Đang tải... (xem toàn văn)
Objectives: To assess impact of costs and efficiency of appendectomy in Sonla Province General Hospital. Subjects and methods: The research was conducted on 322 patients who underwent laparoscopic appendectomy and open appendectomy at Sonla Province General Hospital from 01 - 01 - 2012 to 30 - 12 - 2013.
Journal of military pharmaco-medicine n08-2017 COSTS AND EFFECTIVENESS OF APPENDECTOMY IN SONLA PROVINCE GENERAL HOSPITAL Nguyen Duc Toan*; Pham Le Tuan** SUMMARY Objectives: To assess impact of costs and efficiency of appendectomy in Sonla Province General Hospital Subjects and methods: The research was conducted on 322 patients who underwent laparoscopic appendectomy and open appendectomy at Sonla Province General Hospital from 01 - 01 - 2012 to 30 - 12 - 2013 Sample selection error is controlled by Propensity Score Matching (n = 109 pairs) Results and conclusions: The hospital stay in the group of laparoscopic appendectomy (4.2 ± 2.3 days) was less than that of open appendectomy (5.2 ± 2.2 days), but the difference did not have statistical significance (p > 0.05) The cost of open appendectomy and laparoscopic appendectomy in cases with complications (5,918.7 thousand and 5,247.9 thousand VND) was higher than the group without complications (5,531.9 thousand and 5,126.3 thousand) The cost of treatment of open appendectomy was higher than that of laparoscopic appendectomy, yet the effectiveness of laparoscopic appendectomy (96.3%) was higher than that of open appendectomy (93.6%), (p > 0.05) Therefore, laparoscopic appendectomy is the best choice for the patients with acute appendicitis * Keywords: Appendicitis; Laparoscopic appendectomy; Cost INTRODUCTION Health economic evaluation is a systematic approach designed to offer the policy makers a wide variety of options Cost, effectiveness analysis is a form of cost-benefit analysis Analysis of cost effectiveness has helped choose more effective methods at the same cost or equally effective ones at a lower cost [1, 2] The cost - efficiency laparoscopic appendectomy (LA) and open appendectomy (OA) was one of many authors’ interest [3, 4, 5, 6] The study by Varela J.E et al (2008) [8] on 1,943 patients showed that the hospital stay of LA group was shorter than that of OA (3 days compared to days) and its complication rate was lower (LA: 9% compared with open surgery: 17%) Incision infection rate was also lower (1% vs 3%) Obese patients treated with LA had higher complication rate (27% versus 18%) and the treatment cost was also higher (16,600 dollars compared to 12,300 dollars) Lin K.B et al (2015) [7] revealed that low income patients benefit more from LA than OA due to reduced hospitalization time, fewer complications and fewer hospitalization for treatment of complications Therefore, this study was conducted: To assess the impact of costs and efficiency of appendectomy in Sonla Province General Hospital * Sonla Province General Hospital * Department of Health Corresponding author: Nguyen Duc Toan (nguyenductn29@gmail.com) Date received: 21/08/2017 Date accepted: 29/09/2017 166 Journal of military pharmaco-medicine n08-2017 Five prognosis factors are put into pair SUBJECTS AND RESEARCH METHODS according to PSM method are age, time from sickness until the surgery, time of Subjects OA and LA surgery patients were enrolled in Sonla Province General Hospital from 01 - 01 - 2012 to 30 - 12 - 2013 hospital admission, the progression of acute appendicitis and who pays the costs - Tools, indicators and variables studied: Method - Sample size: All patients were adults who underwent OA and LA surgery in Sonla Province General Hospital from 01 - 01 2012 to 30 - - 2013 - Research design: Descriptive horizontal slicing analysis + On the basis of factors related to prognosis of cost-effectiveness of OA and LA, to control the model selecting errors we applied Propensity Score Matching (PSM) patients interview about direct costs outside health, indirect costs of households based on sets of questions are available after training - The data is handled by the method of biological-medical statistics using IBM SPSS 22.0 software Descriptive statistics with X ± SD Differences are statistically significant when p < 0.05 and highly significant when p < 0.001 RESULTS Table 1: The length of hospital stays of patients with acute appendicitis Time (days) OA (n = 109) (1) LA (n = 109) (2) The number of patients 93 97 X ± SD 5.1 ± 2.1 4.2 ± 2.4 The number of patients 16 12 X ± SD 6.0 ± 2.8 3.9 ± 0.9 > 0.05 > 0.05 5.2 ± 2.2 4.2 ± 2.3 p1-2 No complications (A) With complications (B) pA-B The total number > 0.05 < 0.01 > 0.05 Table shows the hospital stay of LA was less than OA, but the difference did not have statistical significance (p > 0.05) For the group of acute appendicitis with complication, time of hospitalization of LA was less than that of OA, the differences are statistically significant (p < 0.01) 167 Journal of military pharmaco-medicine n08-2017 Table 2: Cost of surgery for complicated acute appendicitis and uncomplicated cases (Unit: thousand VND) Complications of acute appendicitis OA (n = 109) LA (n = 109) p1-2 X ± SD 4,163.0 ± 2,749.0 3,965.0 ± 1,916.0 > 0.05 Median 3,686.6 4,352.2 X ± SD 4,259.7 ± 2,375.4 3,904.6 ± 1,478.1 Median 3,326.4 4,209.0 > 0.05 > 0.05 X ± SD 422.4 801.6 671.1 ± 388.0 Median 740.0 600.0 X ± SD 980.9 ± 382.0 705.8 ± 438.3 Median 970.0 535.0 > 0.05 > 0.05 X ± SD 567.3 ± 770.0 490.1 ± 593.5 Median 350.0 400.0 X ± SD 678.1 ± 926.2 637.5 ± 470.0 Median 425.0 775.0 > 0.05 > 0.05 X ± SD 5,531.9 ± 3,042.3 5,126.3 ± 2,465.8 Median 4,806.9 5,404.6 X ± SD 5,918.7 ± 2,966.0 5,247.9 ± 1,382.1 Median 4,980.9 5,462.8 > 0.05 < 0.05 (A) The cost paid to the hospital > 0.05 Yes (B) pA-B > 0.05 (A) Direct costs in addition to healthcare > 0.05 Yes (B) pA-B > 0.05 (A) Indirect costs > 0.05 Yes (B) pA-B > 0.05 (A) Total < 0.05 Yes (B) pA-B (* Acute appendicitis with complications (OA: 16; LA: 12) Table shows the total costs of OA in the group of appendicitis with complication was higher than that of LA group, the differences were statistically significant with p < 0.05 In both groups, the total costs of the group of acute appendicitis with complications was higher than the group without complication, the differences were statistically significant (p < 0.05) 168 Journal of military pharmaco-medicine n08-2017 Table 3: Cost of surgery for acute appendicitis according to the results of surgery (Unit: thousand VND) OA (n = 109) (1) LA (n = 109) (2) 102 (93.6%) 105 (96.3%) 5,623.1 ± 3,071.6 5,037.8 ± 2,157.2 Median (QL25-QL75) 4,850.0 [3,759.1 - 6,775.9] 5,404.6 [2,938.9 - 6,325.6] n (efficiency) (6.4%) (3.7%) X ± SD (costs) 5,087.6 ± 2,262.0 7,814.3 ± 5,513.6 Median (QL25-QL75) 4,264.4 [3,652.6 - 5,294.8] 5,508.3 [4,342 8-13.592, 0] pA-B > 0.05 < 0.001 n 109 109 X ± SD 5,588.7 ± 3.02 5,139.6 ± 2,366.6 Median 4,833.9 5,404.6 Results of surgery n (efficiency) Good (A) Average (B) The total cost X ± SD (costs) p1-2 > 0.05 < 0.05 < 0.05 We found that in the group with good surgical results, OA was more costly than LA, but the differences were not statistically significant (p > 0.05) In the group of average surgery results, the total cost of LA was greater than that of OA, the differences were statistically significant (p < 0.05) DISCUSSION Cost impact In the OA group, total cost of the group of acute appendicitis with complication was VND 386.8 thousand higher than that of the group without complication For LA patients, the total cost of acute appendicitis with complication was VND 121.6 thousand, higher than the group without complication, the differences were statistically significant (p < 0.05) Therefore, for complicated cases of acute appendicitis, LA as well as OA had higher expenditure compared to group of uncomplicated acute appendicitis This result was similar to other authors’ Dennett K.V et al (2012) [3] made a comparison between direct and indirect hospital cost of 61 households where children with acute appendicitis were operated promptly and unpromptly leading to appendicitis perforation Perforated patients had longer hospital stay (9 days) than the group of early surgery (7 days), (p = 0.02) and the total cost of the hospital stay was also significantly larger ($31.349 compared to $21.323, p = 0.01) No significant difference was seen in the number of school holidays (9 days compared to 10 days, p = 0.23) and adult holiday time for care (5 days versus days, p = 0.18) The authors said that the hospital stay in the group of acute appendicitis and perforation was longer with more costs, but indirect costs were not higher than those were treated early 169 Journal of military pharmaco-medicine n08-2017 Research by Cárdenas-Salomon C.M et al (2011) [1] showed hospitalization time of OA group was higher than that of LA (3.33 compared to 2.52 days, p < 0.0001) The treatment cost of LA group was 25% higher than open surgery (p = 0.0005) The cost of LA without complication was 1.7 times higher compared to open surgery (p < 0.0001) There was no difference in terms of the cost of hospitalization and surgery between groups with complications (p = 0.5319) medical costs are mainly the cost of medicine and nursing costs Cost impact based on efficiency Research results showed that the hospital stay in LA group (4.2 ± 2.3 days) was less than OA (5.2 ± 2.2 days), but the difference did not have statistical significance (p > 0.05) In the surgery group with good results, the total cost of OA (5,623.1 ± 3,071.6 thousand) was higher than that of LA (5,037.8 ± 2,157.2 thousand) but not statistically significant (p > 0.05) In the surgery group with median results, the total cost of LA (7,814.3 ± 5,513.6 thousand) was higher than that of OA (5,087.6 ± 2,262.0 thousand), the differences were statistically significant with p < 0.05 Dhupar R et al (2012) [4] carried out the study on 453 patients with appendectomy found that patients with complication had hospital stays as much as 2.3 times compared to the group without complications (4.4 days versus 1.9 days; p < 0.001) and the average cost was as high as 86% ($14.125 versus $7.595; p < 0.001) The differences in Based on the two criteria of cost and efficacy of LA and OA, we found that OA was more costly than LA, yet LA was more effective The cost-effectiveness table was illustrated as below: Table 4: Cost-effectiveness of LA and OA Cutting performance appendix The cost of the CRT NS < MM MM = NS MM cost > NS MM < NS 1: Increased costeffectiveness ratio 4: NS better than MM 7: NS better than MM MM = NS 2: MM better than NS 5: Consider other factors 8: NS better than MM MM > NS 3: MM better than NS 6: MM better than NS 9: Increased costeffectiveness ratio We can see that LA outweighs OA This is also similar to foreign authors’ research findings Dubois L et al (2010) [5] carried out study on 161 LA patients, the author found that the proportion of patients treated early was 45% (72/161 patients) with mean surgery time of 4.7 hours The group of patients treated early had similar complication rate to other groups (4.3% versus 7.1%), but the time of hospital stay in the recovery room after surgery significantly reduced (4.7 hours compared with 16.2 hours, p < 0.001), the average cost for a patient decreased $323.46 The authors said that if patients, who were discharged from hospital soon after LA, the treatment cost would be reduced 45% of hospital bed demand, so we may save about 300 dollars per patient 170 Journal of military pharmaco-medicine n08-2017 According to Khan S.Y et al (2013) [6], mean cost of LA (534 Oman riyal) was higher than that of open surgery (343 Oman riyal) (p < 0.001) The authors suggested that cost of LA was more expensive than open surgery, but similarly safe and does not increase the rate of complications or time of hospital stay Costa-Navarro D et al (2013) [2] did a research on 142 appendectomy cases (99 LA patients and 43 OA patients) also showed that net costs for OA (1.799 euro) was higher than LA (1.081 euros) The authors suggest that LA technique should be chosen for the treatment of acute appendicitis due to its clinical and economic efficiency Hence, LA reduces the rate of complications, time in hospital and also reduce the costs not directly related to health care and indirect costs Therefore, the total cost of the LA was lower than that of OA, so LA is the best choice for the patients with acute appendicitis CONCLUSION - Time of the LA group (4.2 ± 2.3 days) was less than OA (5.2 ± 2.2 days) - Cost of OA and LA in complicated cases (5,918.7 thousand and 5,247.9 thousand) was higher than that of the group without complication (5,531.9 thousand and 5,126.3 thousand) - The treatment cost of OA was higher than that of LA, yet the effectiveness of LA (96.3%) was higher than OA (93.6%), (p > 0.05) REFERENCES Cárdenas-Salomon C.M, Cervantes-Castro, j j.-S.E.R et al Hospitalization costs of open vs laparoscopic appendectomy: 5-year experience CIR Cir 2011, 79 (6), pp.534-539 Costa-Navarro d, Jiménez-Fuertes m and i.-R A Laparoscopic appendectomy: quality care and cost-effectiveness for today's economy World J Emerg Surg 2013, (1), p.45 Dennett K.V, Tracy s, F.S et al Treatment of perforated appendicitis in children: what is the cost? J Pediatr Surg 2012, 47 (6), pp.1177-1184 r Dhupar Evankovich, j., O.J.B et al Outcomes of operative management of appendicitis Surg Infect (Larchmt) 2012, 13 (3), pp.141-146 Dubois, l., Vogt K.N., D.W et al Impact of an appendectomy outpatient protocol on clinical outcomes and cost: a case-control study J Am Coll Surg 2010, 211 (6), pp.731-737 Khan Al-Balushi, Z.N, S.Y, B.K.M et al Cost comparison between laparoscopic and open appendectomies are unjustified in children Sultan Qaboos Univ Med J 2013, 13 (2), pp 275-279 Lin K.B, Lai Y.N.P, K.R et al Trends and outcomes in the utilization of laparoscopic appendectomies are unjustified in a low-income population in Taiwan from 2003 to 2011 J Equity Health 2015, 14, p.100 j e Varela, H.M.W, Nair N.T Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese Am Surg J 2008,196 (2), pp.218-222 171 ... was no difference in terms of the cost of hospitalization and surgery between groups with complications (p = 0.5319) medical costs are mainly the cost of medicine and nursing costs Cost impact... OA and LA surgery patients were enrolled in Sonla Province General Hospital from 01 - 01 - 2012 to 30 - 12 - 2013 hospital admission, the progression of acute appendicitis and who pays the costs. .. direct costs outside health, indirect costs of households based on sets of questions are available after training - The data is handled by the method of biological-medical statistics using IBM