Multicentre Analysis of Cost, Uptake and Safety of Canadian Multidisciplinary Pancreatic Cyst Guidelines

Background

Pancreatic cystic lesions (PCLs) are common, with several guidelines providing surveillance recommendations. The Canadian Association of Radiologists published surveillance guidelines (CARGs) intended to provide simplified, cost-effective and safe recommendations. This study aimed to evaluate cost savings of CARGs compared to other North American guidelines including American Gastroenterology Association guidelines (AGAG) and American College of Radiology guidelines (ACRG), and to evaluate CARG safety and uptake.

Methods

This is a multicentre retrospective study evaluating adults with PCL from a single health zone. MRIs completed from September 2018–2019, one year after local CARG guideline implementation, were reviewed to identify PCLs. All imaging following 3–4 years of CARG implementation was reviewed to evaluate true costs, missed malignancy and guideline uptake. Modelling, including MRI and consultation, predicted and compared costs associated with surveillance based on CARGs, AGAGs and ACRGs.

Results

6698 abdominal MRIs were reviewed with 1001 (14.9%) identifying PCL. Application of CARGs over 3.1 years demonstrated a >70% cost reduction compared to other guidelines. Similarly, the modelled cost of surveillance for 10-years for each guideline was $516,183, $1,908,425 and $1,924,607 for CARGs, AGAGs and ACRGs respectively. Of patients suggested to not require further surveillance per CARGs, approximately 1% develop malignancy with fewer being candidates for surgical resection. Overall, 44.8% of initial PCL reports provided CARG recommendations while 54.3% of PCLs were followed as per CARGs.

Conclusions

CARGs are safe and offer substantial cost and opportunity savings for PCL surveillance. These findings support Canada-wide implementation with close monitoring of consultation requirements and missed diagnoses.

Cost-utility analysis of normothermic machine perfusion compared to static cold storage in liver transplantation in the Canadian setting

To estimate the incremental cost-effectiveness of a liver transplant program that utilizes normothermic machine perfusion (NMP) alongside static cold storage (SCS) compared to SCS alone (control). A Markov model compared strategies (NMP vs. control) using 1-year cycle lengths over a 5-year time horizon from the public healthcare payer perspective. Primary micro-costing data from a single center retrospective trial were applied along with utility values from literature sources. Transition probabilities were deduced using the retrospective trial cohort, local transplant data, and supplemented with literature values. Scenario and probabilistic sensitivity analysis (PSA) were conducted. The NMP strategy was cost-effective in comparison to the control strategy, which was dominated. The mean cost for NMP was $456 455 (2021 US$) and the control was $519 222. The NMP strategy had greater incremental quality-adjusted life years (QALYs) gains over 5 years compared to the control, with 3.48 versus 3.17, respectively. The overarching results remained unchanged in scenario analysis. In PSA, NMP was cost-effective in 63% of iterations at a willingness-to-pay threshold of $40 941. The addition of NMP to a liver transplant program results in greater QALY gains and is cost-effective from the public healthcare payer perspective.

The Actual Operative Costs of Liver Transplantation and Normothermic Machine Perfusion in a Canadian Setting

BACKGROUND

Liver transplantation is an effective treatment for end-stage liver disease. However, waiting lists continue to lengthen as demand exceeds supply. Use of extended criteria donors has helped but is associated with increased rates of complications. The application of normothermic machine perfusion (NMP) has been shown to be protective, especially in more marginal grafts. Despite this benefit, no cost-effectiveness studies have been published.

OBJECTIVE

This study serves as a prelude to a cost-effectiveness analysis of the costs of liver procurement, transplantation, and machine perfusion in a Canadian setting.

METHODS

The total costs were calculated for 106 in-province procurements, the set cost for 237 out-of-province procurements, and 343 liver transplantations. These costs include overheads, supplies, anaesthesia technologist and nursing salaries, and physician billings. Base and modified costs for all procedures were calculated, with consideration of physician billing modifiers. The total cost per run of NMP was calculated, with a range based on variations in the exchange rates for Great British pounds (₤) to Canadian dollars ($Can), year 2019 values.

RESULTS

Costs were $Can30,770.22 for in-province and $Can44,636.73 for out-of-province liver procurement and transplantation. These increased to $Can35,659.22 and 48,076.18 when considering modifiers. The minimum cost per NMP run was $Can18,593.02.

CONCLUSIONS

Although the cost per run is substantial, NMP could potentially lead to cost savings by decreasing night-time salary premiums, complications, and patient length of stay. A formal cost-effectiveness study of NMP in liver transplantation is underway to help clarify the financial benefit or burden of this new technology.

Hypnotherapy for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder of unknown aetiology. Current pharmacological treatments have limited value. Hypnotherapy has been reported to have beneficial effects for IBS symptoms.

OBJECTIVES

To evaluate the efficacy of hypnotherapy for the treatment of irritable bowel syndrome.

SEARCH STRATEGY

Published and unpublished randomised clinical trials and quasi-randomised clinical trials were identified through structured searches of MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), PsycINFO (1806 to March 2006), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to March 2006), AMED (Allied and Complementary Medicine Database, 1985 to March 2006) and The Cochrane Central Register of Controlled trials. Conference proceedings from Digestive Disease Week (1980 to 2005) were also searched.

SELECTION CRITERIA

Eligible studies included all randomised and quasi-randomised clinical studies comparing hypnotherapy for the treatment of irritable bowel syndrome with no treatment or another therapeutic intervention.

DATA COLLECTION AND ANALYSIS

All studies were evaluated for eligibility for inclusion. Included studies were assessed for quality and data were extracted independently by four authors. The primary outcome measure of interest was the overall bowel symptom severity score which combines abdominal pain, diarrhoea or constipation and bloating. Secondary outcomes included abdominal pain, diarrhoea, constipation, bloating, quality of life, patient's overall assessment of well-being, psychological measures as per validated questionnaires, and adverse events.

MAIN RESULTS

Four studies including a total of 147 patients met the inclusion criteria. Only one study compared hypnotherapy to an alternative therapy (psychotherapy and placebo pill), two studies compared hypnotherapy with waiting-list controls and the final study compared hypnotherapy to usual medical management. Data were not pooled for meta-analysis due to differences in outcome measures and study design. The therapeutic effect of hypnotherapy was found to be superior to that of a waiting list control or usual medical management, for abdominal pain and composite primary IBS symptoms, in the short term in patients who fail standard medical therapy. Harmful side-effects were not reported in any of the trials. However, the results of these studies should be interpreted with caution due to poor methodological quality and small size.

AUTHORS' CONCLUSIONS

The quality of the included trials was inadequate to allow any conclusion about the efficacy of hypnotherapy for irritable bowel syndrome. More research with high quality trials is needed.