The economics of enhanced recovery
Notice bibliographique
Résumé
Enhanced recovery after surgery (ERAS) pathways are multidisciplinary clinical care pathways incorporating multiple evidence-based interventions designed to decrease the surgical stress response, enhance recovery, and improve outcomes. Multiple randomized trials have demonstrated the clinical effectiveness of ERAS over conventional care for elective colorectal surgery, but these pathways require significant resources to design, implement, and maintain. There is little economic evidence to support ERAS, as the existing data are low quality and there are large knowledge gaps regarding post-discharge outcomes and the socioeconomic impact of ERAS. Therefore the objective was to determine the cost-effectiveness of ERAS versus conventional care for patients undergoing elective colorectal surgery.In order to adequately measure recovery, the postoperative recovery construct was conceptually defined as a multidimensional construct that followed an expected trajectory of immediate postoperative deterioration and then a gradual rehabilitation back to or surpassing preoperative baseline. This definition was used to validate the SF-6D, a multi-attribute utility instrument, as a measure of postoperative recovery and for use as the main outcome measure of the cost-effectiveness analysis. Superior validity evidence was also provided for the SF-6D over the EQ-5D, another utility instrument. A pilot study as performed to estimate the cost impact of ERAS for esophagectomy using deviation-based cost-modeling, a novel method to analyze costs and outcomes for clinical pathways. Results from this pilot study were then used for sample size calculations for the cost-effectiveness analysis comparing ERAS and conventional care for colorectal surgery.The main study was a multi-institutional prospective cohort study that recruited adult patients undergoing elective colorectal surgery over a one-year period (10/2012 to 10/2013). One centre utilized ERAS routinely and the other did not. Costs and outcomes were measured over a 60-day time horizon. A total of 190 patients (95 ERAS, 95 conventional care) participated. ERAS was associated with lower length of hospitalization, less productivity loss, less caregiver burden, and decreased outpatient resource utilization. ERAS was also associated with decreased costs from a societal perspective (mean difference -2985 CAN$, 95% CI -5753, -373), but no difference in quality-adjusted life (mean difference: +0.87 quality-adjusted days, 95% CI -1.23, 2.97) compared to conventional care. Uncertainty analysis reported that ERAS was highly probable (>98% at all willingness-to-pay thresholds) to be cost-effective. The base-case results were insensitive to multiple sensitivity scenarios and subgroup analyses. In conclusion, evidence was provided to support the cost-effectiveness of ERAS over conventional care for patients undergoing elective colorectal surgery. In particular, the analysis addressed many of the limitations of previous economic evaluations and used a validated measure for postoperative recovery as the main outcome measure. Future research should focus on the costs and benefits of ERAS on a population level. High value cost-effective healthcare can be obtained through ERAS, as it lowers costs without compromising outcomes.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,004 | 0,014 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,001 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,004 |
| Communication savante | 0,004 | 0,005 |
| Science ouverte | 0,001 | 0,003 |
| Intégrité de la recherche | 0,002 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,012 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».