Power-assisted surgical staplers | Choosing the Right Surgical Stapler
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Electric staplers, or automatic staplers, run on batteries. They are still quite recent. According to a study funded by Ethicon (manufacturer of staplers, part of the Johnson & Johnson group) and published in the journal Advances in Therapy, compared to mechanical staplers, the use of electric staplers in a pulmonary lobectomy: Reduces the risk of complications (particularly bleeding) Shortens patients' recovery time by at least one day Reduces the...
The economic advantages of powered stapler use in VATS lobectomy for lung cancer have been previously reported in retrospective studies from the United States [5] and Korea [6]. Like previous cost studies, our retrospective cost analysis presents significantly lower total hospital costs associated with the use of a powered stapler in China. Therefore, the findings of our study reaffirm the existing pool of economic evidence and external validity for powered stapler use in VATS lobectomy for lung cancer. In addition, a cost-minimization model was implemented in this study to assess the robustness of the findings under the overall uncertainty of model variables. Consequently, the findings of this study can be assuredly used to support hospital budget planning and reimbursement decision making.
The majority of the patients included in this study (76.3%) underwent VATS lobectomy for lung cancer using a powered stapler. Although this study did not survey surgeons for their preferences for the stapler type, the observed differences in patient characteristics in the two study groups suggest the powered stapler as the preferred option for surgeons due to its operational advantages. For example, the greater operability of a powered stapler than a manual stapler in VATS with limited surgical space would lead surgeons to use a powered stapler on patients with a high BMI who often presents further spatial constraints [13, 14]. In addition, the even force distribution of a powered stapler could reduce lung damage [15] and allow surgeons to operate on complex anatomical sites that require precise and delicate operation [16]. Our retrospective cost analysis observed significantly lower total hospital costs associated with the use of a powered stapler as corroborated by previous studies [5, 6]. Both unadjusted and adjusted comparisons of the classified hospital costs of the two stapler types identified that the powered stapler saved sufficient hospital drug costs to fully offset the increase in costs for the acquisition costs of a powered stapler and matching cartridges. This study did not further investigate the utilization of drugs in the two stapler groups. However, our previous study with the same patient cohort found that the powered stapler was associated with significantly shorter post-surgery hospital length of stay [11], which could partially explain the lower hospital drug costs observed in the powered stapler group.
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This study additionally assessed the robustness of its findings under the overall uncertainty of patient characteristics using CMA. The one-way sensitivity analysis of CMA found that patient characteristics had a minimal impact on the differences in the total hospital costs of the two stapler groups. These differences were mainly driven by the acquisition costs of the staplers and matching cartridges. The PSA, which is used to translate model parameter uncertainty into outcome values and decision uncertainty, reported 100% probability for the powered stapler to save total hospital costs in the model cohort. This, therefore, verifies the robustness of our finding that lower total hospital costs were associated with powered stapler use in VATS lobectomy for lung cancer. In comparison to the retrospective cost analysis&#;the most common method used in cost studies&#;the CMA employed in our study has several advantages. First, the simulation was conducted on the entire patient cohort for each stapler type, resulting in a substantial improvement in the model cohort size and reduction in the uncertainty of model outputs for cost outcomes. Next, the use of a paired test in the comparison of the simulated cost outcomes associated with the two staplers in the model cohort excluded any confounding effects in the analysis. Another advantage is that our CMA allowed for the investigation of the impact of the uncertainty of model variables on model outputs through one-way sensitivity analysis and PSA. Our study findings that have gone through the uncertainty assessment can thus better inform the decision making in both clinical and reimbursement contexts. Lastly, the CMA can be adapted to conduct scenario analyses using other types of staplers. For example, we applied the constructed model for CMA to conduct a scenario analysis comparing the powered stapler with another type of manual stapler. After adjusting the prices of the stapler and cartridge, we were able to easily estimate the differences in total hospital costs between the powered stapler and another type of manual stapler.
Our study has several implications on clinical practice, research methods, and policy making. To our knowledge, the economic impact of powered stapler use in VATS lobectomy has never been assessed as comprehensively as in the present study. The identified differences in hospital costs associated with the two stapler types could inform the selection of a stapler type for clinical procedures using an economic lens, which is crucial for reimbursement decision making, hospital budget control, and patient affordability in China. Additionally, our study demonstrates that health economic evaluations should focus on the total costs associated with the complete pathway of the management but not the acquisition costs of the interventions. New technologies are often more costly. However, the potential clinical benefits of such new technologies could have positive economic implications that offset their high costs. In our case, the ECHELON powered stapler cost more than the manual stapler to purchase but incurred lower overall hospital costs. Furthermore, our study suggests that medical costs could be an alternative outcome measure to address the measurement bias frequent in retrospective studies. The lack of standard data collection method for medical information could substantially confound the comparisons of interventions in real-world settings. With growing utilization of real-world evidence in reimbursement decision making and health policy development, measurement bias associated with real-world evidence from retrospective studies should be carefully assessed and economic outcomes should be always considered for validation in real-world studies. Finally, our study demonstrates a great use case of CMA in informing health policy making. The constructed model for CMA can be adapted as a policy making tool to guide policymakers in understanding the cost rationales and the uncertainty of the economic benefits of powered stapler use. CMA can be applied to studying a wide array of stapler types and settings with appropriate adjustments.
Common limitations inherent in the retrospective research method were found in this present study. Despite the low probability of missing data on medical costs and information on stapler utilization as a result of using hospital billing records, there is chance that patients&#; medical records may be missing information that could confound the cost comparison analyses between the two stapler groups. For example, the medical records did not collect sufficient information to adjust for residual confounding in our data analyses because powered stapler use was likely more attractive to surgeons for use in VATS lobectomy and patients with higher socioeconomic status may prefer to receive more expensive and advanced medical devices [17]. Therefore, a prospective study design could be more appropriate than a retrospective design to study the economic benefits of a powered stapler. Additionally, the assumption that the ECHELON manual stapler and the Victor Medical manual stapler share the same clinical effects and health resource utilization in the scenario analysis should be confirmed in the future. Interpreting evidence from the scenario analysis therefore requires caution.
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