Type of intervention Anaesthesia. Economic study type Cost-effectiveness analysis.

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1 Analisis de minimizacion de costes de la anestesia epidural comparada con la anestesia general en la cirugia oncologica coloproctologica [Cost analysis of the combined epidural anaesthesia in comparison with general anaesthesia in coloproctology surgery] Sabate A, Pena M J, Vila C, Alemany O Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The use of two anaesthetic procedures, a combined general-epidural anaesthesia (EA) and a general anaesthesia (GA), for patients undergoing elective coloproctologic resection and reconstruction. EA was performed using a lumbar epidural injection to inject a solution consisting of bupivacaine (1.25 mg/ml), fentanyl (7.5 microg/ml) and morphine (0.5 mg/ml) before the general anaesthesia was conducted. GA was performed using a dose of fentanyl ( microg). The doses were varied according to the weight of the patients and their age. Type of intervention Anaesthesia. Economic study type Cost-effectiveness analysis. Study population The study population comprised patients diagnosed with neoplastic process, who were undergoing elective coloproctologic resection and reconstruction. Patients were excluded if the surgical intervention was not elective, or if the coloproctologic reconstruction was performed in a second operation. Setting The setting of the study was a hospital. The study was conducted at the Department d'anestesia i Reanimacio, Ciutat Sanitoria de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain. Dates to which data relate The effectiveness evidence and data on resource use were gathered from January 1993 to December The price year was not reported. Source of effectiveness data The effectiveness data were derived from a single study. Link between effectiveness and cost data The costing was carried out prospectively on the same patient sample as that used in the effectiveness analysis. Study sample Power calculations were not carried out to determine the sample size. The study included eligible patients who were Page: 1 / 5

2 undergoing elective coloproctologic resection and reconstruction at the study institution from January 1993 to December Overall, 184 patients were identified. Of these, 29 patients (15 were men) undergoing EA and 30 patients (13 were men) undergoing GA were selected. The mean age was 68 (+/- 11) years (range: 45-87) in the EA group and 66 (+/- 12) years (range: 38-84) in the GA group. The last group of patients was selected for comparative purpose from the wider group of 154 patients undergoing GA. Originally, the patients in the EA group numbered 30, but one patient was immediately excluded from the initial sample because the outcome of the anaesthesia was not clearly assessed. Study design This was a prospective case-control study, conducted in a single centre. The 30 patients in the GA group were selected randomly from the group of 154 patients who underwent GA, in order to compare the two study groups. The patients were followed-up until discharge from the hospital. In each study group, a single anaesthetist performed the anaesthetic procedure. Analysis of effectiveness All patients included in the study were accounted for in the effectiveness analysis. The primary health outcomes assessed were: the number of blood units required during the intervention (pre-, intra-, and post-operative period); the duration of anaesthesia; the need for the surgical intensive care unit (SICU); severe adverse events, such as death; hospital stay; and the time elapsed between the end of the intervention and the first analgesic drug. The groups were shown to be comparable in terms of their demographics and clinical characteristics, such as age, gender, height, coronary pathologies, cardiac insufficiency, and diabetes mellitus. Effectiveness results The number of blood transfusions required during the intervention were 1.7 (+/- 3) in the EA group and 1.4 (+/- 1.9) in the GA group. The duration of anaesthesia was 160 (+/- 51) minutes in the EA group and 164 (+/- 43) minutes in the GA group. After the operation, 92% of the patients in the EA group and 100% of those in the GA group went to the SICU. Hospital mortality occurred in two cases, both of which were in the EA group. This was due to the failure of surgical anastomosis. Hospital stay was 13 (+/- 5) days in the EA group and 13 (+/- 6) days in the GA group. The time elapsed between the end of the intervention and the first analgesic drug was significantly higher in the EA group than in the GA group. The times elapsed were 659 (+/- 339) minutes (EA group) versus 168 (+/- 197) minutes (GA group), respectively, (p<0.001). Apart from the last outcome measure, there was no statistical difference in the remaining outcomes between the groups. Secondary outcome measures were also reported, but in general, these did not differ statistically. Page: 2 / 5

3 Clinical conclusions The authors concluded that there was no substantial difference in the effectiveness of the two anaesthetic procedures, which differed only in terms of a few outcomes. For example, the extubation process was faster and less cardiovascular drugs were consumed in the EA group, and antibiotics were used less in the GA group. Measure of benefits used in the economic analysis The health outcomes were left disaggregated and no summary benefit measure was used. Since the health outcomes were almost similar between the two study groups, the authors stated that a cost-minimisation analysis was carried out. Direct costs No discounting was carried out due to the short time horizon of the study. The unit costs and the quantities of resources were not reported separately. The cost/resource boundary adopted was that of the hospital where the study was carried out. The cost items included in the analysis were anaesthesia, intraoperative monitoring, blood transfusion, crystals used in the operation room, stay in the SICU, mechanical ventilation, eventual parenteral nutrition, physician visits, additional laboratory and diagnostic tests, specific treatments, and hospital stay. The costs occurring before and during the surgical intervention that related to the personnel, operation room and surgical materials, were not included as they were similar between the study groups. The costs and quantities of the resources used were estimated using actual data derived from the hospital where the study was conducted. The quantities of resources used were gathered from January 1993 to December The price year was not reported. Statistical analysis of costs A statistical analysis of the total costs was carried out to test for statistical significance of the results. Indirect Costs No indirect costs were included. Currency Spanish pesetas (Pta). Sensitivity analysis No sensitivity analysis was carried out. Estimated benefits used in the economic analysis See the 'Effectiveness Results' section. Cost results The total costs were Pta 433,501 (+/- 182,237) in the GA group and Pta 437,735 (+/- 149,572) in the EA group The difference was not statistically significant, (p=0.92). Synthesis of costs and benefits Not relevant. Authors' conclusions None of the two anaesthetic techniques proved to be more effective or less expensive, since no statistically significant difference was found in terms of the majority of the health outcomes and the total costs. Page: 3 / 5

4 CRD COMMENTARY - Selection of comparators The rationale for the selection of the comparators arose from debate in the literature about the potentially greater effectiveness of EA over GA. You should assess whether these techniques represent widely used health interventions in your own setting. Validity of estimate of measure of effectiveness The effectiveness analysis used a case-control study, which appears to have been appropriate. However, the main limitation to the validity of the analysis was the lack of randomisation in allocating the patients, although the authors noted that the study groups were comparable in terms of their demographics and clinical characteristics. In addition, power calculations were not performed to determine the sample size. There was no evidence that the initial study sample was appropriate for the clinical study question. Validity of estimate of measure of benefit No benefit measure was used in the economic analysis, since the differences between the health outcomes were similar between the two groups. However, the authors noted that it would have been interesting to have measured the outcomes of the interventions in terms of the gains in health, using utility measures. Validity of estimate of costs The perspective of the study appears to have been that of the hospital. Therefore, only the direct costs related to the interventions were included in the analysis. The cost items common to both procedures were not included. Statistical analyses were conducted only for the total costs. The price year was not reported. The cost estimates appear somewhat specific to the study setting. Other issues The results of the study were compared with those from some other studies. The generalisability of the study to other settings was quite limited. The authors' conclusions should be limited to the specific study population selected in the analysis. Implications of the study The study indicates that there was no difference between the two anaesthetic approaches. The authors stated that previous studies reached controversial conclusions. Source of funding Funded by the Fondo de Investigation Sanitario, Ministerio de Sandidad y Consumo, grant BAE 96/5062. Bibliographic details Sabate A, Pena M J, Vila C, Alemany O. Analisis de minimizacion de costes de la anestesia epidural comparada con la anestesia general en la cirugia oncologica coloproctologica. [Cost analysis of the combined epidural anaesthesia in comparison with general anaesthesia in coloproctology surgery] Anales de Medicina Interna 1997; 14(6): PubMedID Indexing Status Subject indexing assigned by NLM MeSH Page: 4 / 5

5 Powered by TCPDF ( Adolescent; Adult; Aged; Aged, 80 and over; Anesthesia, Epidural /economics; Anesthesia, General /economics; Colorectal Neoplasms /surgery; Costs and Cost Analysis; Female; Humans; Male; Middle Aged AccessionNumber Date bibliographic record published 30/09/2002 Date abstract record published 30/09/2002 Page: 5 / 5