US$6685-7092) and no surgery US$7032 (95% CI; US$6454-7651).

CONCLUSION

Healthcare costs following a HF are high relative to the gross domestic product per capita and per capita spending on health in SA. As the population ages, this significant economic burden to the health system will increase.

Budget impact analysis of a bovine pericardial aortic bioprosthesis versus mechanical aortic valve replacement in adult patients with aortic stenosis in Romania

AIMS

An analysis of the budget impact of using a bovine pericardial aortic bioprosthesis (BPAB) or a mechanical valve (MV) in aortic stenosis (AS) patients in Romania.

MATERIALS AND METHODS

A decision-tree with a partitioned survival model was used to predict the financial outcomes of using either a BPAB (the Carpentier-Edwards Perimount Magna Ease Valve) or MV in aortic valve replacement (AVR) procedure over a 5-year period. The budget impact of various resource consumption including disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments were compared for both types of valves. One-way sensitivity analyses (OWSA) were conducted on the input costs and probabilities.

RESULTS

The use of BPAB compared to MV approaches budget neutrality due to incremental savings year-on-year. The initial surgical procedure and reoperation costs for BPAB are offset by savings in acenocoumarol use, disabling strokes, major bleeding, minor thromboembolic events, and anticoagulation complications. The cost of the initial procedure per patient is 460 euros higher for a BPAB due to the higher valve acquisition cost, although this is partially offset by a shorter hospital stay. The OWSA shows that the total procedure costs, including the hospital stay, are the primary cost drivers in the model.

LIMITATIONS

Results are limited by cost data aggregation in the DRG system, exclusion of costs for consumables and capital equipment use, possible underestimation of outpatient complication costs, age-related variations of event rates, and valve durability.

CONCLUSIONS

Adopting BPAB as a treatment option for AS patients in Romania can lead to cost savings and long-term economic benefits. By mitigating procedure costs and increasing anticoagulation treatment costs, BPAB offers a budget-neutral option that can help healthcare providers, policymakers, and patients alike manage the growing burden of AS in Romania.

Cost-effectiveness analysis of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke

OBJECTIVE

Intravenous (IV) recombinant tissue plasminogen activator (r-tPA) may not provide additional benefit in terms of functional outcomes in patients with acute ischemic stroke (AIS) who undergo endovascular treatment (EVT). In this context, the cost-effectiveness of EVT alone compared with its application following IV r-tPA has not been evaluated.

METHODS

The authors determined the average rates of death or disability in each of the two treatment groups from four randomized clinical trials that enrolled patients with AIS within 4.5 hours of symptom onset and randomly assigned patients to EVT alone and IV r-tPA and EVT. By using three sources derived from previous studies, the authors determined the cost of IV r-tPA, cost of staff time for administration, cost of the EVT, cost of hospital stay, costs of supported discharge and community care, and cost of posthospitalization care and disability. They then assessed the cost-effectiveness of EVT alone using a decision tree for the 1st year after AIS and a Markov model with a 10-year horizon, including probabilistic assessment by Monte Carlo simulations.

RESULTS

The 1-year cost was higher with IV r-tPA and EVT compared with EVT alone (incremental cost ranging between $3554 and $13,788 per patient). The mean incremental cost-effectiveness ratios (ICERs) were -$1589, -$78,327, and -$15,471 per quality-adjusted life-year gained for cost sources 1, 2, and 3, respectively, for EVT alone compared with IV r-tPA and EVT at 10 years. The ceiling ICER (willingness to pay) for a probability of 100% that EVT alone was more cost-effective ranged between $25,000 and $100,000 in the three models.

CONCLUSIONS

EVT alone appears to be more cost-effective compared with EVT and IV r-tPA for the treatment of AIS patients presenting within 4.5 hours of symptom onset.

The costs of complications after emergency gastrointestinal surgery in Kenya

BACKGROUND

The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications.

METHOD

Patients undergoing emergency gastrointestinal operations at a center in Kenya were reviewed between January 2017 and June 2019. In a cost analysis, we ascertained the outcome of total hospital costs, adjusted for inflation, and converted to international dollars using purchasing power parities. Costs were analyzed for their association with a postoperative complication, defined using standardized criteria. We calculated the Africa Surgical Outcomes Study surgical risk scores and clustered for discharge diagnosis in a mixed-effects generalized linear model accounting for confounding factors related to costs and complications.

RESULTS

A total of 361 individuals had cost data available. The cohort had 251 men (69.5%) and 110 women (30.5%) with a median age of 41 years (interquartile range: 29-57 years). A total of 122 (33.8%) patients experienced a postoperative complication with an overall all-cause mortality rate of 10.5%. The median total cost of hospitalization was 1,949 (interquartile range: 1,516-2,788) international dollar purchasing power parities. When controlling for patient factors and diagnoses, patients who did not develop complications had costs of 2,119 (95% confidence interval 1,898-2,340) compared to costs of 3,747 (95% confidence interval 3,327-4,167) for patients who developed a postoperative complication, leading to a 77% increase of 1,628 international dollar purchasing power parities for patients with complications.

CONCLUSION

Our findings demonstrated a substantial financial burden generated by postoperative complications in patients undergoing emergency gastrointestinal operations. Reducing complications could allow cost savings, an important consideration in variable-resource settings.

Costs of Next-Generation Sequencing Assays in Non-Small Cell Lung Cancer: A Micro-Costing Study

Background: Next-generation sequencing (NGS) of tumor genomes has changed and improved cancer treatment over the past few decades. It can inform clinicians on the optimal therapeutic approach in many of the solid and hematologic cancers, including non-small lung cancer (NSCLC). Our study aimed to determine the costs of NGS assays for NSCLC diagnostics. Methods: We performed a micro-costing study of four NGS assays (Trusight Tumor 170 Kit (Illumina), Oncomine Focus (Thermo Fisher), QIAseq Targeted DNA Custom Panel and QIASeq Targeted RNAscan Custom Panel (Qiagen), and KAPA HyperPlus/SeqCap EZ (Roche)) at the StemCore Laboratories, the Ottawa Hospital, Canada. We used a time-and-motion approach to measure personnel time and a pre-defined questionnaire to collect resource utilization. The unit costs were based on market prices. The cost data were reported in 2019 Canadian dollars. Results: Based on a case throughput of 500 cases per year, the per-sample cost for TruSight Tumor 170 Kit, QIASeq Targeted DNA Custom Panel and QIASeq Targeted RNAscan Custom Panel, Oncomine Focus, and HyperPlus/SeqCap EZ were CAD 1778, CAD 599, CAD 1100 and CAD 1270, respectively. The key cost drivers were library preparation (34–60%) and sequencing (31–51%), followed by data analysis (6–13%) and administrative support (2–7%). Conclusions: Trusight Tumor 170 Kit was the most expensive NGS assay for NSCLC diagnostics; however, an economic evaluation is required to identify the most cost-effective NGS assay. Our study results could help inform decisions to select a robust platform for NSCLC diagnostics from fine needle aspirates, and future economic evaluations of the NGS platforms to guide treatment selections for NSCLC patients.

Scoping review of costs of implementation strategies in community, public health and healthcare settings

OBJECTIVES

To identify existing evidence concerning the cost of dissemination and implementation (D&I) strategies in community, public health and health service research, mapped with the 'Expert Recommendations for Implementing Change' (ERIC) taxonomy.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library were searched to identify any English language reports that had been published between January 2008 and December 2019 concerning the cost of D&I strategies.

DATA EXTRACTION

We matched the strategies identified in each article using ERIC taxonomies; further classified them into five areas (eg, dissemination, implementation, integration, capacity building and scale-up); and extracted the corresponding costs (total costs and cots per action target and per evidence-based programme (EBP) participant). We also recorded the reported level of costing methodology used for cost assessment of D&I strategies.

RESULTS

Of the 6445 articles identified, 52 studies were eligible for data extraction. Lack of D&I strategy cost data was the predominant reason (55% of the excluded studies) for study exclusion. Predominant topic, setting, country and research design in the included studies were mental health (19%), primary care settings (44%), the US (35%) and observational (42%). Thirty-five (67%) studies used multicomponent D&I strategies (ranging from two to five discrete strategies). The most frequently applied strategies were Conduct ongoing training (50%) and Conduct educational meetings (23%). Adoption (42%) and reach (27%) were the two most frequently assessed outcomes. The overall costs of Conduct ongoing training ranged from $199 to $105 772 ($1-$13 973 per action target and $0.02-$412 per EBP participant); whereas the cost of Conduct educational meetings ranged from $987 to $1.1-$2.9 million/year ($33-$54 869 per action target and $0.2-$146 per EBP participant). The wide range of costs was due to the varying scales of the studies, intended audiences/diseases and the complexities of the strategy components. Most studies presented limited information on costing methodology, making interpretation difficult.

CONCLUSIONS

The quantity of published D&I strategy cost analyses is increasing, yet guidance on conducting and reporting of D&I strategy cost analysis is necessary to facilitate and promote the application of comparative economic evaluation in the field of D&I research.

Is robotic lobectomy cheaper? A micro-cost analysis

Higher capital costs and operating room costs associated with Lobectomy via Robot Assisted Thoracic Surgery (RATS) have previously been suggested as the principal contributors to the elevated overall cost. This study uses a micro-costing approach to a previous analysis of clinical outcomes of RATS, Video-Assisted Thoracic Surgery (VATS) and Open Lobectomy to evaluate the most significant cost drivers for the higher cost of robot-assisted lobectomy. A micro-costing model was developed to reflect the pathway of patients from day of surgery through the first 30 days following lobectomy. Costs were provided for RATS, VATS and Open approaches. Sensitivity analysis was performed specifically in the area of staff costs. A threshold sensitivity analysis of the overall cost components was also performed. Total cost per case for the RATS approach was €13,321 for the VATS approach €11,567, and for the Open approach €12,582. The overall cost differences were driven primarily by the elevated consumable costs associated with RATS Lobectomy. Capital costs account for a relatively small proportion of the per-case cost difference. This study presents a detailed analysis of the cost drivers for lobectomy, modelled for the three primary surgical approaches. We believe this is a useful tool for surgeons, hospital management, and service commissioning agencies to accurately and comprehensively determine where cost savings can be applied in their programme to improve the cost-effectiveness of RATS lobectomy.

Budget impact analysis of a bioprosthetic valve with a novel tissue versus mechanical aortic valve replacement in patients older than 65 years with aortic stenosis in Saudi Arabia

AIMS

A budget impact analysis (BIA) comparing bioprosthetic valves with RESILIA tissue and mechanical valves in aortic stenosis (AS) patients > 65 years in the public and private sectors of Saudi Arabia.

MATERIALS AND METHODS

A decision-tree with a partitioned survival model was adapted to estimate the financial consequences of either a RESILIA tissue valve or a mechanical valve in aortic valve replacement (AVR) procedures up to 5 years. The budget impact of resource consumption for both valve types was compared and included disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments. One-way sensitivity analyses (OWSA) were performed on cost and probability inputs.

RESULTS

RESILIA tissue valves versus mechanical valves are overall budget saving commencing in Year 1 and savings gradually increase year-on-year. The higher costs of the initial procedure, reoperation, and additional monitoring (echocardiogram tests and visits) associated with RESILIA tissue valves are offset by savings in warfarin use, disabling strokes, major bleeding, and anticoagulation complications. The cost per initial procedure per patient is SAR795 higher for a RESILIA tissue valve reflecting the higher valve acquisition cost, which is partially offset by a shorter hospital stay. The OWSA suggests that total procedure costs of each valve, including the hospital stay, are the main cost drivers in the model.

LIMITATIONS

The variability of cost inputs and the presence of multiple payers with multiple costing data is a key challenge in Saudi Arabia. Budget impact results may, therefore, change if repeated per AVR center and may also be impacted by the long-term durability of RESILIA tissue valves.

CONCLUSIONS

An AVR in patients > 65 years with a RESILIA tissue valve is budget-saving from the first year in Saudi Arabia. Patients, payers, providers and policymakers may benefit economically from increased implantation of RESILIA tissue valves.

Endovascular stent grafting and open surgical replacement for chronic thoracic aortic aneurysms: a systematic review and prospective cohort study

Background

The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice.

Objective

To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms.

Design

A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life.

Setting

Thirty NHS vascular/cardiothoracic units.

Participants

Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta.

Interventions

Endovascular stent grafting and open surgical replacement.

Main outcomes

Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample.

Results

The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible.

Limitations

The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions.

Conclusions

Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging.

Future work

Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes.

Trial registration

Current Controlled Trials ISRCTN04044627 and NCT02010892.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.

Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy

BACKGROUND

Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques.

METHODS AND ANALYSIS

Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN10081873.

Using the MEAT VBP Framework to analyse and understand the value of surgical gloves: an explanatory case study

BACKGROUND

Value-based healthcare is being extensively piloted, scaled and implemented by healthcare providers and systems around the world. However, the ability of the healthcare supply chain function to strategically contribute to the improvement of value has been held back by a lack of practical tools for turning value-based procurement from concept into action. Two recently developed conceptual models - the American CQO Movement and the European MEAT VBP Framework - have been developed to support the implementation of value-based procurement in healthcare. We demonstrate how the latter of these models can be adapted and applied pragmatically to generate insights into the value of a specific medical device, technology or consumable.

METHODS

We undertook an explanatory, qualitative, single-case study focused on a specific consumable - surgical gloves - that provide a critical example of a type of medical device usually procured in high volumes but at risk of commoditisation due to a widespread lack of understanding of their value. Since the global Covid-19 pandemic prevented fieldwork, structured interviews were conducted via Zoom and corroborated by a literature review.

RESULTS

We identified ten cost criteria and eight outcome criteria with which the value of surgical gloves can be analysed and understood. For each of these criteria we propose definitions and value impact metrics that decision-makers can use during a procurement exercise to describe, quantify and compare glove value.

CONCLUSION

The MEAT VBP Framework provides a highly practical and adaptable means of imposing both structure and rigour on a value analysis process and of qualitatively describing the potential value impact of surgical gloves for patients, professionals, providers and health systems.

Cost comparison between botulinum neurotoxin and surgery in the treatment of infantile esotropia in a tertiary public hospital

Objective

To compare the cost implications of botulinum neurotoxin (BNT) injection to surgery in infantile esotropia (IE) in a public/government funded hospital.

Methods and analysis

A simple costing comparison was undertaken for a randomised clinical trial in IE. Patients were randomised to receive either BNT or standard surgery. The participants in the BNT arm were further subdivided into subgroups based on their age in months and degree of esotropia in prism dioptres (PD) at presentation: G1 ≤60 PD/24 months, G2 ≤24 months/>60 PD, G3 >24 months/≤60 PD, G4 >24 months/>60 PD. The costs were calculated for each arm from primary treatment to eventual satisfactory outcome defined as orthophoria or microtropia (≤10 PD). A bottom-up costing analysis was done for single and multiple procedures for each arm. Comprehensive variable costs as well as fixed costs were calculated at each point of intervention and expressed in local currency ZAR (US$1=ZAR15.00). Costing was analysed for surgery and BNT subgroups (based on clinical success).

Results

There were 101 patients enrolled in the trial. 54 in the BNT arm and 47 in the surgery arm. Cost for single surgery and single BNT was ZAR 7743.04 and 1713.14, respectively. A favourable clinical outcome was achieved in 72% of surgery arm and 37% of BNT arm. The mean cost for eventual favourable outcome in BNT arm was ZAR9158.08 and in surgery arm ZAR9124.27 (p=0.26). Mean cost in G1 was ZAR6328.45, in G2 ZAR7197.45, in G3 ZAR11891.93 and G4 ZAR12882.44 (p=0.018).

Conclusion

BNT has a cost-benefit in IE and is a viable option in the primary treatment of IE in resource constrained regions. Clinical outcomes and economic benefit in smaller angle of esotropia and younger patients are comparable to surgery.

A microcosting analysis of ICU expenditure in the interval between brain death and organ donation

Objective: The cost of providing care in an intensive care unit (ICU) after brain death to facilitate organ donation is unknown. The objective of this study was to estimate expenditure for the care delivered in the ICU between the diagnosis of brain death and subsequent organ donation. Design: Cohort study of direct and indirect costs using bottom-up and top-down microcosting techniques. Setting: Single adult ICU in Australia. Participants: All patients who met criteria for brain death and proceeded to organ donation during a 13-month period between 1 January 2018 and 31 January 2019. Main outcome measures: A comprehensive cost estimate for care provided in the ICU from determination of brain death to transfer to theatre for organ donation. Results: Forty-five patients with brain death became organ donors during the study period. The mean duration of postdeath care in the ICU was 37.9 hours (standard deviation [SD], 16.5) at a mean total cost of $7520 (SD, $3136) per donor. ICU staff salaries were the greatest contributor to total costs, accounting for a median proportion of 0.72 of total expenditure (interquartile range, 0.68-0.75). Conclusions: Substantial costs are incurred in ICU for the provision of patient care in the interval between brain death and organ donation.

Protocol for a mixed-method study to inform the feasibility of undertaking a large-scale multicentre study comparing the clinical and patient-reported outcomes of oncoplastic breast conservation as an alternative to mastectomy with or without immediate breast reconstruction in women unsuitable for standard breast-conserving surgery (the ANTHEM Feasibility Study)

INTRODUCTION

Approximately 40% of the 55 000 women diagnosed with breast cancer each year in the UK undergo mastectomy because they are considered unsuitable for standard breast-conserving surgery (BCS) due to tumour size or multiple tumour foci. Mastectomy can significantly impact women's quality of life, and only one in four women currently undergo immediate breast reconstruction (IBR).Level 2 oncoplastic breast-conserving surgery (OPBCS) combines removing the cancer with a range of plastic surgical volume replacement (eg, local perforator flaps) and volume displacement techniques (eg, therapeutic mammaplasty) that can extend the role of BCS and may allow some women not suitable for standard BCS to avoid mastectomy. High-quality research to determine whether OPBCS offers a safe and effective alternative to mastectomy±IBR is currently lacking. Preliminary work is needed to ensure a future large-scale study is feasible and well designed and addresses questions important to patients and the National Health Service.

METHODS AND ANALYSIS

Mixed methods will be used to inform feasibility and design of a future large-scale study comparing the clinical effectiveness and cost-effectiveness of OPBCS and mastectomy±IBR. It will have four parts: (1) a National Practice Questionnaire to determine current practice and provision of oncoplastic breast and reconstructive surgery in the UK; (2) a pilot multicentre prospective cohort study to explore the proportion of patients choosing OPBCS versus mastectomy, the proportion in OPBCS is successful and clinical and patient-reported outcomes of different techniques at 3 and 12 months postsurgery; (3) a qualitative interview study to explore patients' attitudes to different procedures, rationale for decision-making and perceptions of outcomes; and (4) design of the future study.All centres offering OPBCS and mastectomy in the UK will be invited to participate. Recruitment is planned to commence winter 2020 and continue for 12 months.

ETHICS AND DISSEMINATION

The study has ethical approval from the Wales Research Ethics Committee 6 National Research Ethics Service (REC Ref 20/WA/0225). Results will be presented at national and international meetings and published in peer-reviewed journals. We will work with patients to develop lay summaries and share these through patient groups and breast cancer charities.

TRIAL REGISTRATION NUMBER

ISRCTN18238549.

Costing Methods as a Means to Measure the Costs of Pharmacogenomics Testing

Clinical implementation of pharmacogenomics and personalized medicine interventions relies on addressing important financial aspects of the delivery of genetic testing to the patients, be it from public or private providers. Details on how to determine the cost items of the genetic testing are often limited. The goal of this study is to present a costing methodology in order to estimate and measure the costs as far as the technical process of pharmacogenomics testing is concerned. Moreover, an overall cost mindset strategy based on the selective genotyping workflow to guide specialized laboratories of interest effectively is provided. We particularly accounted for the resources consumed within the laboratory premises such as cost of reagents for DNA isolation, cost of consumables, cost of personnel, while costs associated with patient recruitment, blood sample collection and maintenance, administration costs in the hospital, and costs of blood sample shipment were not taken into consideration. Our article presents the first-time detailed information on a costing framework for pharmacogenomic testing that could be employed to laboratories involved in routine clinical implementation of pharmacogenomics.