急诊手术治疗住院成人常见急性胃肠道疾病的临床效果和成本效益:ESORT研究

Richard Grieve, Andrew Hutchings, Silvia Moler Zapata, Stephen O’Neill, David G Lugo-Palacios, Richard Silverwood, David Cromwell, Tommaso Kircheis, Elizabeth Silver, Claire Snowdon, Paul Charlton, Geoff Bellingan, Ramani Moonesinghe, Luke Keele, Neil Smart, Robert Hinchliffe
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Objectives We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups. Methods The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems , Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year. Results Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery. Limitations The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers. Conclusions Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective. Future work For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery. Study registration This study is registered as reviewregistry784. Funding This project was funded by the National Institute for Health and Care Research (IHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research ; Vol. 11, No. 1. 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Results Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. 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引用次数: 1

摘要

背景:急诊手术与非急诊手术策略(包括医疗管理、非外科手术和选择性手术)相比,对住院常见急性胃肠道疾病患者的临床效果和成本效益需要证据。我们旨在评估两种策略(即急诊手术与非急诊手术策略)对五种常见急症患者的相对临床效果;(2)五种常见急性病的成本效益;(3)针对特定患者亚群的替代策略的临床效果和成本效益。方法从2010年4月1日至2019年12月31日期间英国175家急性医院急诊收治的急性阑尾炎、胆结石、憩室病、腹壁疝或肠梗阻的成人记录中提取,并与英国国家统计局的死亡率数据相关联。使用经临床专家组共识同意的《国际疾病和相关健康问题统计分类第十版》诊断代码确定资格。接受紧急手术的病人是根据人口普查和调查办公室的程序代码确定的。该研究通过工具变量设计解决了潜在的无法测量的混杂。工具变量是每家医院使用紧急手术与非紧急手术策略的倾向。主要指标是90天的“存活和出院天数”。我们报告了替代策略的总体相对有效性,以及预先指定的亚组(即年龄,合并症数量和虚弱程度)。成本效益分析利用相关数据中的资源利用和死亡率,得出增量成本、质量调整寿命年和1年增量净货币效益的估计。结果队列大小如下:阑尾炎患者268,144人,胆结石患者240,977人,憩室疾病患者138,869人,疝气患者106,432人,肠梗阻患者133,073人。总的来说,在1年,平均存活天数和90天出院天数,成本和质量调整生命年在两种策略下相似,在调整混杂因素后。总的来说,对于五种情况中的每一种,增量净货币效益估计的95%置信区间(ci)都包括零。对于严重虚弱的患者,紧急手术导致存活和出院天数减少,与非紧急手术相比,其成本效益不高,阑尾炎的增量净货币效益估计为- 18,727英镑(95% CI - 23,900英镑至- 13,600英镑),胆石症的增量净货币效益估计为- 7700英镑(95% CI - 13,000英镑至- 2370英镑),憩室病的增量净货币效益估计为- 9230英镑(95% CI - 24,300英镑至5860英镑)。-疝气- 16,600英镑(95% CI - 21,100英镑- 12,000英镑),肠梗阻- 19,300英镑(95% CI - 25,600英镑- 13,000英镑)。对于“适合”的患者,急诊手术相对具有成本效益,估计憩室疾病的净增量货币效益估计为5180英镑(95% CI为684英镑至9680英镑),疝气为2040英镑(95% CI为996英镑至3090英镑),肠梗阻为7850英镑(95% CI为5020英镑至10700英镑),阑尾炎为369英镑(95% CI为728英镑至1460英镑),胆结石为718英镑(95% CI为294英镑至1140英镑)。公众和患者参与翻译研讨会的参与者强调,这些发现应该广泛提供给未来的手术决策。工具变量方法不能消除混淆的风险,急性医院的观点排除了其他提供者的成本。结论两种策略总体上都不具有更高的成本效益。对于严重虚弱的患者,非急诊手术策略相对具有成本效益。对于身体健康的患者,紧急手术更具成本效益。对于患有多种长期疾病的患者,需要进一步的研究来评估急诊手术的收益和成本。研究注册本研究注册号为reviewregistry784。该项目由国家卫生和保健研究所(IHR)卫生和社会保健提供研究方案资助,将全文发表在《卫生和社会保健提供研究》上;第11卷第1期请参阅NIHR期刊图书馆网站了解更多项目信息。
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Clinical effectiveness and cost-effectiveness of emergency surgery for adult emergency hospital admissions with common acute gastrointestinal conditions: the ESORT study
Background Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions. Objectives We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups. Methods The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems , Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year. Results Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery. Limitations The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers. Conclusions Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective. Future work For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery. Study registration This study is registered as reviewregistry784. Funding This project was funded by the National Institute for Health and Care Research (IHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research ; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.
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