On All Accounts: Cost-Effectiveness Analysis of Limited Preoperative Optimization Efforts before Colon Cancer Surgery

Abstract

BACKGROUND: Reports suggest that preoperative optimization of a patient's serious comorbidities is associated with a reduction in postoperative complications. OBJECTIVE: The purpose of this study was to assess the cost and benefits of preoperative optimization, accounting for total costs associated with postoperative morbidity. DESIGN: This study is a decision tree cost-effectiveness analysis with probabilistic sensitivity analysis (10,000 iterations). SETTING: This is a hypothetical scenario of stage II colon cancer surgery. PATIENT: The simulated 65-year-old patient has left-sided, stage II colon cancer. INTERVENTION: Focused preoperative optimization targets high-risk comorbidities. OUTCOMES: Total discounted (3%) economic costs (US $2018), effectiveness (quality-adjusted life-years), incremental cost-effectiveness ratio (incremental cost-effectiveness ratio, cost/quality-adjusted life-years gained), and net monetary benefit. RESULTS: We calculated the per individual expected health care sector total cost of preoperative optimization and sequelae to be $12,395 versus $15,638 in those not optimized (net monetary benefit: $1.04 million versus $1.05 million). A nonoptimized patient attained an average 0.02 quality-adjusted life-years less than one optimized. Thus, preoperative optimization was the dominant strategy (lower total costs; higher quality-adjusted life-years). Probabilistic sensitivity analysis demonstrated 100% of simulations favoring preoperative optimization. The breakeven cost of optimization to remain cost-effective was $6421 per patient. LIMITATIONS: Generalizability must account for the lack of standardization among existing preoperative optimization efforts, and decision analysis methodology provides guidance for the average patient or general population, and is not patient-specific. CONCLUSIONS: Although currently not comprehensively reimbursed, focused preoperative optimization may reduce total costs of care while also reducing complications from colon cancer surgery. See Video Abstract at http://links.lww.com/DCR/B494.