Jones Chris N, Morrison Ben L, Kelliher Leigh Js, Dickinson Matthew, Scott Michael, Cecconi Ebm Claudia, Karanjia Nariman, Quiney Nial
Royal Surrey NHS Foundation Trust, Guildford, United Kingdom.
Humanitas University, Milan, Italy.
JMIR Perioper Med. 2021 Feb 1;4(1):e16829. doi: 10.2196/16829.
The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics.
We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection.
The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival.
Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of -£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery.
ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
强化康复计划（ERPs）的临床益处已得到广泛研究，但很少有研究评估其成本效益。我们用于开放性肝切除术的ERP严格遵循手术加速康复学会（2016年）制定的指南。本研究是在之前的一项随机对照试验基础上开展的。我们还对原试验中纳入的患者进行了长期随访，并对相关卫生经济学进行了分析。
作为一项研究开放性肝切除术ERP实施情况的试验的一部分，我们旨在进行卫生经济学和长期生存分析。
所采用的强化康复要素包括额外的术前教育、碳水化合物负荷、口服营养补充剂、术后目标导向性液体治疗（LiDCOrapid）、早期活动及物理治疗（每天两次，而标准护理组为每天一次）。使用决策分析模型比较ERP与为接受开放性肝切除术患者提供的标准护理的研究终点。获得的结果包括每获得一个生命年的成本。资源使用和成本从英国国家医疗服务体系的角度进行估算。利用我们早期试验的结果构建决策树和马尔可夫模型，并通过其他已发表临床试验的外部数据进行补充。术后还进行了长达5年的长期随访，并对数据进行分析以确定ERP是否对长期生存有任何益处。
接受ERP的患者平均预期寿命为6.9年，而标准护理组为6.1年。ERP的总体成本为9538.279英镑（1英镑 = 1.60美元），标准治疗为14793.05英镑。这导致成本效益比为 - 6748.33英镑/质量调整生命年。与标准护理组患者相比，接受ERP的患者看全科医生的次数更少（P = 0.006），在家中进行日常活动所需的帮助也更少（P = 0.04）。接受ERP的患者在2年时生存率显著提高，为91%（42/46），而标准护理组为73%（33/45）（P = 0.03）。术后5年无统计学显著差异。
对于接受开放性肝切除术的患者，ERPs可改善其中期生存，且对医院和社区环境均具有成本效益。
