Cost-effectiveness of Laparoscopic vs Open Gastrectomy for Gastric Cancer: An Economic Evaluation Alongside a Randomized Clinical Trial

Abstract

Importance: Laparoscopic gastrectomy is rapidly being adopted worldwide as an alternative to open gastrectomy to treat gastric cancer. However, laparoscopic gastrectomy might be more expensive as a result of longer operating times and more expensive surgical materials. To date, the cost-effectiveness of both procedures has not been prospectively evaluated in a randomized clinical trial.

Objective: To evaluate the cost-effectiveness of laparoscopic compared with open gastrectomy.

Design, setting, and participants: In this multicenter randomized clinical trial of patients undergoing total or distal gastrectomy in 10 Dutch tertiary referral centers, cost-effectiveness data were collected alongside a multicenter randomized clinical trial on laparoscopic vs open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). A modified societal perspective and 1-year time horizon were used. Costs were calculated on the individual patient level by using hospital registry data and medical consumption and productivity loss questionnaires. The unit costs of laparoscopic and open gastrectomy were calculated bottom-up. Quality-adjusted life-years (QALYs) were calculated with the EuroQol 5-dimension questionnaire, in which a value of 0 indicates death and 1 indicates perfect health. Missing questionnaire data were imputed with multiple imputation. Bootstrapping was performed to estimate the uncertainty surrounding the cost-effectiveness. The study was conducted from March 17, 2015, to August 20, 2018. Data analyses were performed between September 1, 2020, and November 17, 2021.

Interventions: Laparoscopic vs open gastrectomy.

Main outcomes and measures: Evaluations in this cost-effectiveness analysis included total costs and QALYs.

Results: Between 2015 and 2018, 227 patients were included. Mean (SD) age was 67.5 (11.7) years, and 140 were male (61.7%). Unit costs for initial surgery were calculated to be €8124 (US $8087) for laparoscopic total gastrectomy, €7353 (US $7320) for laparoscopic distal gastrectomy, €6584 (US $6554) for open total gastrectomy, and €5893 (US $5866) for open distal gastrectomy. Mean total costs after 1-year follow-up were €26 084 (US $25 965) in the laparoscopic group and €25 332 (US $25 216) in the open group (difference, €752 [US $749; 3.0%]). Mean (SD) QALY contributions during 1 year were 0.665 (0.298) in the laparoscopic group and 0.686 (0.288) in the open group (difference, -0.021). Bootstrapping showed that these differences between treatment groups were relatively small compared with the uncertainty of the analysis.

Conclusions and relevance: Although the laparoscopic gastrectomy itself was more expensive, after 1-year follow-up, results suggest that differences in both total costs and effectiveness were limited between laparoscopic and open gastrectomy. These results support centers' choosing, based on their own preference, whether to (de)implement laparoscopic gastrectomy as an alternative to open gastrectomy.

Figure 1.. Trial Flowchart

All 227 patients who underwent random assignment were included in the intention-to-treat analysis, 115 in the laparoscopic gastrectomy group and 112 in the open gastrectomy group. A total of 211 patients underwent their allocated treatment according to the protocol, 106 in the laparoscopic gastrectomy group and 105 in the open gastrectomy group. ^aThe Dutch Upper GI Cancer Audit (DUCA) is a mandatory registration that contains information about every patient who underwent a gastrectomy for gastric cancer, including open-close procedures. DUCA data were used to calculate the total number of patients who met the study inclusion criteria during the inclusion period of each trial center.

Figure 2.. Distributions of Per-Patient Costs

A, Distribution of the per-patient total costs during 1-year follow-up for patients undergoing either laparoscopic or open gastrectomy. B, Distribution of the per-patient costs during 1-year follow-up for patients undergoing either laparoscopic or open gastrectomy for hospital admissions, intensive care unit (ICU), rehabilitation center or nursing home, and home care. Hospital admission and ICU costs were the observed costs because there were no missing values. Rehabilitation center, nursing home, and home care costs also included imputations of missing values. The transparent body of the violin plot displays the estimated density of the data: costs on the y-axis and the corresponding number of individuals on the x-axis (ie, the broader the shape, the more individuals). The circles indicate individual outliers. A standard box plot is displayed within the transparent body of the violin plot for total costs, hospital admissions, and home care. The box plot displays the median (horizontal line), IQRs (box), and the minimum and maximum excluding outliers (central black line). Current exchange rate: €1 = $0.99545.

Figure 3.. Cost-effectiveness Plane

Costs and quality-adjusted life-years (QALYs) gained of the laparoscopic group compared with the open group for 2000 bootstrap iterations displayed in a cost-effectiveness plane. Of all bootstrap iterations, 13% (260 of 2000) were in the bottom right quadrant (lower costs and higher effectiveness for the laparoscopic group), 14% (280) in the upper right quadrant (higher costs and higher effectiveness), 32% (640) in the bottom left quadrant (lower costs and lower effectiveness), and 41% (820) in the upper left quadrant (higher costs and lower effectiveness). Each dot indicates the difference in costs and QALYs between laparoscopic and open gastrectomy, of 1 bootstrap iteration. Blue, purple, and red colors indicate overlapping dots (bootstrap iterations) in increasing densities (with red indicating the highest density).