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Morton AJ, Simpson A, Humes DJ. Regional variations and deprivation are linked to poorer access to laparoscopic and robotic colorectal surgery: a national study in England. Tech Coloproctol 2023; 28:9. [PMID: 38078978 PMCID: PMC10713759 DOI: 10.1007/s10151-023-02874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/18/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Laparoscopic and now robotic colorectal surgery has rapidly increased in prevalence; however, little is known about how uptake varies by region and sociodemographics. The aim of this study was to quantify the uptake of minimally invasive colorectal surgery (MIS) over time and variations by region, sociodemographics and ethnicity. METHODS Retrospective analysis of routinely collected healthcare data (Clinical Practice Research Datalink linked to Hospital Episode Statistics) for all adults having elective colorectal resectional surgery in England from 1 January 2006 to 31 March 2020. Sociodemographics between modalities were compared and the association between sociodemographic factors, region and year on MIS was compared in multivariate logistic regression analysis. RESULTS A total of 93,735 patients were included: 52,098 open, 40,622 laparoscopic and 1015 robotic cases. Laparoscopic surgery surpassed open in 2015 but has plateaued; robotic surgery has rapidly increased since 2017, representing 3.2% of cases in 2019. Absolute differences up to 20% in MIS exist between regions, OR 1.77 (95% CI 1.68-1.86) in South Central and OR 0.75 (95% CI 0.72-0.79) in the North West compared to the largest region (West Midlands). MIS was less common in the most compared to least deprived (14.6% of MIS in the most deprived, 24.8% in the least, OR 0.85 95% CI 0.81-0.89), with a greater difference in robotic surgery (13.4% vs 30.5% respectively). Female gender, younger age, less comorbidity, Asian or 'Other/Mixed' ethnicity and cancer indication were all associated with increased MIS. CONCLUSIONS MIS has increased over time, with significant regional and socioeconomic variations. With rapid increases in robotic surgery, national strategies for procurement, implementation, equitable distribution and training must be created to avoid worsening health inequalities.
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Affiliation(s)
- A J Morton
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- NIHR Nottingham BRC, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - A Simpson
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J Humes
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham BRC, University of Nottingham and Nottingham University Hospitals NHS Trust, Nottingham, UK
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Tan EJKW, Chen HLR, Chok AY, Tan IEH, Zhao Y, Lee RS, Ang KA, Au MKH, Ong HS, Ho HSS, Poopalalingam R, Tan HK, Kwek KYC. A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore. Int J Colorectal Dis 2023; 38:257. [PMID: 37882868 DOI: 10.1007/s00384-023-04551-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs. METHODS We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS. RESULTS 1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001). CONCLUSION Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.
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Affiliation(s)
- Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Hui Lionel Raphael Chen
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Rachel Shiyi Lee
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Kwok Ann Ang
- Finance, Singapore General Hospital, Singapore, 169608, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, Singhealth Community Hospitals, Singapore, 168582, Singapore
| | - Hock Soo Ong
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore, 169608, Singapore
| | - Henry Sun Sien Ho
- Department of Urology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Ruban Poopalalingam
- Department of Anesthesiology, Singapore General Hospital, Singapore, 169608, Singapore
| | - Hiang Khoon Tan
- Singapore General Hospital, Singapore, 169608, Singapore
- SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - Kenneth Yung Chiang Kwek
- Singapore General Hospital, Singapore, 169608, Singapore
- Singapore Health Services, Singapore, 168582, Singapore
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Bhimani N, Wong GY, Molloy C, Dieng M, Kelly PJ, Hugh TJ. Lifetime direct healthcare costs of treating colorectal cancer: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:513-537. [PMID: 35844018 DOI: 10.1007/s10198-022-01497-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 06/23/2022] [Indexed: 05/12/2023]
Abstract
Colorectal cancer is a global public health issue and imposes a significant economic burden on populations and healthcare systems. This paper systematically reviews the literature to estimate the direct costs of colorectal cancer incurred during different phases of treatment (initial, continuing and end of life). MEDLINE, EMBASE, Web of science, Evidence-based medicine reviews: National health service economic evaluation database guide, econlit and grey literature from the 1st of January 2000 to the 1st of February 2020. The methodological quality of the included studies was assessed using the Evers' Consensus on health economic criteria checklist. In total, 39,489 records were retrieved, and 17 studies were included. Costs by phase of treatment varied due to heterogeneity. However, studies that examined average costs for each phase of treatment showed a V-shaped distribution where the initial and end of life phases contribute the most and the continuing phase the least. The initial phase ranged from $7,893 to $60,289; the continuing annual phase ranged from $2,323 to $15,744; and the end of life phase ranged from $15,916 to $99,687. Studies that provided the total cost of each phase conversely showed that the continuing phase was the highest contributor to the cost of treating CRC. This study estimates the cost of the contemporary management of colorectal cancer despite the methodological heterogeneity. These costs place a heavy burden on healthcare providers, patients and their families. Identifying these costs can impact health care budgets and guide policymakers in making informed decisions for the future.
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Affiliation(s)
- Nazim Bhimani
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A, Acute Services Building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| | - Geoffrey Ym Wong
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A, Acute Services Building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Charles Molloy
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A, Acute Services Building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Mbathio Dieng
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Patrick J Kelly
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Thomas J Hugh
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A, Acute Services Building, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Chok AY, Zhao Y, Tan IEH, Au MKH, Tan EJKW. Cost-effectiveness comparison of minimally invasive, robotic and open approaches in colorectal surgery: a systematic review and bayesian network meta-analysis of randomized clinical trials. Int J Colorectal Dis 2023; 38:86. [PMID: 36988723 DOI: 10.1007/s00384-023-04361-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE This study compares the cost-effectiveness of open, laparoscopic (LAP), laparoscopic-assisted (LAPA), hand-assisted laparoscopic (HAL), and robotic colorectal surgery using a network meta-analysis. METHODS Randomized clinical trials (RCTs) evaluating the cost-effectiveness of comparing the five different approaches in colorectal surgery were included in a literature search until September 2022. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area (SUCRA) values, odds ratio (OR), and 95% credible intervals (CrIs) were reported for total costs, surgical costs, operating time, length of stay (LOS), and postoperative outcomes. Cluster analysis was performed to examine the similarity and classification of surgical approaches into homogeneous clusters. The cophenetic correlation coefficient (cc) was evaluated to identify the most cost-effective clustering method. The primary outcomes assessed were: costs-morbidity, costs-mortality, and costs-efficacy, measuring total costs against postoperative complications, mortality rate, and LOS, respectively. RESULTS 22 RCTs with 4239 patients were included. Open surgery had the lowest total costs, surgical costs, and operating time but the longest LOS and most postoperative complications. LOS was significantly decreased in LAP compared to open surgery (OR 0.67, 95% CrI 0.46-0.96). Robotic surgery resulted in the highest total costs, surgical costs, and most extended operative duration but the shortest LOS and lowest mortality. LAPA and robotic surgery were superior in the costs-morbidity analysis. HAL was associated with the worst costs-mortality profile. LAP, LAPA, and HAL were better in terms of costs-efficacy. CONCLUSION Overall, LAP and LAPA are the most cost-effective approaches for colorectal surgery in terms of overall postoperative complications, mortality, and LOS.
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Affiliation(s)
- Aik Yong Chok
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
| | - Yun Zhao
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Emile John Kwong Wei Tan
- Department of Colorectal Surgery, Singapore General Hospital, Academia, 20 College Road, 169856, Singapore, Singapore.
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