تجزیه و تحلیل به حداقل رساندن هزینه : مقایسه خارج سازی کلیه به روش باز، خارج سازی کلیه به روش لاپاروسکوپی و خارج سازی کلیه به روش دستیار - تجزیه و تحلیل حداقل رسانی هزینه ها

Background Live donor kidney transplantation is the treatment of choice for end-stage renal disease. Open donor nephrectomy (ODN) was the standard until the introduction of the laparoscopic donor nephrectomy (LDN) in 1995. Hand-assisted laparoscopic donor nephrectomy (HALDN) was added shortly thereafter. The laparoscopic techniques are associated with increased operating room times and equipment costs; however, these techniques speed patient return to normal activity. The aim of this study is to evaluate the cost of these techniques. Materials and Methods A decision analysis model was developed to simulate outcomes for donors undergoing ODN, LDN, and HALDN. Outcomes were simulated from both the institutional perspective (IP) and the societal perspective (SP). Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. Results From the IP, ODN is the least costly strategy with a cost of $11,000, while the cost is $15,200 for HALDN and $15,800 for LDN. From the SP, HALDN is the least costly strategy costing $27,800, while the cost for LDN is $29,000 and for ODN is $41,000. In sensitivity analysis, ODN only became the dominant strategy if the days till return to work exceeded 58 in the HALDN strategy. LDN and HALDN were nearly equivalent as the rate of open conversion of LDN approached zero. Conclusions HALDN is the least costly donor nephrectomy strategy, especially from the SP. The primary determinants of cost in this model are conversion to open and days till return to work.

The treatment of choice for end-stage renal disease is kidney transplantation; however, the number of potential recipients far exceeds the number of available donor organs [1]. Living donation is the only means of reliably increasing the donor supply and closing the gap between recipients and available organs. Additionally, kidney transplantation from a live donor provides superior graft survival and outcomes compared with cadaveric donors [2]. For several decades, open donor nephrectomy (ODN) was the only procedure available to those who wished to donate. Most donors are young, healthy adults, and this approach was unattractive because it entailed a painful flank incision often hindering their return to normal activity or work. In 1995, Ratner and colleagues introduced the laparoscopic donor nephrectomy (LDN) [3]. This technique yields less pain, shorter convalescence, and superior quality of life [4], [5], [6], [7] and [8]. In an effort to improve on LDN, hand-assisted laparoscopic donor nephrectomy (HALDN) was introduced and provided better vascular control and ease of retrieval of the kidney. With the introduction of these minimally invasive techniques, the number of live donor candidates increased greatly [9]. The objective of this study was to evaluate the cost-effectiveness of ODN, LDN, and HALDN from the institutional perspective (IP) and the societal perspective (SP) using a decision analysis model. By modeling the outcomes of these three procedures, we can better understand the determinants of the cost-effectiveness of donor nephrectomy.

The benefits of living donor nephrectomy of any type of surgical approach to both the recipient of the organ and society are substantial. For living donor kidney transplants, cost savings of at least $50,000 a year are realized by society and over seven Quality Adjusted Life Years are gained by the recipient [25]. The donor stands to gain little from the procedure other than emotional rewards or satisfaction. Therefore, we should strive to ensure the safety of the procedure and perform nephrectomy operations that return the donor to their baseline level of activity and quality of life as soon as possible. Open donor nephrectomy has long provided a safe operation for the donor but results in a significant convalescence period during which the donor is subject to lost productivity and wages. With the advent of minimally invasive techniques, there is a significant decrease in the period of convalescence. HALDN and LDN both offer less post-operative pain, shorter hospital stays, and earlier return to work. Therefore, they are clearly superior to ODN, and this has been demonstrated in multiple studies [4], [5], [6], [7], [8] and [9]. However, within these procedures there are differences in conversion rates and perioperative complications leading to a debate as to which procedure is the most cost-effective. In this study we collected data from multiple well designed studies and reviews done in the last 15 y and used decision analytic techniques to model ODN, LDN, and HALDN strategies from the institutional and societal perspectives in attempt to determine the most cost-effective strategy. From the institutional or hospital’s perspective the most cost-effective strategy is ODN. Through threshold analyses, we showed that the minimally invasive techniques would only become the optimal strategy if the hospital stay for ODN exceeded 10 d. In most centers, a hospital stay over 7 d for ODN is highly unlikely [6], [15], [17] and [19]. Therefore, in this model that concentrates on costs of the procedure to the hospital or payer, the financial advantage of ODN remained valid over a wide range of direct costs. From the societal or patient’s perspective, the least costly strategy is HALDN. Sensitivity analyses performed from this perspective revealed that ODN would only become the optimal strategy if the days till return to work after HALDN were greater than 58 d. These analyses also demonstrated that as the rate of open conversion of LDN approached zero, there was little difference in the cost-effectiveness of HALDN and LDN. Alternatively, as the open conversion rate of the laparoscopic procedures approached 10%, they continued to remain more cost-effective than ODN. All of these threshold values are well outside those values seen clinically in most centers [12], [13], [14] and [15]. Again, the model remained valid over a wide range of clinical scenarios and demonstrated HALDN to be the most cost-effective operative approach in relation to the patient and societal costs. In two-way sensitivity analysis, we varied the indirect costs of the procedures and the number of days till return to work after HALDN simultaneously. This demonstrated that again ODN only becomes the preferable strategy at high number of days till return to work or at very low indirect cost. The indirect costs or cost of lost productivity and wages would have to be less than $50 per day for ODN to become cost-effective from the societal perspective. Again, these values are clinically unlikely and support the validity of the model. Most importantly, this model allows us to identify the significant determinants of cost within these procedures. The driving force behind the decreased cost of the minimally invasive techniques was the days till return to work of the donor. Although, this operative approach costs more for the institution or payer, the ability of the donor to return to work sooner and the savings in lost productivity and wages make HALDN and LDN the least overall costly strategies. The primary difference between HALDN and LDN was the rate of conversion to ODN: higher in LDN. There still remain slight differences in the rates of perioperative complications within these procedures, but the most important factor contributing to the cost was the ability to complete the procedure without conversion. The limitations of this study are that it distills ODN, LDN, and HALDN into a very basic model. In this model, we used published data and meta-analyses to approximate the most likely clinical scenarios in these procedures. While some of the studies from which we derived our probabilities looked at differences in donor characteristics such as BMI or arterial anatomy, we chose to make a more general model and did not look specifically at differences in outcomes based on the donor characteristics. These are important clinical parameters that have been shown to alter procedural outcomes in some studies [22] and [23]. Also, time off from work and lost wages can be a highly variable element in most patient populations. In this study, the base case was a 35 y-old woman who worked outside the home. This is a fairly typical patient for donor nephrectomy and allowed us to more reliably account for indirect costs. The strengths of decision analytic techniques are that the models can be adapted to a wide range of clinical scenarios and patient characteristics. The models can be constructed to account for as many variables and outcomes of interest as there are data to support. Decision analysis can be used with large databases to simulate national trends or with small datasets to profile an individual surgeon’s experience. In this study, our decision analysis model helps elucidate the factors that contribute to the determination of the optimal economic strategy of donor nephrectomy. In doing so, we have provided data that allow centers to tailor the model to their practice and therefore perform the least costly procedure for their own surgeon and patient cohort. For example, at centers that have a great deal of experience in donor nephrectomy and have almost no conversions in the LDN procedure, HALDN and LDN could be used interchangeably, depending on the donor, and provide similar cost. Whereas at centers that perform fewer LDN procedures and have higher conversion rates, HALDN should be performed preferentially in order to better serve the donor. These data will also allow transplant centers to better council potential donors on the risks of the procedures and what the donors can expect in terms of the length of time until they can return to normal activity or work. The improved education of the donors will likely decrease the number of donors who decide not to donate after being medically cleared.