Health State Utility Values for Ileostomies and Colostomies: a Systematic Review and Meta-Analysis

Cost-Effectiveness of a Digital Leakage Notification System (Heylo™) for People with Ileostomies or Colostomies in the United Kingdom

BACKGROUND

People with stomas report a substantial negative impact of stomal effluent leaking outside the ostomy baseplate and subsequent complications in their professional and social lives, causing immense worry. However, many patients are not able to recognize leakages in a timely manner. We conducted a cost-effectiveness study to evaluate the impact of a digital leakage notification system (DLNS) to reduce leakages outside the baseplate (LOB) and worry about leakage for people with intestinal stomas from a UK National Health Service and Personal Social Services perspective.

METHODS

A Markov model for ostomy care was used to compare health-related quality of life and costs for adults with ileostomies or colostomies using UK standard of care ostomy products with the DLNS (intervention) or without the DLNS (comparator). The base case model used a 3-year time horizon with 1-week cycles and an annual 3.5% discounting of utilities and costs. Patients in all health states experience LOB events and/or worry about leakage as events associated with one-time utility decrements and costs of additional healthcare provider visits and ostomy product use. Probabilities of LOB (DLNS, 46.5%; comparator, 78.6%) and worry about leakage (DLNS, 39.1%; comparator, 78.6%) were based on clinical trial results. Peristomal skin complications were included in the model with the same probabilities of occurrence in the intervention and comparator arms. Sensitivity and scenario analyses were performed to test the robustness of the base case model assumptions.

RESULTS

In the base case analysis, the DLNS arm had 49.81 fewer LOB events per person than the comparator arm, resulting in 0.309 incremental quality-adjusted life-years (QALYs) and cost savings of British Pound Sterling (GBP) £1703 per person over 3 years (2023/2024 costing year). The DLNS arm had 56.98 fewer worry about leakage events per person, resulting in cost savings of £403 per person. Total costs and QALYs were £18,600 and 1.818 for the intervention arm, respectively, and £18,566 and 1.509 for the comparator arm. Overall, the DLNS provided 0.309 incremental QALYs at an incremental cost of £34 versus the comparator arm for an incremental cost-effectiveness ratio of £110/QALY gained, well below a willingness-to-pay threshold of £20,000/QALY. Sensitivity analyses showed the DLNS was cost-effective in 97.6% of simulations.

CONCLUSIONS

This analysis suggests that the DLNS added to standard of care ostomy products is a cost-effective intervention to help prevent LOB events and reduce worry about leakage for people with stomas in the UK. Results of the present study suggest that timely awareness of leakage has a positive impact on the health-related quality of life of people with stomas and on the direct costs of stoma management in the UK.

EAES rapid guideline: surgical management of complicated diverticulitis - with ESCP participation

BACKGROUND

The surgical management of complicated diverticulitis varies across Europe. EAES members prioritized this topic to be addressed by a clinical practice guideline through an online questionnaire.

OBJECTIVE

To develop evidence-informed clinical practice recommendations for key stakeholders involved in the treatment of complicated diverticulitis; to improve operative and perioperative outcomes, patient experience and quality of life through a systematic evidence-to-decision approach by a diverse, multidisciplinary panel.

METHODS

Informed by a linked individual participant data network meta-analysis of resection and primary anastomosis (PRA) versus Hartmann's resection (HR) versus laparoscopic lavage (LPL), a panel of general and colorectal surgeons, patient partners, trialists, and fellows appraised the certainty of the evidence using GRADE and CINeMA. The panel discussed the evidence using the evidence-to-decision framework during a synchronous consensus meeting. An asynchronous modified Delphi survey was used to establish consensus.

RESULTS

The panel suggests that patients with complicated diverticulitis without sepsis receive PRA over HR or LPL when there is availability of a surgeon with skills and experience in colorectal surgery. HR is suggested over PRA or LPL in the subgroups of septic, frail, as well as immunocompromised patients. These recommendations apply to patients with an indication for surgery. Surgeons and patients should first consider conditionally recommended interventions, then conditionally recommended against. Based on the evidence, the key benefit of PRA was a higher likelihood of not having a stoma at 1 year, with similar risks across comparisons. Conditional recommendations call for shared decision-making when considering management options. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/7490 .

CONCLUSION

This clinical practice guideline provides evidence-informed recommendations on the management of patients with complicated diverticulitis in accordance with the highest methodological standards through a structured framework informed by an international, multidisciplinary panel of stakeholders.

Determination of quality of life-related health utilities for surgical complications in ovarian cancer

OBJECTIVE

To assess the health state utilities of ovarian cancer patients, clinicians, and non-cancer controls regarding surgical complications in ovarian cancer.

METHODS

Utilities for 14 surgical complications were assessed from patients with recently diagnosed or recurrent ovarian cancer, clinicians, and non-cancer controls using the visual analog scale (VAS) and time trade-off (TTO) methods. Health state utilities were converted to a 0-to-1 scale, where 0 represents the least favorable outcome and 1 represents the most favorable outcome.

RESULTS

Fifty patients, 50 clinicians, and 50 controls participated. Median VAS scores were lower than TTO scores across all groups (p < 0.01). Patients viewed 'bleeding requiring transfusion' most favorably (VAS utility 0.75), followed in order by less favorable utility scores for hernia, thromboembolism, pleural effusion, abscess, ileus/bowel obstruction, wound infection, bowel obstruction requiring surgery, anastomotic leak requiring drain, temporary ostomy, anastomotic leak requiring surgery, genito-urinary fistula, permanent ostomy, and genito-intestinal fistula (VAS utility 0.2). Overall, clinicians perceived complications more favorably than patients by VAS (overall utility score 0.49 vs 0.43, p < 0.01), but not by the TTO. There were no differences in overall utility scores between patients and controls. Patients who had not experienced certain surgical complications had less favorable scores than patients who did (utility score for ostomy = 0.2 for patients without ostomy vs. 0.7 for patients with ostomy, p = 0.02).

CONCLUSIONS

This study establishes health state utilities for surgical complications associated with ovarian cancer. These utilities can be used in future cost-effectiveness evaluations to determine quality-adjusted outcomes and may help in counseling patients during the shared decision-making process.

Gastrointestinal Ostomies in Children: A Primer for the Pediatrician

Despite the advancement of medical therapies in the care of the preterm neonate, in the management of short bowel syndrome and the control of pediatric inflammatory bowel disease, the need to create fecal ostomies remains a common, advantageous treatment option for many medically complex children.

Assessment of risk factors and establishment of a nomogram model to predict early high-output ileostomy

OBJECTIVE

This study evaluated the prevalence and perioperative risk factors for early high-output ileostomy (EHOI) and developed a precise nomogram model to predict the occurrence of EHOI.

METHODS

140 patients who underwent ileostomy surgery at three hospitals in Wuhan, Hubei Province, between January 2022 and May 2022 were enrolled in this prospective cohort study. By using univariate and multifactorial logistic regression, independent risk variables for the development of EHOI were examined, and the nomogram model for predicting the risk of EHOI was created by using R software. The calibration curve and area under the receiver operating characteristic curve (ROC AUC) were used to evaluate the calibration and discrimination of the prediction model, Hosmer-Lemeshow to verify the fit of the model. Clinical impact curve (CIC) and decision curve analysis (DCA) were used to assess the model's clinical efficacy.

RESULTS

A total of 132 patients participated in the study, and the incidence of EHOI was 25.8% (34/132). The nomogram model incorporated 3 risk factors hypertension, drinking habits, and high white blood cell (WBC) count after surgery. The AUC was 0.742, and the nomogram showed great calibration and clinical validity by comparing the calibration curve, DCA, and CIC.

CONCLUSIONS

Hypertension, drinking, and high WBC was significantly correlated with EHOI. The nomogram model has great clinical value in predicting the EHOI.

Value-Based Healthcare in Ostomies

In order to achieve significant improvements in quality, cost, and accessibility (the health “iron triangle”), innovation in organizational and service delivery models is necessary to increase the value of healthcare. The aim of this study is to evaluate the efficiency of a model of organizational innovation based on advanced practice nurse in the care of people with ostomies (APN-O) versus usual care. An observational, exploratory, analytical, prospective study with a six-month follow-up was carried out at 12 hospitals that implemented this model in Andalusia. A total of 75 patients who had undergone a digestive elimination ostomy and/or a urinary ostomy were followed for six months. Clinical outcomes, healthcare resources, health-related quality of life, and willingness to pay (WTP) were analyzed. The economic evaluation was conducted from a societal perspective, including healthcare costs and indirect costs. The cost difference between the two models was €136.99 and the quality-adjusted life year (QALY) gained was 0.05965 (€2297 per QALY gained). At six months, the mean of WTP was €69 per APN-O consultation. This model contributes to increasing the value-based healthcare in ostomies. Results of this study suggested that APN-O is an effective patient management model for improving their health status and is highly efficient.

Optimal Operative Strategy for Hinchey III Sigmoid Diverticulitis: A Decision Analysis

BACKGROUND

Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life.

OBJECTIVE

This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis.

DESIGN

We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters.

SETTING

This study measured outcomes over patients' lifetime horizon.

PATIENTS

The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned.

INTERVENTIONS

Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed.

MAIN OUTCOME MEASURES

Quality-adjusted life years were the primary outcome measured.

RESULTS

Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters.

LIMITATIONS

This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published.

CONCLUSIONS

Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.