Comparative effectiveness of emerging technology in surgery

Abstract

Introduction: New surgical technology plays a major part in healthcare in the developed world but also must be considered as infrastructure grows for surgical care in low- and middle-income countries. Reliable epidemiologic and statistical methods for comparative effectiveness must be applied when choosing whether or not to adopt a new surgical approach or technology. Methods: For Part I of this thesis, we performed a comparative effectiveness study of conventional and minimally invasive approaches to major and challenging hepatectomies using logistic regression and a non-inferiority approach. For Part II of this thesis, we use temporal trend analyses to examine outcomes and utilization among patients treated by either conventional surgical repair or endoluminal stenting for benign esophageal perforation. Results: For patients undergoing major hepatectomy, minimally invasive approaches were non-inferior to conventional open surgery. In an assessment of patients with benign esophageal perforation, we observed a four-fold increase in the rate of treatment by stenting. While there was no difference in trends of adverse outcomes, stented patients had higher rates of death and healthcare utilization across. Conclusions: Studies of comparative effectiveness should apply appropriate methods to match the clinical problem and data source. In this study, neither assessment suggests that the new technology was more effective than existing approaches. Reporting on comparative effectiveness of new surgical technology will be critical to policy makers and clinicians in the US and the developing world.