Mohiuddin Syed, Reeves Barnaby C, Smart Neil J, Hollingworth William
Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, UK.
Colorectal Dis. 2021 Nov;23(11):2967-2979. doi: 10.1111/codi.15848. Epub 2021 Aug 12.
Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer.
We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses.
Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £1,706 (£1,692 to £1,720) (stage I) and £684 (£678 to £690) (stage IV) for synthetic versus no mesh, and £2,038 (£1,997 to £2,079) (stage I) and £1,671 (£1,653 to £1,689) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.95 for stages I-III and ≥0.93 for stage IV. [Correction added on 05 October 2021 after first online publication: The estimation of health outcomes (QALYs) for all three interventions evaluated (synthetic mesh; biologic mesh; no mesh) have been corrected in this version.] CONCLUSIONS: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.
造口旁疝（PSH）是结肠造口术后常见的问题。在末端结肠造口术中使用预防性补片可能会降低PSH的发生率，但对于补片的最佳类型、潜在的长期并发症及其使用的成本效益仍存在担忧。我们评估了补片预防在直肠癌患者末端结肠造口术中预防PSH的成本效益。
我们建立了一个决策分析模型，根据直肠癌I-IV期进行分层，从英国国民健康服务体系（NHS）的角度估计合成补片、生物补片和不使用补片的终身成本、质量调整生命年（QALY）和净货币效益（NMB）。我们汇总了13项随机对照试验（RCT）中与补片相关的PSH相对风险，并将其叠加在基于人群队列的基线（不使用补片）风险上。在敏感性分析中评估不确定性。
对于所有直肠癌分期，合成补片在预防PSH方面比生物补片和不使用补片成本更低且更有效。在支付意愿阈值为20000英镑/QALY时，合成补片与不使用补片相比，增量NMBs（95%CI）在I期为1706英镑（1692英镑至1720英镑）至IV期为684英镑（678英镑至690英镑）之间，合成补片与生物补片相比，在I期为2038英镑（1997英镑至2079英镑）至IV期为1671英镑（1653英镑至1689英镑）之间。除非I-III期PSH的相对风险≥0.95且IV期≥0.93，否则合成补片比不使用补片更具成本效益。[2021年10月5日首次在线发表后添加的更正：此版本中已对评估的所有三种干预措施（合成补片；生物补片；不使用补片）的健康结局（QALY）估计进行了更正。]结论：对于任何直肠癌分期的患者，在末端结肠造口术后预防PSH形成，合成补片是最具成本效益的策略；然而，结论取决于认为哪些RCT子集能提供最有力的证据。
