Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost‐effectiveness analysis

• Published in: BJS open Vol. 4; no. 5; pp. 830 - 839
• Main Authors: Gosselin‐Tardif, A., Abou‐Khalil, M., Mata, J., Guigui, A., Cools‐Lartigue, J., Ferri, L., Lee, L., Mueller, C.
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01-10-2020; Oxford University Press
• Subjects: Clinical outcomes; Costs; Decision trees; Gastric cancer; Laparoscopy; Laparotomy; Literature reviews; Monte Carlo simulation; Mortality; Original; Patients; Postoperative period; Probability; Purchasing power parity; Quality of life; Secondary analysis; Sensitivity analysis; Surgery; Upper GI; Canada; China; Japan
• ISSN: 2474-9842; 2474-9842
• DOI: 10.1002/bjs5.50327

Background
Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches.
Methods
A cost–effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision‐tree cohort model with a healthcare system perspective and a 12‐month time horizon. Model inputs were informed by a meta‐analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality‐adjusted life‐years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed.
Results
In the base‐case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost–effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost‐effective at willingness‐to‐pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG.
Conclusion
In this decision analysis model, LSG was cost‐effective compared with OSG for gastric cancer.
Antecedentes
Pese a su mayor coste, la gastrectomía subtotal laparoscópica se asocia con buenos resultados perioperatorios y una mejor calidad de vida en comparación con la cirugía abierta en el tratamiento del cáncer. Se realizó una evaluación económica comparando los dos abordajes.
Métodos
Se efectuó un análisis de coste‐efectividad de la gastrectomía subtotal laparoscópica (laparoscopic subtotal gastrectomy, LSG) o de la gastrectomía subtotal abierta (open subtotal gastrectomy, OSG) en el cáncer gástrico utilizando un modelo de cohortes con árbol de decisión desde la perspectiva del sistema de salud y con un horizonte temporal de 12 meses. Los gastos del modelo fueron evaluados tras un metaanálisis de literatura relevante y expresados en dólares canadienses (Canadian dollars, CAD) del 2016. Los resultados se midieron en años de vida ajustados por su calidad (quality‐adjusted life years, QALYs). Se realizó un análisis secundario utilizando los datos extraídos únicamente de estudios europeos y norteamericanos. Además, se realizaron análisis de sensibilidad determinístico y probabilístico (deterministic and probabilistic sensitivity analyses, DSA y PSA).
Resultados
En el modelo del caso base, los costes de la LSG fueron de 934,78$ (565€) más que en la OSG, con una ganancia incremental de 0,050 QALYs, que supuso una relación coste‐efectividad incremental (incremental cost‐effectiveness ratio, ICER) de 18.846,12$ (11.398€) por QALY adicional en la LSG. En el DSA, los resultados fueron más sensibles a cambios en el postoperatorio, quirófano y coste de los equipos, así como en la duración de la intervención y la hospitalización. El PSA demostró que la probabilidad de que la LSG fuera rentable en términos de disposición de pago (willingness‐to‐pay, WTP) para dos umbrales, de 50.000$ (30.240€) y 100.000$ (60.480€) por QALY fue del 64% y del 68%, respectivamente. En el análisis secundario utilizando los datos europeos y norteamericanos se demostró que la LSG era claramente dominante (más barata y más efectiva) que la OSG, en gran parte debido a la reducción de la estancia hospitalaria de la LSG.
Conclusión
En este modelo de análisis de decisión, la LSG fue coste‐efectiva en comparación con la OSG para el cáncer gástrico.
Laparoscopic subtotal gastrectomy (LSG) is associated with good perioperative outcomes and superior quality of life compared with the open approach to resection of gastric adenocarcinoma, albeit at higher cost. A cost–effectiveness analysis comparing the two approaches found LSG to be cost‐effective compared with the open approach, with an incremental cost–effectiveness ratio of $18 846 per quality‐adjusted life‐year. In a secondary analysis of studies from Europe and North America, where reduction in duration of hospital stay after laparoscopic gastrectomy is greater, the minimally invasive approach became dominant (both cheaper and more effective) in comparison with open gastrectomy. OR, operating room; LOS, length of hospital stay.
Analysis favours laparoscopic approach