Financial benefit of a smoking cessation program prior to elective colorectal surgery

Abstract

Background: Cigarette smoking increases the risk of postoperative complications nearly 2-fold. Preoperative smoking cessation programs may reduce complications as well as overall postoperative costs. We aim to create an economic evaluation framework to estimate the potential value of preoperative smoking cessation programs for patients undergoing elective colorectal surgery.

Methods: A decision-analytic model from the payer perspective was developed to integrate the costs and incidence of 90-day postoperative complications and readmissions for a cohort of patients undergoing elective colorectal surgery after a smoking cessation program versus usual care. Complication, readmission, and cost data were derived from a cohort of 534 current smokers and recent quitters undergoing elective colorectal resections in Washington State's Surgical Care and Outcomes Assessment Program linked to Washington State's Comprehensive Hospital Abstract Reporting System. Smoking cessation program efficacy was obtained from the literature. Sensitivity analyses were performed to account for uncertainty.

Results: For a cohort of patients, the base case estimates imply that the total direct medical costs for patients who underwent a preoperative smoking cessation program were on average $304 (95% CI: $40-$571) lower per patient than those under usual care during the first 90 days after surgery. The model was most sensitive to the odds of recent quitters developing complications or requiring readmission, and smoking program efficacy.

Conclusions: A preoperative smoking cessation program is predicted to be cost-saving over the global postoperative period if the cost of the intervention is below $304 per patient. This framework allows the value of smoking cessation programs of variable cost and effectiveness to be determined.

Keywords: Colorectal; Cost; Smoking cessation program; Surgery; Tobacco.

Figure 1

Decision tree entrance for a cohort of smokers undergoing elective colorectal surgery, either under preoperative smoking cessation program or usual care. Probability of patients continuing as current smokers or becoming recent quitters is displayed for each treatment course.

Figure 2

Decision tree continuation from figure 1 for cohort of smokers undergoing elective colorectal surgery who have now either continued smoking or become recent quitters. Superscript designations (a-l) indicate probability of events and associated costs as reported on Table 2.

Figure 3

Tornado diagram for one-way sensitivity analysis of model variables compared to the base case scenario of $304 (solid black line). The transition probabilities not included in the figure remained cost-saving. OR represents the adjusted odds of the probability outcome when comparing recent quitters (RQ) to current smokers.