Division of General Surgery, Department of Surgery, Toronto, Ontario, Canada.
Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
BJS Open. 2020 Oct;4(5):914-923. doi: 10.1002/bjs5.50311. Epub 2020 Jun 30.
Adhesive small bowel obstruction (aSBO) is a potentially recurrent disease. Although non-operative management is often successful, it is associated with greater risk of recurrence than operative intervention, and may have greater downstream morbidity and costs. This study aimed to compare the current standard of care, trial of non-operative management (TNOM), and early operative management (EOM) for aSBO.
Patients admitted to hospital between 2005 and 2014 in Ontario, Canada, with their first episode of aSBO were identified and propensity-matched on their likelihood to receive EOM for a cost-utility analysis using population-based administrative data. Patients were followed for 5 years to determine survival, recurrences, adverse events and inpatient costs to the healthcare system. Utility scores were attributed to aSBO-related events. Cost-utility was presented as the incremental cost-effectiveness ratio (ICER), expressed as Canadian dollars per quality-adjusted life-year (QALY).
Some 25 150 patients were admitted for aSBO and 3174 (12·6 per cent) were managed by EOM. Patients managed by TNOM were more likely to experience recurrence of aSBO (20·9 per cent versus 13·2 per cent for EOM; P < 0·001). The lower recurrence rate associated with EOM contributed to an overall net effectiveness in terms of QALYs. The mean accumulated costs for patients managed with EOM exceeded those of TNOM ($17 951 versus $11 594 (€12 288 versus €7936) respectively; P < 0·001), but the ICER for EOM versus TNOM was $29 881 (€20 454) per QALY, suggesting cost-effectiveness.
This retrospective study, based on administrative data, documented that EOM may be a cost-effective approach for patients with aSBO in terms of QALYs. Future guidelines on the management of aSBO may also consider the long-term outcomes and costs.
黏连性小肠梗阻（aSBO）是一种潜在的复发性疾病。尽管非手术治疗通常是成功的，但它与手术干预相比，复发的风险更高，并且可能有更大的下游发病率和更高的成本。本研究旨在比较 aSBO 的现行标准治疗方案，即尝试非手术治疗（TNOM）和早期手术治疗（EOM）。
在加拿大安大略省，2005 年至 2014 年间住院的患者中，对首次发生 aSBO 的患者进行了识别，并基于人群进行了倾向匹配，以进行成本效用分析，使用基于人群的行政数据来确定接受 EOM 的可能性。对患者进行了 5 年的随访，以确定生存率、复发率、不良事件和医疗系统的住院费用。将效用评分归因于 aSBO 相关事件。成本效用以增量成本效果比（ICER）表示，以加拿大元每质量调整生命年（QALY）表示。
共有 25150 名患者因 aSBO 住院，其中 3174 名（12.6%）接受了 EOM 治疗。接受 TNOM 治疗的患者更有可能出现 aSBO 复发（20.9%对 13.2%的 EOM；P<0.001）。EOM 治疗相关的低复发率有助于 QALY 方面的整体净效果。接受 EOM 治疗的患者的平均累积费用超过接受 TNOM 治疗的患者（分别为 17951 加元和 11594 加元（12288 欧元和 7936 欧元）；P<0.001），但 EOM 与 TNOM 的 ICER 为 29881 加元（20454 欧元）每 QALY，表明具有成本效益。
这项基于行政数据的回顾性研究表明，EOM 可能是 aSBO 患者在 QALY 方面的一种具有成本效益的治疗方法。未来关于 aSBO 管理的指南也可能考虑长期结果和成本。
