Health Economic Evaluation Of "Non-tube No Fasting" Enhanced Recovery After Minimally Invasive Esophagectomy

Background and ObjectiveEsophageal cancer is the sixth leading cause of death from cancer worldwide and the incidence rate has been rising over the past decades.In case of localized non-metastatic esophageal cancer,surgical resection of the esophagus with en-bloc lymphadenectomy combined with induction therapy is the recommended treatment strategy.Survival following esophageal resection for cancer has improved considerably over the past decades due to advances in surgical treatment and perioperative care.But esophageal cancer still seriously threatens the lives of patients,and it takes up a lot of medical resources,bring a huge social and economic burden,therefore,the research on the diagnosis and treatment of esophageal cancer is of great significance to people's health and social health economy.At present,minimally invasive esophageal surgery has gradually become a trend in the treatment of esophageal surgery.A large body of research focused on clinical outcomes of minimally invasive esophagectomy(MIE)has demonstrated improved surgical and clinical outcomes,such as decreased blood loss,reduced length of stay,and fewerpulmonary complications,does not increase medical expenses for patients with esophageal cancer.The current increase in health care expenses worldwide has encouraged healthcare providersto place emphasis on both improving quality of(cancer)care and reducing costs.It is well recognized that complications after esophageal surgery are associated with increased length of hospital stay,long-term morbidity and mortality.Quality of life(QoL)is currently an important indicator for evaluating the prognosis of cancer patients.However,the study of QoL in patients with esophageal cancer is mainly focused on the effects of surgery,adjuvant chemotherapy and so on.Recently,our department successfully developed and implemented “non-tube no fasting”enhanced recovery after surgery for oesophageal cancer,changed the postoperative management mode of traditional esophageal cancer.Exploring the advantages of‘‘Non-tube No Fasting” enhanced recovery after minimally invasive esophagectomy and traditional postoperative fasting in terms of hygiene economics and quality of life,in order to optimally allocate resources for quality improvement initiatives and postoperatively management model in the future.MethodThis study included 78 consecutive patients with Minimally invasive esophagectomy who have chosen the ‘non-tube no fasting' enhanced recovery programme at the Department of Thoracic Surgery of the Affiliated Cancer Hospital of Zhengzhou University from October 2017 to February 2018.Forty-two patients were in Group EOF,and 36 patients were in Group LOF.The study was approved by the Institutional Review Board.The Ethics Review Committee of the Cancer Hospital of ZhengZhou University also approved the study,all patients signed informedconsent.ResultsLOF accounted for the highest proportion of intraoperative costs,respectively accounting for the total medical expenses(54.75% versus 51.03%),the two groups ofpatients had the highest proportion of disposable consumables expenses,respectively for the total medical expenses(42.07% versus 39.80%),which accounted for a higher percentage of intraoperative medical costs(76.84% versus 77.98%),Secondly,the difference between the costs of the two groups was mainly due to western medicine costs,total western medicine costs,and postoperative western medicine costs on the LOF,which were significantly higher than those in the EOF(18360.9±4090.1 RMB versus 12787.2±3889.7 RMB;13773.8±3986.5 RMB versus 8734.1 ± 3560.7 RMB,respectively P <0.001).On the other hand,the rate of surgical costs for patients with both EOF and LOF is only(10.31% versus9.26%),or even less than the proportion of cost of imaging examination(11.14% versus10.23%).Another interesting phenomenon is that although EOF has a shorter hospital stay,the cost of care is significantly higher than that of LOF(636.0±223.3 RMB versus 418.1±171.8 RMB,P<0.001),however,the proportion of nursing costs in medical expenses is extremely low,only(1.06% versus 0.62%),even less than bed charges.Compared with EOF,the non-medical cost of LOF was significantly higher(12722.5±1912.9 RMB versus 10579.9±2429.2 RMB,P<0.001),accounting for the total cost(15.97% versus 14.94%).From the perspective of the cost category,the non-medical cost of LOF is higher than EOF mainly for the charge for loss of working time and food expenses(7114.7±1423.1 RMB versus 5526.3±1599.1 RMB,P<0.001;2094.4±491.6 RMB versus 1757.1±622.0 RMB,P= 0.01).No significant differences in baseline QOL scores were observed between the 2groups.No patient in each group died during the 8 weeks of follow-up.All 76 patients were followed up.Two weeks after the operation,global QOL(P =0.017),physical function(P=0.028),emotional function(P =0.002),and social function(P=0.001)were significantly higher in patients in the EOF group than in patients in the LOF group.Two weeks after the operation,the patients in the LOF group reported statistically significantly more problems with fatigue(P= 0.001),nausea and vomiting(P =0.001),pain(P= 0.001),appetite loss(P = 0.007),diarrhea(P = 0.002),dysphagia(P = 0.001),eating difficulties(P = 0.016),and trouble swallowing saliva(P = 0.003)than patients in the EOF group.Four weeks after the operation,the patients in the EOF group reported higher global QOL(P = 0.030)and fewer symptoms of nauseaand vomiting(P = 0.017).There was no significant difference in quality of life between the two groups after 8 weeks.Conclusions“Non-tube no fasting” enhanced recovery after MIE could reduce postoperative length of stay,medical cost and non-medical cost and improve postoperative QOL without increasing complications.