- Email: [email protected]
The impact of laparoscopic cholecystectomy in Canada and Australia
Health
Policy 26 (1994) 221-230
The impact of laparoscopic cholecystectomy Canada and Australia Deborah
Marshall”,
in
Edie Clarkb, David Hailey*’
“Swedish Council on Technology Assessment in Health Care, Slockholm. Sweden hCanadian Coordinating Officefor Health Technology Assessmenl. Ottawa. Canada “Australian fnstirure of Health and Welfare. GPO BO.Y570, Canherru. ACT 2601. Auslralitr (Accepted
I5 September
1993)
Abstract
The introduction of laparoscopic cholecystectomy in Canada and Australia has been associated in each country with an increase in the rates of all cholecystectomies following a period
where these had remained constant. Estimated costs of cholecystectomies to health programs declined by about 13% in Canada after the laparoscopic procedure became widely available, and by about 2% in Australia. Days lost to patients because of surgery, and associated costs to them, decreased in each country. Neither country is realising the potential savings through use of laparoscopic cholecystectomy because of the increase in the number of procedures. The utility of these additional operations remains unclear. These trends associated with the advent of laparoscopic cholecystectomy suggest the need for caution in the introduction and application of other minimal-access surgery techniques. Key word.7: Laparoscopic
surgery; Cholecystectomy;
Impact;
Costs
1. Introduction
Laparoscopic cholecystectomy has become widely established in western countries and is increasingly regarded as the method of choice for treatment of most patients with symptomatic gallstone disease. It provides a less invasive alternative to open surgery for removal of the gallbladder. Access to the operating field is obtained through four small incisions in the abdomen. In a small proportion of cases surgery * Corresponding
author
0168-8510/94/$06.00 0 1994 Elsevier Scientific Publishers Ireland Ltd. All rights reserved SSDI 0168-8510(93)00590-W
222
D. Marshall et al. /Health Policy 26 (1994) 221-230
cannot be completed laparoscopically and the procedure has to be converted to an open operation. The technique points the way to replacement of other open surgical procedures with laparoscopic and other minimally invasive approaches. In both Canada and Australia the diffusion of the technique has been rapid, with minimal regulatory delay and prior to formal proof of effectiveness or assurance of appropriate training for surgeons and other hospital staff. Laparoscopic cholecystectomy has been promoted as offering benefits through shorter hospital stay, faster return to normal activities and decreased costs to health care systems. An early report suggested that the laparoscopic method is costeffective in comparison with open cholecystectomy [ 11, and this has been supported by a more recent study [2]. A modelling approach [3] has suggested that laparoscopit cholecystectomy is likely to be less costly and more effective for most patients, provided it is not associated with routine postoperative tests, higher fees or increased risk of complications. However, there are still few data on how the introduction of the technique has broadly affected health care in different countries or how various issues related more generally to laparoscopic surgery [4], including changes to training and infrastructure, have been addressed. In this paper we present a summary of a preliminary analysis of the impact of laparoscopic cholecystectomy in Canada and Australia. The focus is on the effect of its introduction on rates of procedures for removal of the gallbladder, costs to health programs and costs to patients. 2. Methods The approach taken was to obtain data on numbers of cholecystectomies undertaken annually before and after the introduction of laparoscopic cholecystectomy, and to estimate the costs of these procedures to health programs and patients. Nationwide data on a newly introduced technique such as laparoscopic cholecystectomy are not readily available. This preliminary analysis has relied on information obtained directly from hospitals and on projections from existing data bases, including those held by Ministries of Health. A number of assumptions were made to derive a broad perspective of current developments. 2.1. Canada Data on total numbers of cholecystectomies undertaken in Canada from 1987/88 to 1991/92 were obtained by survey from all provincial and territorial Ministries of Health, and population data from Statistics Canada. Further data were obtained through two surveys of individual hospitals undertaken by the Canadian Coordinating Office for Health Technology Assessment. The first of these measured the diffusion of laparoscopic cholecystectomy throughout Canada [5], obtaining data on the numbers of hospitals that were performing or planning to perform this technique. In the second survey, data were obtained for the years 1987/88 to 1991192 from 21 hospitals on the average length of stay (ALOS) and post-hospital recovery time for open and laparoscopic cholecystectomy; the numbers of laparoscopic, converted
D. Marshall et al. /Health Policy 26 (1994) 221-230
223
laparoscopic and open procedures; complications that led to hospital stay of more than 1 month; and costs of hospital stay, fees, surgery and diagnostic procedures. Information on professional fees was also obtained from Ministries of Health. Data obtained and derived from the surveys were extrapolated to give national estimates, using information from Ministries of Health on total numbers of cholecystectomies performed. 2.2. Australia
Information on total numbers of cholecystectomies performed in Australia, and associated ALOS, was obtained from collections of hospital morbidity data (HMD) made available by state health authorities. Data were available for New South Wales and South Australia for 1988/89 and 1991/92, corresponding to the periods immediately prior to introduction of laparoscopic cholecystectomy and after diffusion of the technique had occurred to a significant extent. National estimates for numbers of procedures were derived by multiplying the totals for these states by appropriate population ratios obtained from the Australian Bureau of Statistics and taking account of known inter-state variation in rates of surgery [6]. Data for ALOS prior to the introduction of laparoscopic cholecystectomy were based on the available HMD figures, adjusted to take account of known variations in ALOS between states [7] and population factors. Estimates for ALOS for the different types of procedure following introduction of laparoscopic cholecystectomy and time for patients to return to normal activity were based on data from recent Australian assessments [8,9]. Data on cholecystectomies performed on a fee-for-service basis and that attracted Medicare Benefits were obtained from the Health Insurance Commission (HIC) for 1987/88 to 1991192, with individual totals for laparoscopic, converted laparoscopic and open procedures for 1990/91 and 1991192. Numbers of non-fee-for-service cases were obtained by subtracting the HIC totals for 1988/89 and 1991192 from the HMD totals for those years. It was assumed that the proportions of open, laparoscopic and converted procedures shown by the HIC data were applicable to procedures on non-fee-for-service patients. Data made available by four major teaching hospitals suggested that this was a reasonable assumption. Costs of procedures performed on a fee-for-service basis were derived using Medicare Benefits Schedule fees adjusted to reflect actual fees charged [lo], and costs per average hospital bed-day published by the Australian Institute of Health and Welfare [7]. Costs of procedures in non-fee-for-service cases were based on those obtained in a recent assessment [9]. 2.3. Both countries
In order to obtain a general indication of levels of cost to patients through surgery, data from a recent Australian study were applied to each country. Estimates of costs to patients, comprising those due to loss of employment, home duties, leisure activities and costs of carers, were based on an analysis by Street [I 11, which related to
D. Marshall et al. /Health Policy 26 (1994) 221-230
224
patients at a Melbourne hospital. The analysis by Street derived estimates for costs to patients of open cholecystectomy of $A3232-4337, with a corresponding range of $A141 6- 1831 for laparoscopic cholecystectomy. It was assumed that the levels of cost derived by Street were broadly applicable to both Australian and Canadian populations. For each country these estimates were adjusted to take account of data that were obtained from hospitals on ALOS and time for patients to return to normal activity. For each country, numbers of procedures were adjusted to a constant-population basis (1987/88) and all costs to 1991/92 dollars. Costs of disposable instruments were not included. 3. Results Numbers of procedures for each country between 1987/88 and 1991/92 are shown in Table 1. The laparoscopic technique was introduced in Canada in the latter half of 1990 and in February of that year in Australia. In both countries, rates for all cholecystectomies increased markedly after the laparoscopic method became available, following a period where surgery rates had shown little or no increase. The increases were 17 and 26% for Canada and Australia, respectively. Within the Australian data, numbers of procedures performed on a fee-for-service basis increased by 48% following the introduction of laparoscopic cholecystectomy. The higher proportion of laparoscopic procedures in the Australian data may reflect the earlier introduction of the technique in that country. There was a striking difference between the two countries in the proportion of laparoscopic procedures that were converted to open operations. The Australian rate of 14.3% is substantially higher than published values, while the Canadian rate of 4.2% is more typical of experience in other countries. Table I Numbers of cholecystectomy procedures, Canada and Australia Year
Open procedures
Laparoscopic procedures
1987188 1988/89 I989190 l990/9 I 1991192
55 900 55 491 56 954 54 856 31 743
-
I987/88 1988/89 1989/90 199019I 1991192
27 I05 2-l 050 26 564 24 369 9042
Converted laparoscopic procedures
Total cholecystectomies
Canada
4684 32 439
129 1418
55 900 55 491 56 954 59 669 65 600
531 3588
21 I05 27 050 26 564 28 397 34 134
Australia
3221 21 504
D. Marshall
et al. 1 Health
Table 2 Total hospital
bed-days
Policy
and estimated
Annual bed-days, 1987/88 Annual bed-days, I99 l/92 Ratio of bed-days, 1991192 Total costs, 1987188 Total costs, 1991192 Ratio of costs, 1991/92
26 (1994)
221-230
costs to health
: 1987/88
: 1987/88
225
programs
associated
with cholecystectomies
Canada
Australia
537 199 367 997 0.69
260 208 232 I IO 0.89
$C 273 M $C 231 M 0.87
$A 124 M $A I21 M 0.98
Total hospital bed-days and costs to health programs of cholecystectomies are shown in Table 2. In both countries, numbers of bed-days decreased following introduction of the new method. Cost to health programs also decreased, though only marginally in Australia, with reduction in bed-day costs being apparently offset by higher fees and equipment costs associated with laparoscopic cholecystectomy. Preliminary estimates of current costs per patient to health programs for open cholecystectomy in each country are $C4890 (Canada) and $A5000 (Australia). The corresponding estimates for laparoscopic cholecystectomy are $C23 10 (Canada) and $A2750 (Australia). In societal terms, an important component of the impact of laparoscopic cholecystectomy is the effect on time lost by patients through hospitalisation and on their return to normal activities after discharge. Table 3 gives values for days lost to patients through surgery, calculated using information from the Canadian survey and Australian hospital data, and the associated costs, using the estimates derived by Street [ 111. For both countries, availability of the laparoscopic procedure was associated with significant savings to patients with reductions in days lost and associated costs. A further consideration in assessing the impact of laparoscopic cholecystectomy is the extent to which potential savings through use of the technique have been
Table 3 Estimates
of days lost and costs to patients Patient-days
Year
1987/88 1991192 Ratio, 1991/92
: 1987/88
“Ranges
derived
from cholecystectomies Cost to patients”
lost
Canada
Australia
Canada
(SC)
Australia
($A)
2.5 M 1.9 M
1.4 M I.1 M
201-274 163-218
M M
114-154 85-113
M M
0.76
0.79
0.80
from the estimates
of Street
[I I].
0.74
D. Marshall et al. /Health Policy 26 (1994) 221-230
226
Table 4 Proportion of potential savings achieved for health program costs and patient-days lost
Costs, 1987/88 Potential costs, 1991/92 Actual costs, 1991/92 Proportion of potential savings achieved Patient-days lost, 1987/88 Potential patient-days lost, 1991/92 Actual patient-days lost, 1991/92 Proportion of potential savings achieved
Canada ($C)
Australia ($A)
273 M 214 M 237 M 61% (Million days) 2.5 1.7 1.9 75%
124 M 100 M I21 M 13% (Million days) 1.4 0.9 I.1 60%
achieved. In each country, rates of cholecystectomy were stable prior to the introduction of the laparoscopic technique and can be taken as a baseline. A simple approach to estimating savings is to compare the actual differences in costs before and after introduction of laparoscopic cholecystectomy with those had there been no increase in the number of procedures. Table 4 compares actual costs to health programs and patient-days lost in 1991/92 with the corresponding values had there been no increase in the rate for all cholecystectomies from that in 1987/88. For this analysis it was assumed that all the procedures additional to those corresponding to the 1987188 rate of surgery were undertaken laparoscopically. Because of the overall increase in the rates of surgery since the introduction of laparoscopic cholecystectomy, neither country is realising the potential savings that introduction of the new method might achieve. Canada appears to have achieved over half the potential savings in health program costs, while those for Australia are more limited. Both countries have made gains through reducing patient-days lost, but the overall increase in number of procedures limits the benefit achieved.
Table 5 Sensitivity analysis for estimates of health program costs and proportion of potential savings achieved Variable
Proportion of laparoscopic procedures ( f 10%) ALOS (f I day) Non-LOS-related hospital costs (f 20%)
Ratio of health program costs, postlap. to prelap.
Percentage of potential savings achieved
Canada
Australia
Canada
Australia
0.84-0.90
0.95-I .02
37-67
-19-23
0.85-0.89
0.95-0.99
52-63
4-24
0.85-0.88
0.95-0.99
55-61
4-24
D. Marshall et al. /Health Policy 26 (1994) 221-230
721
Table 5 presents the results of a brief sensitivity analysis of the estimates of costs to health programs and the proportion of potential savings achieved. The proportions of laparoscopic procedures undertaken were varied by f lo%, ALOS by f 1 day and non-length-of-stay-related hospital costs by +20%. The limits chosen for each variable reflected the distribution of data from hospitals in the Canadian surveys and Australian data bases. The results suggest that the estimates for ratios of health program costs before and after introduction of laparoscopic cholecystectomy are reasonably robust. Greater variation is seen in the estimates for potential savings achieved, though the overall impression of a high proportion of savings forgone remains unchanged. Cost of cholecystectomies will include a component due to complications. There is considerable interest in defining the rates of major complications for laparoscopic surgery in comparison with those for open procedures, particularly with reference to the size of the centre performing the surgery and levels of training. Data on complication rates remain sparse, and there are no standard detinitions on what is considered a complication. The limited data available from the survey of Canadian hospitals showed a higher rate of complications associated with cholecystectomy following introduction of the laparoscopic procedure. However, the rate of major complications following laparoscopic cholecystectomy (7.4%) was lower than that after open surgery ( 12.0%). Data on complications were not available for Australia. The hospital morbidity data show that for all values of length of stay of more than 8 days there were lower proportions of cases in 1991/92 than in 1989/90, suggesting an overall decrease in morbidity following introduction of laparoscopic surgery. 4. Discussion The results presented here are from a preliminary analysis of the impact of laparoscopic cholecystectomy during the initial diffusion of this technique. A number of assumptions were made in order to derive estimates from national perspectives. For both countries, data on numbers of laparoscopic procedures, ALOS and hospital costs were incomplete. It was assumed that the projections made from various available data bases reflected the national values. Many of the data were obtained by survey and have the inherent problems of bias and generalisability associated with such an approach. There is a further difficulty in making comparisons between two countries that differ in their health care systems and in the types of statistics that are available. The estimates of costs to patients can provide only a very approximate indication of levels of impact. Nevertheless, we suggest that this study has given a useful general perspective on some trends that have emerged during the introduction of this minimal-access surgery technique. In both countries the introduction of the laparoscopic technique for cholecystectomy has been associated with an increase in the total number of cholecystectomies performed. The increases are striking, as they follow a period of several years when rates for cholecystectomies had been steady. This increase in numbers of procedures has offset the savings expected from laparoscopic cholecystectomy through reduc-
228
D. Marshall et al. /Health Policy 26 (1994) 221-230
tion in ALOS. A crude estimate is that only 61% of potential savings to health programs has been achieved in Canada, and 13% in Australia. These may be optimistic estimates of savings, as no provision has been made for use of disposable instruments, which would have been used in laparoscopic cholecystectomy for a certain proportion of cases. While the relative overall costs of disposable and reusable instruments do not seem to have been well defined, use of disposable equipment at a cost of up to $700 per procedure in Canada ($600 in Australia) might be expected to increase the cost of laparoscopic surgery. Reduction in numbers of days lost to patients through surgery and associated costs to them have been achieved in both countries, but potential savings have not been fully realised, again because of the overall increase in the number of procedures. The estimates in this paper of potential and actual savings achieved through introduction of laparoscopic cholecystectomy have been derived making the assumptions that rates of gallstone disease have not undergone any recent change and that the rates of surgery prior to 1990/9 1 were appropriate for management of this condition. It is recognised that this may be a simplistic approach and that there is a need to consider in more detail the reasons for the recent increase in rates of cholecystectomies. The trend to higher rates of surgery was established very rapidly in both Canada and Australia. While further study is required, it seems possible that four factors may have contributed to this trend. Firstly, in a proportion of cases, the availability of the laparoscopic technique means that treatment may be offered to frailer patients who would not otherwise be candidates for surgery. Extending the availability of treatment in this way is an important gain offered by minimally invasive therapies, and has been demonstrated, for example, in the application of renal lithotripsy. However, a difficulty in this case is that a proportion of laparoscopic procedures will be completed as open surgery, so that careful judgement in patient selection would be needed. As an extension to this situation, the availability of laparoscopic cholecystectomy may tend to increase the probability of surgical intervention in symptomatic patients who are potential candidates for open surgery, and decrease the likelihood of conservative management. The new technique may be seen as providing a better opportunity to definitively resolve a clinical problem. A further possibility is that the technique is being offered in asymptomatic cases, for example when gallstones are detected opportunistically during an unrelated imaging examination. The rationale for cholecystectomy in such circumstances would appear to require very careful consideration, including appraisal of the relative risks to the patient of watchful waiting as against laparoscopic surgery. Finally, laparoscopic cholecystectomy is possibly being offered following inappropriate diagnosis. Spiro [12] has considered the situation where symptoms remain after surgery has been undertaken, when part of the rationale for surgery was that the new procedure was much less invasive. The possibility of this category of surgical intervention points to the need for adequate training and appropriate guidelines for physicians and surgeons in this field. These possibilities will tend to be driven by the awareness by the public of the availability of less invasive surgery and a wish by health professionals to extend use
D. Marshall et al. / Health Policy 26 (1994) 221-230
229
of the technology to new applications. The utility of these additional surgical procedures remains unclear, and further clinical and economic studies would be highly desirable. In Australia a high proportion of laparoscopic cholecystectomies are converted to open operations, with associated increase in hospital stay (and in time taken to return to normal activity). Debate continues about what might be an appropriate proportion of conversions to open surgery. and a very low rate could be associated with unacceptable risks to patients. However, the Australian conversion rates are high in comparison with results from other countries, for reasons that are not clear. The difference between the Australian and Canadian data on the proportion of conversions points to the need for a definition of appropriate standards for laparoscopic procedures, including case selection and training. It will be of some interest to observe whether the Australian conversion rate declines in the future. The subsequent trends in the proportion of cholecystectomies undertaken laparoscopically and in ALOS will also be of interest. The data available for the study reported here suggested that diffusion of laparoscopic cholecystectomy in Canada was still at a relatively early stage, and that the technique will spread more widely. In Australia by late 1992 all major hospitals and the majority of minor centres had acquired the technique (Royal Australasian College of Surgeons, personal communication), but some further increase in the proportion of laparoscopic cholecystectomies undertaken seems likely. Information obtained from hospitals in each country suggests that ALOS for laparoscopic cholecystectomy is continuing to decrease as further experience is gained with the technique and hospitals undertake restructuring. There may well be further decreases in the short to medium term, with a proportion of laparoscopic procedures being carried out as day surgery. This would lead to a consequent decrease in costs to health programs beyond the estimates presented in this paper, which reflect early national experience with the technique. For the full benefits of any such trends to be realised it will clearly be necessary for appropriate postdischarge support systems for patients to be in place as well as back-up for those procedures that are converted to open surgery. Further changes to the ALOS for laparoscopic surgery and any trend towards performance outside the acute hospital setting will increase the need for more accurate information on complications. Problems through complications associated with laparoscopic cholecystectomy, such as bile duct injury, were not revealed through the data available for this study. The experience of Canada and Australia suggests that the introduction of laparoscopic cholecystectomy has produced benefits, though these have been less than optimum. The increase in the rates of cholecystectomies that has been observed suggests the need for appropriate trials, clear guidelines and adequate standards of training for other minimal-access surgical techniques. 5. Acknowledgements
We are most grateful to Mr Dennis Lowe, MS Naarilla Hirsch and Mr Wolodja Dankiw for assistance in provision of data and for helpful comments.
D. Marshall et al. /Health Policy 26 (1994)
230
221-230
6. References 1 2
3 4 5 6
Peters, J., Ellison, E.C., Innes, J.T., et al.. Safety and efficacy of laparoscopic cholecystectomy: a prospective analysis of 100 initial patients, Annals of Surgery, 213 (1991) 3-12. Kelley, J.E., Burrus, G.R., Burns, P.R.. Graham, L.D.. and Chandler, K.E., Safety, efftcacy, cost and morbidity of laparoscopic versus open cholecystectomy: a prospective analysis of 228 consecutive patients, American Surgeon, 59 (1993) 23-27. Bass. E.B., Pitt, H.A., and Lillemoe, K.D.. Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy, American Journal of Surgery, 165 (1993) 466-471. Hailey, D.M., and Hirsch, N.A., Laparoscopic surgery: some unresolved issues, Medical Journal of Australia, I57 (1993) 58 l-582. Menon, D., and Marshall, D., Laparoscopic cholecystectomy diffusion in Canada, International Journal of Technology Assessment in Health Care, in press. Renwick, M.. and Sadkowsky, K., Variations in Surgery Rates (Health Services Series, no. 2). Australian Institute of Health and Welfare, Canberra, 1992. Gillett, S., Liu, Z., and Solon, R., Hospital Utilisation and Costs Study, 1989-90 (Health Services Series, no. 4) Australian Institute of Health and Welfare, Canberra, 1993. Cook, J., Richardson, J., and Street, A., Cost utility analysis of treatment options for gallstone disease: preliminary results and methodological issues. In C. Selby Smith (Ed.), Economics and Health, 1992, Monash University, National Centre for Health Program Evaluation, Melbourne, 1993, pp. 244-215. St Vincent’s Hospital, Melbourne, Biliary Lithotripsy Assessment Program: Final Report, Australian Institute of Health and Welfare. Canberra, 1993. Australian Institute of Health and Welfare, Australia’s Health, 1992, Australian Government Publishing Service, Canberra, 1992. p. 141. Street, A., Gallstone Disease: the Cost of Treatment (Working paper no. 29). National Centre for Health Program Evaluation, Melbourne, 1993. Spiro, H.M., Diagnostic laparoscopic cholecystectomy, Lancet. 339 (1992) 167-168.
Policy 26 (1994) 221-230
The impact of laparoscopic cholecystectomy Canada and Australia Deborah
Marshall”,
in
Edie Clarkb, David Hailey*’
“Swedish Council on Technology Assessment in Health Care, Slockholm. Sweden hCanadian Coordinating Officefor Health Technology Assessmenl. Ottawa. Canada “Australian fnstirure of Health and Welfare. GPO BO.Y570, Canherru. ACT 2601. Auslralitr (Accepted
I5 September
1993)
Abstract
The introduction of laparoscopic cholecystectomy in Canada and Australia has been associated in each country with an increase in the rates of all cholecystectomies following a period
where these had remained constant. Estimated costs of cholecystectomies to health programs declined by about 13% in Canada after the laparoscopic procedure became widely available, and by about 2% in Australia. Days lost to patients because of surgery, and associated costs to them, decreased in each country. Neither country is realising the potential savings through use of laparoscopic cholecystectomy because of the increase in the number of procedures. The utility of these additional operations remains unclear. These trends associated with the advent of laparoscopic cholecystectomy suggest the need for caution in the introduction and application of other minimal-access surgery techniques. Key word.7: Laparoscopic
surgery; Cholecystectomy;
Impact;
Costs
1. Introduction
Laparoscopic cholecystectomy has become widely established in western countries and is increasingly regarded as the method of choice for treatment of most patients with symptomatic gallstone disease. It provides a less invasive alternative to open surgery for removal of the gallbladder. Access to the operating field is obtained through four small incisions in the abdomen. In a small proportion of cases surgery * Corresponding
author
0168-8510/94/$06.00 0 1994 Elsevier Scientific Publishers Ireland Ltd. All rights reserved SSDI 0168-8510(93)00590-W
222
D. Marshall et al. /Health Policy 26 (1994) 221-230
cannot be completed laparoscopically and the procedure has to be converted to an open operation. The technique points the way to replacement of other open surgical procedures with laparoscopic and other minimally invasive approaches. In both Canada and Australia the diffusion of the technique has been rapid, with minimal regulatory delay and prior to formal proof of effectiveness or assurance of appropriate training for surgeons and other hospital staff. Laparoscopic cholecystectomy has been promoted as offering benefits through shorter hospital stay, faster return to normal activities and decreased costs to health care systems. An early report suggested that the laparoscopic method is costeffective in comparison with open cholecystectomy [ 11, and this has been supported by a more recent study [2]. A modelling approach [3] has suggested that laparoscopit cholecystectomy is likely to be less costly and more effective for most patients, provided it is not associated with routine postoperative tests, higher fees or increased risk of complications. However, there are still few data on how the introduction of the technique has broadly affected health care in different countries or how various issues related more generally to laparoscopic surgery [4], including changes to training and infrastructure, have been addressed. In this paper we present a summary of a preliminary analysis of the impact of laparoscopic cholecystectomy in Canada and Australia. The focus is on the effect of its introduction on rates of procedures for removal of the gallbladder, costs to health programs and costs to patients. 2. Methods The approach taken was to obtain data on numbers of cholecystectomies undertaken annually before and after the introduction of laparoscopic cholecystectomy, and to estimate the costs of these procedures to health programs and patients. Nationwide data on a newly introduced technique such as laparoscopic cholecystectomy are not readily available. This preliminary analysis has relied on information obtained directly from hospitals and on projections from existing data bases, including those held by Ministries of Health. A number of assumptions were made to derive a broad perspective of current developments. 2.1. Canada Data on total numbers of cholecystectomies undertaken in Canada from 1987/88 to 1991/92 were obtained by survey from all provincial and territorial Ministries of Health, and population data from Statistics Canada. Further data were obtained through two surveys of individual hospitals undertaken by the Canadian Coordinating Office for Health Technology Assessment. The first of these measured the diffusion of laparoscopic cholecystectomy throughout Canada [5], obtaining data on the numbers of hospitals that were performing or planning to perform this technique. In the second survey, data were obtained for the years 1987/88 to 1991192 from 21 hospitals on the average length of stay (ALOS) and post-hospital recovery time for open and laparoscopic cholecystectomy; the numbers of laparoscopic, converted
D. Marshall et al. /Health Policy 26 (1994) 221-230
223
laparoscopic and open procedures; complications that led to hospital stay of more than 1 month; and costs of hospital stay, fees, surgery and diagnostic procedures. Information on professional fees was also obtained from Ministries of Health. Data obtained and derived from the surveys were extrapolated to give national estimates, using information from Ministries of Health on total numbers of cholecystectomies performed. 2.2. Australia
Information on total numbers of cholecystectomies performed in Australia, and associated ALOS, was obtained from collections of hospital morbidity data (HMD) made available by state health authorities. Data were available for New South Wales and South Australia for 1988/89 and 1991/92, corresponding to the periods immediately prior to introduction of laparoscopic cholecystectomy and after diffusion of the technique had occurred to a significant extent. National estimates for numbers of procedures were derived by multiplying the totals for these states by appropriate population ratios obtained from the Australian Bureau of Statistics and taking account of known inter-state variation in rates of surgery [6]. Data for ALOS prior to the introduction of laparoscopic cholecystectomy were based on the available HMD figures, adjusted to take account of known variations in ALOS between states [7] and population factors. Estimates for ALOS for the different types of procedure following introduction of laparoscopic cholecystectomy and time for patients to return to normal activity were based on data from recent Australian assessments [8,9]. Data on cholecystectomies performed on a fee-for-service basis and that attracted Medicare Benefits were obtained from the Health Insurance Commission (HIC) for 1987/88 to 1991192, with individual totals for laparoscopic, converted laparoscopic and open procedures for 1990/91 and 1991192. Numbers of non-fee-for-service cases were obtained by subtracting the HIC totals for 1988/89 and 1991192 from the HMD totals for those years. It was assumed that the proportions of open, laparoscopic and converted procedures shown by the HIC data were applicable to procedures on non-fee-for-service patients. Data made available by four major teaching hospitals suggested that this was a reasonable assumption. Costs of procedures performed on a fee-for-service basis were derived using Medicare Benefits Schedule fees adjusted to reflect actual fees charged [lo], and costs per average hospital bed-day published by the Australian Institute of Health and Welfare [7]. Costs of procedures in non-fee-for-service cases were based on those obtained in a recent assessment [9]. 2.3. Both countries
In order to obtain a general indication of levels of cost to patients through surgery, data from a recent Australian study were applied to each country. Estimates of costs to patients, comprising those due to loss of employment, home duties, leisure activities and costs of carers, were based on an analysis by Street [I 11, which related to
D. Marshall et al. /Health Policy 26 (1994) 221-230
224
patients at a Melbourne hospital. The analysis by Street derived estimates for costs to patients of open cholecystectomy of $A3232-4337, with a corresponding range of $A141 6- 1831 for laparoscopic cholecystectomy. It was assumed that the levels of cost derived by Street were broadly applicable to both Australian and Canadian populations. For each country these estimates were adjusted to take account of data that were obtained from hospitals on ALOS and time for patients to return to normal activity. For each country, numbers of procedures were adjusted to a constant-population basis (1987/88) and all costs to 1991/92 dollars. Costs of disposable instruments were not included. 3. Results Numbers of procedures for each country between 1987/88 and 1991/92 are shown in Table 1. The laparoscopic technique was introduced in Canada in the latter half of 1990 and in February of that year in Australia. In both countries, rates for all cholecystectomies increased markedly after the laparoscopic method became available, following a period where surgery rates had shown little or no increase. The increases were 17 and 26% for Canada and Australia, respectively. Within the Australian data, numbers of procedures performed on a fee-for-service basis increased by 48% following the introduction of laparoscopic cholecystectomy. The higher proportion of laparoscopic procedures in the Australian data may reflect the earlier introduction of the technique in that country. There was a striking difference between the two countries in the proportion of laparoscopic procedures that were converted to open operations. The Australian rate of 14.3% is substantially higher than published values, while the Canadian rate of 4.2% is more typical of experience in other countries. Table I Numbers of cholecystectomy procedures, Canada and Australia Year
Open procedures
Laparoscopic procedures
1987188 1988/89 I989190 l990/9 I 1991192
55 900 55 491 56 954 54 856 31 743
-
I987/88 1988/89 1989/90 199019I 1991192
27 I05 2-l 050 26 564 24 369 9042
Converted laparoscopic procedures
Total cholecystectomies
Canada
4684 32 439
129 1418
55 900 55 491 56 954 59 669 65 600
531 3588
21 I05 27 050 26 564 28 397 34 134
Australia
3221 21 504
D. Marshall
et al. 1 Health
Table 2 Total hospital
bed-days
Policy
and estimated
Annual bed-days, 1987/88 Annual bed-days, I99 l/92 Ratio of bed-days, 1991192 Total costs, 1987188 Total costs, 1991192 Ratio of costs, 1991/92
26 (1994)
221-230
costs to health
: 1987/88
: 1987/88
225
programs
associated
with cholecystectomies
Canada
Australia
537 199 367 997 0.69
260 208 232 I IO 0.89
$C 273 M $C 231 M 0.87
$A 124 M $A I21 M 0.98
Total hospital bed-days and costs to health programs of cholecystectomies are shown in Table 2. In both countries, numbers of bed-days decreased following introduction of the new method. Cost to health programs also decreased, though only marginally in Australia, with reduction in bed-day costs being apparently offset by higher fees and equipment costs associated with laparoscopic cholecystectomy. Preliminary estimates of current costs per patient to health programs for open cholecystectomy in each country are $C4890 (Canada) and $A5000 (Australia). The corresponding estimates for laparoscopic cholecystectomy are $C23 10 (Canada) and $A2750 (Australia). In societal terms, an important component of the impact of laparoscopic cholecystectomy is the effect on time lost by patients through hospitalisation and on their return to normal activities after discharge. Table 3 gives values for days lost to patients through surgery, calculated using information from the Canadian survey and Australian hospital data, and the associated costs, using the estimates derived by Street [ 111. For both countries, availability of the laparoscopic procedure was associated with significant savings to patients with reductions in days lost and associated costs. A further consideration in assessing the impact of laparoscopic cholecystectomy is the extent to which potential savings through use of the technique have been
Table 3 Estimates
of days lost and costs to patients Patient-days
Year
1987/88 1991192 Ratio, 1991/92
: 1987/88
“Ranges
derived
from cholecystectomies Cost to patients”
lost
Canada
Australia
Canada
(SC)
Australia
($A)
2.5 M 1.9 M
1.4 M I.1 M
201-274 163-218
M M
114-154 85-113
M M
0.76
0.79
0.80
from the estimates
of Street
[I I].
0.74
D. Marshall et al. /Health Policy 26 (1994) 221-230
226
Table 4 Proportion of potential savings achieved for health program costs and patient-days lost
Costs, 1987/88 Potential costs, 1991/92 Actual costs, 1991/92 Proportion of potential savings achieved Patient-days lost, 1987/88 Potential patient-days lost, 1991/92 Actual patient-days lost, 1991/92 Proportion of potential savings achieved
Canada ($C)
Australia ($A)
273 M 214 M 237 M 61% (Million days) 2.5 1.7 1.9 75%
124 M 100 M I21 M 13% (Million days) 1.4 0.9 I.1 60%
achieved. In each country, rates of cholecystectomy were stable prior to the introduction of the laparoscopic technique and can be taken as a baseline. A simple approach to estimating savings is to compare the actual differences in costs before and after introduction of laparoscopic cholecystectomy with those had there been no increase in the number of procedures. Table 4 compares actual costs to health programs and patient-days lost in 1991/92 with the corresponding values had there been no increase in the rate for all cholecystectomies from that in 1987/88. For this analysis it was assumed that all the procedures additional to those corresponding to the 1987188 rate of surgery were undertaken laparoscopically. Because of the overall increase in the rates of surgery since the introduction of laparoscopic cholecystectomy, neither country is realising the potential savings that introduction of the new method might achieve. Canada appears to have achieved over half the potential savings in health program costs, while those for Australia are more limited. Both countries have made gains through reducing patient-days lost, but the overall increase in number of procedures limits the benefit achieved.
Table 5 Sensitivity analysis for estimates of health program costs and proportion of potential savings achieved Variable
Proportion of laparoscopic procedures ( f 10%) ALOS (f I day) Non-LOS-related hospital costs (f 20%)
Ratio of health program costs, postlap. to prelap.
Percentage of potential savings achieved
Canada
Australia
Canada
Australia
0.84-0.90
0.95-I .02
37-67
-19-23
0.85-0.89
0.95-0.99
52-63
4-24
0.85-0.88
0.95-0.99
55-61
4-24
D. Marshall et al. /Health Policy 26 (1994) 221-230
721
Table 5 presents the results of a brief sensitivity analysis of the estimates of costs to health programs and the proportion of potential savings achieved. The proportions of laparoscopic procedures undertaken were varied by f lo%, ALOS by f 1 day and non-length-of-stay-related hospital costs by +20%. The limits chosen for each variable reflected the distribution of data from hospitals in the Canadian surveys and Australian data bases. The results suggest that the estimates for ratios of health program costs before and after introduction of laparoscopic cholecystectomy are reasonably robust. Greater variation is seen in the estimates for potential savings achieved, though the overall impression of a high proportion of savings forgone remains unchanged. Cost of cholecystectomies will include a component due to complications. There is considerable interest in defining the rates of major complications for laparoscopic surgery in comparison with those for open procedures, particularly with reference to the size of the centre performing the surgery and levels of training. Data on complication rates remain sparse, and there are no standard detinitions on what is considered a complication. The limited data available from the survey of Canadian hospitals showed a higher rate of complications associated with cholecystectomy following introduction of the laparoscopic procedure. However, the rate of major complications following laparoscopic cholecystectomy (7.4%) was lower than that after open surgery ( 12.0%). Data on complications were not available for Australia. The hospital morbidity data show that for all values of length of stay of more than 8 days there were lower proportions of cases in 1991/92 than in 1989/90, suggesting an overall decrease in morbidity following introduction of laparoscopic surgery. 4. Discussion The results presented here are from a preliminary analysis of the impact of laparoscopic cholecystectomy during the initial diffusion of this technique. A number of assumptions were made in order to derive estimates from national perspectives. For both countries, data on numbers of laparoscopic procedures, ALOS and hospital costs were incomplete. It was assumed that the projections made from various available data bases reflected the national values. Many of the data were obtained by survey and have the inherent problems of bias and generalisability associated with such an approach. There is a further difficulty in making comparisons between two countries that differ in their health care systems and in the types of statistics that are available. The estimates of costs to patients can provide only a very approximate indication of levels of impact. Nevertheless, we suggest that this study has given a useful general perspective on some trends that have emerged during the introduction of this minimal-access surgery technique. In both countries the introduction of the laparoscopic technique for cholecystectomy has been associated with an increase in the total number of cholecystectomies performed. The increases are striking, as they follow a period of several years when rates for cholecystectomies had been steady. This increase in numbers of procedures has offset the savings expected from laparoscopic cholecystectomy through reduc-
228
D. Marshall et al. /Health Policy 26 (1994) 221-230
tion in ALOS. A crude estimate is that only 61% of potential savings to health programs has been achieved in Canada, and 13% in Australia. These may be optimistic estimates of savings, as no provision has been made for use of disposable instruments, which would have been used in laparoscopic cholecystectomy for a certain proportion of cases. While the relative overall costs of disposable and reusable instruments do not seem to have been well defined, use of disposable equipment at a cost of up to $700 per procedure in Canada ($600 in Australia) might be expected to increase the cost of laparoscopic surgery. Reduction in numbers of days lost to patients through surgery and associated costs to them have been achieved in both countries, but potential savings have not been fully realised, again because of the overall increase in the number of procedures. The estimates in this paper of potential and actual savings achieved through introduction of laparoscopic cholecystectomy have been derived making the assumptions that rates of gallstone disease have not undergone any recent change and that the rates of surgery prior to 1990/9 1 were appropriate for management of this condition. It is recognised that this may be a simplistic approach and that there is a need to consider in more detail the reasons for the recent increase in rates of cholecystectomies. The trend to higher rates of surgery was established very rapidly in both Canada and Australia. While further study is required, it seems possible that four factors may have contributed to this trend. Firstly, in a proportion of cases, the availability of the laparoscopic technique means that treatment may be offered to frailer patients who would not otherwise be candidates for surgery. Extending the availability of treatment in this way is an important gain offered by minimally invasive therapies, and has been demonstrated, for example, in the application of renal lithotripsy. However, a difficulty in this case is that a proportion of laparoscopic procedures will be completed as open surgery, so that careful judgement in patient selection would be needed. As an extension to this situation, the availability of laparoscopic cholecystectomy may tend to increase the probability of surgical intervention in symptomatic patients who are potential candidates for open surgery, and decrease the likelihood of conservative management. The new technique may be seen as providing a better opportunity to definitively resolve a clinical problem. A further possibility is that the technique is being offered in asymptomatic cases, for example when gallstones are detected opportunistically during an unrelated imaging examination. The rationale for cholecystectomy in such circumstances would appear to require very careful consideration, including appraisal of the relative risks to the patient of watchful waiting as against laparoscopic surgery. Finally, laparoscopic cholecystectomy is possibly being offered following inappropriate diagnosis. Spiro [12] has considered the situation where symptoms remain after surgery has been undertaken, when part of the rationale for surgery was that the new procedure was much less invasive. The possibility of this category of surgical intervention points to the need for adequate training and appropriate guidelines for physicians and surgeons in this field. These possibilities will tend to be driven by the awareness by the public of the availability of less invasive surgery and a wish by health professionals to extend use
D. Marshall et al. / Health Policy 26 (1994) 221-230
229
of the technology to new applications. The utility of these additional surgical procedures remains unclear, and further clinical and economic studies would be highly desirable. In Australia a high proportion of laparoscopic cholecystectomies are converted to open operations, with associated increase in hospital stay (and in time taken to return to normal activity). Debate continues about what might be an appropriate proportion of conversions to open surgery. and a very low rate could be associated with unacceptable risks to patients. However, the Australian conversion rates are high in comparison with results from other countries, for reasons that are not clear. The difference between the Australian and Canadian data on the proportion of conversions points to the need for a definition of appropriate standards for laparoscopic procedures, including case selection and training. It will be of some interest to observe whether the Australian conversion rate declines in the future. The subsequent trends in the proportion of cholecystectomies undertaken laparoscopically and in ALOS will also be of interest. The data available for the study reported here suggested that diffusion of laparoscopic cholecystectomy in Canada was still at a relatively early stage, and that the technique will spread more widely. In Australia by late 1992 all major hospitals and the majority of minor centres had acquired the technique (Royal Australasian College of Surgeons, personal communication), but some further increase in the proportion of laparoscopic cholecystectomies undertaken seems likely. Information obtained from hospitals in each country suggests that ALOS for laparoscopic cholecystectomy is continuing to decrease as further experience is gained with the technique and hospitals undertake restructuring. There may well be further decreases in the short to medium term, with a proportion of laparoscopic procedures being carried out as day surgery. This would lead to a consequent decrease in costs to health programs beyond the estimates presented in this paper, which reflect early national experience with the technique. For the full benefits of any such trends to be realised it will clearly be necessary for appropriate postdischarge support systems for patients to be in place as well as back-up for those procedures that are converted to open surgery. Further changes to the ALOS for laparoscopic surgery and any trend towards performance outside the acute hospital setting will increase the need for more accurate information on complications. Problems through complications associated with laparoscopic cholecystectomy, such as bile duct injury, were not revealed through the data available for this study. The experience of Canada and Australia suggests that the introduction of laparoscopic cholecystectomy has produced benefits, though these have been less than optimum. The increase in the rates of cholecystectomies that has been observed suggests the need for appropriate trials, clear guidelines and adequate standards of training for other minimal-access surgical techniques. 5. Acknowledgements
We are most grateful to Mr Dennis Lowe, MS Naarilla Hirsch and Mr Wolodja Dankiw for assistance in provision of data and for helpful comments.
D. Marshall et al. /Health Policy 26 (1994)
230
221-230
6. References 1 2
3 4 5 6
Peters, J., Ellison, E.C., Innes, J.T., et al.. Safety and efficacy of laparoscopic cholecystectomy: a prospective analysis of 100 initial patients, Annals of Surgery, 213 (1991) 3-12. Kelley, J.E., Burrus, G.R., Burns, P.R.. Graham, L.D.. and Chandler, K.E., Safety, efftcacy, cost and morbidity of laparoscopic versus open cholecystectomy: a prospective analysis of 228 consecutive patients, American Surgeon, 59 (1993) 23-27. Bass. E.B., Pitt, H.A., and Lillemoe, K.D.. Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy, American Journal of Surgery, 165 (1993) 466-471. Hailey, D.M., and Hirsch, N.A., Laparoscopic surgery: some unresolved issues, Medical Journal of Australia, I57 (1993) 58 l-582. Menon, D., and Marshall, D., Laparoscopic cholecystectomy diffusion in Canada, International Journal of Technology Assessment in Health Care, in press. Renwick, M.. and Sadkowsky, K., Variations in Surgery Rates (Health Services Series, no. 2). Australian Institute of Health and Welfare, Canberra, 1992. Gillett, S., Liu, Z., and Solon, R., Hospital Utilisation and Costs Study, 1989-90 (Health Services Series, no. 4) Australian Institute of Health and Welfare, Canberra, 1993. Cook, J., Richardson, J., and Street, A., Cost utility analysis of treatment options for gallstone disease: preliminary results and methodological issues. In C. Selby Smith (Ed.), Economics and Health, 1992, Monash University, National Centre for Health Program Evaluation, Melbourne, 1993, pp. 244-215. St Vincent’s Hospital, Melbourne, Biliary Lithotripsy Assessment Program: Final Report, Australian Institute of Health and Welfare. Canberra, 1993. Australian Institute of Health and Welfare, Australia’s Health, 1992, Australian Government Publishing Service, Canberra, 1992. p. 141. Street, A., Gallstone Disease: the Cost of Treatment (Working paper no. 29). National Centre for Health Program Evaluation, Melbourne, 1993. Spiro, H.M., Diagnostic laparoscopic cholecystectomy, Lancet. 339 (1992) 167-168.