Introduction
Materials and methods
Design and eligibility
Economic evaluation
Resource utilization
Unit costs
Costs: calculations
Statistical analyses
Results
Main clinical findings
Characteristic | On demand | Planned |
---|---|---|
APACHE II >20, n (%)a | 16 (14) | 19 (17) |
Mannheim Peritonitis Index [28], mean (95% CI)a | 27 (23 to 32) | 29 (24 to 33) |
One or more comorbidity present, n (%)a | 64 (56) | 72 (63) |
Mortality at 1 year, n (%)b | 32 (29) | 41 (36) |
Major morbidity in survivors, n (%)c | 32 (40) | 32 (44) |
Resource utilization and costs
OD (n = 114) | PR (n = 115) | Difference (PR-OD) | ||||
---|---|---|---|---|---|---|
Unit | Mean volume | Mean costs p.p. (€) | Mean volume | Mean costs p.p.(€) | Mean costs p.p. (€) | |
Direct medical costs
| ||||||
Index admission
| ||||||
Admission | ||||||
Ward stay, index (excl ICU) | Day | 26 | 11,609 | 27 | 11,784 | 175 |
ICU stay | Day | 12 | 21,040 | 18 | 31,248 | 10,208 |
Interventions | ||||||
(re)Laparotomy | ||||||
Index laparotomy | Procedure | 1.0 | 2,267 | 1.0 | 2,267 | 0 |
Second-look | Procedure | 0.62 | 1,139 | 1.5 | 2,831 | 1,692 |
with other surgical procedures | Procedure | 0.37 | 1,211 | 0.47 | 1,543 | 332 |
Percutaneous drainage | Procedure | 0.41 | 123 | 0.67 | 199 | 84 |
Diagnostic CT and cultures | ||||||
CT | Procedure | 1.2 | 302 | 1.4 | 341 | 39 |
Microbiology | Cultures | 43 | 586 | 58 | 792 | 206 |
Medication and other materials | ||||||
Antibiotic therapy (excl ICU) | Day | 6.0 | 474 | 6.1 | 619 | 145 |
Enterostomy careb | Day | 24 | 741 | 29 | 917 | 176 |
Blood products | Unit | 0.61 | 89 | 1.04 | 178 | 89 |
Mechanical ventilation | Day | 8.3 | 3,080 | 12 | 4,360 | 1,280 |
SUBTOTAL |
42,661
|
57,079
|
14,418
| |||
Follow-up | ||||||
OD (n = 112) | PR (n = 113) | |||||
Inpatient care | ||||||
Ward stay, follow up | Day | 9.5 | 4,280 | 11.8 | 5,083 | 803 |
Elective surgery | Procedure | 0.39 | 875 | 0.51 | 1,163 | 288 |
Percutaneous drainage | Procedure | 0.08 | 24 | 0.11 | 32 | 84 |
Outpatient care | ||||||
Specialist consultationa | Visit | 16.3 | 1,297 | 16.7 | 1,333 | 36 |
CT abdomen | Procedure | 0.07 | 18 | 0.03 | 7 | -11 |
US abdomen | Procedure | 0.05 | 5 | 0.03 | 2 | -2 |
Plain radiograph | Procedure | 0.18 | 8 | 0.12 | 5 | -3 |
Enterostomy careb | Day | 140 | 4,449 | 150 | 4,767 | 318 |
Other health care providers | ||||||
Primary care physiciana | Visit | 9.4 | 194 | 8.5 | 175 | -19 |
Company doctora | Visit | 1.8 | 42 | 1.4 | 31 | -10 |
Paramedical specialista | Visit | 29 | 675 | 29 | 667 | -7 |
District nursea | Hour | 45 | 1,836 | 71 | 2,947 | 1,111 |
Rehabilitation centera | Day | 19 | 6,480 | 23 | 8,040 | 1,560 |
SUBTOTAL |
20,183
|
24,252
|
4,069
| |||
Direct nonmedical costs | ||||||
Travel costsa | Km | 395 | 71 | 393 | 71 | 0 |
Indirect costs | ||||||
Absence from paid worka | Day | 70 | 2,854 | 50 | 2,048 | -806 |
Total costs (€) |
65,768
|
83,450
|
17,682
|
Mean | Mean | % | ||||
---|---|---|---|---|---|---|
Description | OD | PR | difference | 95% CIa | Difference | |
Analysis | ||||||
Main | Main analysis (most probable assumptions) | 65,768 | 83,450 | 17,682 | (5,062 to 29,004) | 21.2% |
1 | Percutaneous drainage procedures (reimbursement fee as opposed to AMC estimate) | 65,754 | 83,428 | 17,674 | (5,057 to 28,975) | 21.2% |
2 | Ward-stay unit costs (weighted average of Academic and General hospitals)b | 62,938 | 81,016 | 18,078 | (5,437 to 28,640) | 22.3% |
3 | ICU-day unit costs (AMC top-down calculation instead of guideline) | 70,694 | 90,980 | 20,286 | (5,959 to 32,160) | 22.3% |
4 | With ICU-day unit costs estimated for | |||||
A United Kingdom | 63,235 | 79,688 | 16,453 | (4,788 to 28,439) | 20.6% | |
B Germany | 61,541 | 77,172 | 15,631 | (4,578 to 28,037) | 20.3% | |
C France | 69,102 | 88,401 | 19,299 | (5,371 to 29,721) | 21.8% | |
D Norway | 77,225 | 100,465 | 23,240 | (5,948 to 31,306) | 23.1% | |
E Austria | 63,794 | 80,518 | 16,724 | (4,851 to 28,560) | 20.8% | |
F Canada | 58,960 | 73,338 | 14,378 | (4,223 to 27,415) | 19.6% | |
5 | Exclude all costs of relaparatomy procedures | 62,543 | 77,913 | 15,370 | (3,018 to 25,395) | 19.7% |
Relaparotomy strategy | ||||||
---|---|---|---|---|---|---|
On demand | Planned | Differencea | ||||
Mean costs p.p. |
n
| Mean costs p.p. |
n
| % from planned | P valueb | |
Overall | 66,216 | 112 | 84,152 | 113 | -23.8% | |
Comorbidity | 0.26 | |||||
No | 64,948 | 48 | 89,738 | 41 | -32.8% | |
Yes | 67,168 | 64 | 80,971 | 72 | -17.1% | |
Apache II | 0.58 | |||||
11-20 | 66,956 | 96 | 84,683 | 94 | -22.3% | |
>20 | 61,777 | 16 | 81,525 | 19 | -32.3% | |
Etiology | 0.09 | |||||
Inflammation (1) | 40,810 | 4 | 81,074 | 5 | -21.7% | |
Perforation (2) | 62,236 | 63 | 88,985 | 67 | -37.0% | |
Ischemia (1) | 59,591 | 6 | 72,080 | 8 | -- | |
Anastomotic leakage (3) | 76,171 | 35 | 72,751 | 27 | 6.8% | |
Other (4) | 77,153 | 4 | 100,149 | 6 | -6.9% | |
Elimination of infectious source | 0.81 | |||||
No | 71,113 | 10 | 90,254 | 11 | -24.2% | |
Yes | 65,736 | 102 | 83,494 | 102 | -18.3% | |
Localization | 0.45 | |||||
Upper GT (1) | 69,828 | 30 | 81,146 | 27 | -25.9% | |
Lower GT (2) | 67,402 | 70 | 82,446 | 74 | -42.7% | |
Biliary tract (3) | 63,496 | 2 | 100,115 | 5 | -28.8% | |
Appendix (3) | 32,075 | 3 | 26,575 | 1 | -- | |
Pancreas (3) | 59,352 | 5 | 92,446 | 2 | -- | |
Gynecol (3) | 41,650 | 2 | 67,720 | 1 | -- | |
Other (3) | 145,821 | 3 | -- | |||
Extent of index operation | 0.49 | |||||
1 quadrant | 66,079 | 9 | 73,381 | 16 | 3.0% | |
2 quadrants | 62,439 | 34 | 84,791 | 26 | -30.6% | |
Diffuse | 68,096 | 70 | 86,102 | 69 | -24.8% | |
Nature of contamination | 0.18 | |||||
Clear (1) | 59,306 | 6 | 97,791 | 8 | -25.9% | |
Turbid (2) | 57,179 | 18 | 96,672 | 29 | -42.7% | |
Purulent (3) | 55,746 | 43 | 77,003 | 30 | -28.8% | |
Fecal (4) | 84,707 | 41 | 81,977 | 41 | -2.4% | |
Bile (3) | 40,281 | 4 | 61,984 | 3 | - | |
Survival (at 12 mo) | ||||||
No | 73,275 | 80 | 85,326 | 72 | -17.8% | 0.13 |
Yes | 48,569 | 32 | 82,089 | 41 | -38.6% |
Discussion
Conclusions
Key messages
-
Patients with severe peritonitis require intensive monitoring and medical treatment, often including lengthy ICU stays, and therefore incur substantial costs to the healthcare system.
-
The first randomized clinical trial comparing on-demand versus a planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary clinical outcomes.
-
To assess the economic impact of differences in resource use, we performed a full economic evaluation from a societal perspective alongside this trial.
-
Mean total costs per patient were 20% lower in the on-demand group as compared with the planned group.
-
The substantial difference in costs renders the on-demand strategy a far more efficient relaparotomy strategy in patients with severe peritonitis.