Early operative management in patients with adhesive small bowel obstruction: population-based cost analysis. Issue 5 (30th June 2020)

• Record Type: Journal Article
• Authors: Behman, R; Nathens, A B; Pechlivanoglou, P; Karanicolas, P; Jung, J; Look Hong, N
• Is Part Of: BJS open. Volume 4:Issue 5(2020)
• Page Start: 914
• Page End: 923
• Publication Date: 2020-06-30
• Subjects: Surgery -- Periodicals; 617.005
• DOI: 10.1002/bjs5.50311
• Languages: English
• ISSNs: 2474-9842

Abstract

Abstract: Background: Adhesive small bowel obstruction (aSBO) is a potentially recurrent disease. Although non-operative management is often successful, it is associated with greater risk of recurrence than operative intervention, and may have greater downstream morbidity and costs. This study aimed to compare the current standard of care, trial of non-operative management (TNOM), and early operative management (EOM) for aSBO. Methods: Patients admitted to hospital between 2005 and 2014 in Ontario, Canada, with their first episode of aSBO were identified and propensity-matched on their likelihood to receive EOM for a cost–utility analysis using population-based administrative data. Patients were followed for 5 years to determine survival, recurrences, adverse events and inpatient costs to the healthcare system. Utility scores were attributed to aSBO-related events. Cost–utility was presented as the incremental cost-effectiveness ratio (ICER), expressed as Canadian dollars per quality-adjusted life-year (QALY). Results: Some 25 150 patients were admitted for aSBO and 3174 (12·6 per cent) were managed by EOM. Patients managed by TNOM were more likely to experience recurrence of aSBO (20·9 per cent versus 13·2 per cent for EOM; P < 0·001). The lower recurrence rate associated with EOM contributed to an overall net effectiveness in terms of QALYs. The mean accumulated costs for patients managed with EOM exceeded those of TNOM ($17 951 versus $11 594 (€12 288 versus €7936) respectively; P < 0·001), but the ICER for EOM versus TNOM was $29 881 (€20 454) per QALY, suggesting cost-effectiveness. Conclusion: This retrospective study, based on administrative data, documented that EOM may be a cost-effective approach for patients with aSBO in terms of QALYs. Future guidelines on the management of aSBO may also consider the long-term outcomes and costs. Graphical Abstract: This population-based cost–utility analysis compared early operative management (EOM) for adhesive small bowel obstruction (SBO) to the current standard of care of a trial of non-operative management. Although EOM was more costly, it was associated with a significantly lower risk of recurrence and reduced exposure to the morbidity and costs associated with multiple admissions for adhesive SBO. With longer follow-up, EOM becomes increasingly cost-effective, and crosses published willingness-to-pay thresholds within 5 years of the first admission. Early operative management in small bowel occlusion