The cost effectiveness of metal oesophageal stenting in malignant disease compared with conventional therapy

Expanding metal oesophageal stents are being used more commonly to palliate patients with inoperable oesophageal carcinoma. Many reports have so far d ocumented their clinical effectiveness, however, their high acquisition cos t has caused on-going concern when compared with the cost of conventional t herapies. We reviewed 64 consecutive patients with inoperable oesophageal c arcinoma, half of whom had received our conventional method of palliation u sing a variety of techniques including, BICAP diathermy, alcohol injection and Atkinson tube insertion, The other half (32 patients) were treated with expandable metal stents - Gianturco Z stents (Cook UK Ltd) and uncovered U ltraflex stents (Microvasive, Boston Scientific). The physical amount of re sources consumed were identified and measured (number of diagnostic and sup port procedures, days as in patients, number of day cases or outpatient att ending) and an average NHS cost was applied to this resource use. All costs were summated over the period of palliation from the date of the first int ervention with palliative intent until death. Although the patients in this study were not randomized, the two groups were matched to ensure comparabi lity in clinical manifestation (uncomplicated biopsy proven oesophageal car cinoma) and the average age of patients from each group. A difference was i dentified between the length of survival in both patient groups and the ana lysis was corrected for this by estimating a cost per day of palliative sup port. Patients palliated with metal stents underwent fewer procedures and spent f ewer days in hospital during the time period from presentation until death even when corrected for differences in survival. Patient outcome (effective ness of palliation) was measured by recording mean dysphagia scores which w ere recorded before and after palliation, Metal stents were found to lead t o a significantly higher improvement in dysphagia in comparison to conventi onal therapy. In addition, the mortality related to metal oesophageal stent s was lower than Atkinson tube insertion. The average cost of palliation wa s much lower in the metal stent group (mean = pound 2817) compared with the cost in those palliated conventionally (mean = pound 4566). However, once this was corrected for survival the difference in the cost of palliation on a per diem basis was reduced (metal stents = pound 60 per day, conventiona l group = pound 72 per day). The results of our study indicate that the initial high cost of metal stent s is more than outweighed by resource savings elsewhere in the hospital by virtue of reduced need for re-intervention and shorter length of hospital i n patient stay. Such cost savings taken in combination with the improved cl inical effectiveness and low mortality related to metal stents provide sign ificant support for introducing their use into clinical practice.