Hospital costs associated with thyroidectomy performed with a Harmonic device compared to conventional techniques: a systematic review and meta-analysis

Figures & data

Table 1. Study and baseline characteristics for studies meeting inclusion criteria.

Study	Country	Patient population/procedure	Intervention	n	Age (mean ± SD)	% Male	Original cost units	Types of costs included
Frazzetta et al.^12, 2005	Italy	Total thyroidectomy	UltraCision Harmonic Scalpel	60	54.5 (23–83)*	25.0%	2005 Euros	Anesthesia kit OR time and personnel OR equipment and HS device Drugs
			Ligatures + cauterization	60	53.5 (21–83)*	36.7%
Hallgrimsson et al.^13, 2008	Sweden	Total thyroidectomy Graves’ disease	UltraCision Harmonic Scalpel	27	42 (20–70)†	33.3%	2006 Euros	OR time (anesthesia included) OR equipment and HS device
			Mono/bipolar coagulation, ligatures/clips	24	34 (20–59)†	12.5%
Konturek et al.^14, 2012	Poland	Total thyroidectomy Bilateral, non-toxic multinodular goiter	Ultrasonic Harmonic FOCUS shears	41	41.1 ± 7.5	17.1%	2012 Euros	OR time Anesthesia time OR consumables (e.g. ligatures) HS device
			Bipolar coagulation and clip-ligation	41	42.0 ± 7.5	19.5%
Kowalski et al.^15, 2012	Brazil	Total thyroidectomy Benign or malignant disease	Ultrasonic Harmonic Scalpel + ACE	128	47.9 ± 12.9	8.6%	2009 USD	OR time Intra-operative resources HS device Drugs LOS
			Cut + ligature technique	133	48.8 ± 11.7	6.8%
Lombardi et al.^25, 2008	Italy	Total thyroidectomy Various thyroid diseases§	Harmonic Scalpel CS-14 C	100	49.5 ± 14.2	25.0%	2008 Euros	OR personnel OR utilization Disposable materials (e.g. HS) Drugs Admissions/discharge Medical assistance & nursing charges Pre-operative examination Unit general cost
			Knot-tying technique	100	52.5 ± 23.4	22.0%
Ortega et al.^26, 2004	Spain	Total thyroidectomy Lobectomy Benign thyroid disease	UltraCision Harmonic Scalpel CS-14 C	100	53.5 (21–83)*	19.0%	2004 Euros	Charges generated by patient over hospital stay (i.e. drug, OR time, disposable material, LOS) Assume HS cost included
			Clamp + tie technique	100	52.5 (18–76)*	18.0%
Pons et al.^22, 2009‡	France	Total thyroidectomy Multinodular goiter Benign disease	Harmonic FOCUS	20	55.0 ± 11.0	20.0%	2009 USD	Staff cost operative theatre Annual investment in materials Consumables Assume HS cost included
			Clamp + tie and bipolar electrocautery	20

*Age reported as mean (range);

†Age reported as median (range);

‡Three-armed study; Ligasure arm was excluded from the analysis;

§Euthyroid multinodular goiter, toxic multinodular goiter, Graves’ disease, intermediate or suspicious nodule, or papillary carcinoma.

Figure 1. PRISMA diagram for the systematic literature review.

Figure 2. Proportion of included studies reporting statistically significant or non-significant reductions or increases in total reported costs using the Harmonic scalpel compared to conventional methods.

Figure 3. Forest plot of primary meta-analysis results for total reported costs (USD) expressed as ratio of means.

Table 2. Cost inputs and assumptions for primary analysis on total reported costs.

Reference	Intervention	Primary analysis
		Total reported cost (Original cost units)		Total reported cost (2015 USD)
		Mean	SD	Mean	SD
Frazzetta et al.^12, 2005	UltraCision Harmonic Scalpel	€978.60	€120.02	$1342.43	$164.64
	Ligatures + cauterization	€1328.68	€105.65	$1822.67	$144.93
Hallgrimsson et al.^13, 2008	UltraCision Harmonic Scalpel	18,910.80 kr	132.60 kr	$2408.43	$168.83
	Mono & bipolar coagulation, ligatures & clips	22,368.51 kr	233.95 kr	$2848.80	$297.88
Konturek et al.^14, 2012	Ultrasonic Harmonic FOCUS dissecting shears	€666.00	€37.50	$831.72	$46.83
	Bipolar coagulation and clip-ligation	€718.00	€69.20	$896.65	$86.42
Kowalski et al.^15, 2012	Ultrasonic Harmonic Scalpel	$2554.00	$525.10	$2820.00	$579.70
	Cut + ligature technique	$2470.00	$923.90	$2727.00	$1019.98
Lombardi et al.^25, 2008	Harmonic Scalpel CS-14 C	€2238.10	€406.50	$2875.80	$522.32
	Knot-tying technique	€2368.10	€489.90	$3042.84	$629.49
Ortega et al.^26, 2004	UltraCision Harmonic Scalpel CS-14 C	€985.77	€107.08	$1607.41	$174.61
	Clamp-and-tie technique	€1148.40	€153.25	$1872.59	$249.89
Pons et al.^22, 2009	Harmonic FOCUS	$2486.00	$153.00	$2744.52	$168.91
	Clamp-and-tie, and bipolar electrocautery	$2571.00	$296.00	$2838.36	$326.78

SD, standard deviation; HS, Harmonic Scalpel; USD, US Dollars.

Table 3. Percentage and absolute reduction in total reported costs with Harmonic scalpel compared with conventional care.

	Total reported costs,* RoM (95% CI); p-value	% Reduction in cost	Mean baseline total reported costs in 2015 USD (Conventional technique)	Absolute reduction in cost expressed in 2015 USD, Mean (Range)
Primary Analysis (RoM)	0.90 (0.83, 0.97); 0.007	10%	$2292.70	$229.27 ($89.67–$304.28)
Sensitivity Analyses:
Analysis using RoGM	0.90 (0.83, 0.98); 0.02	10%	$2292.70	$229.27 ($89.67–$304.28)
Inclusion of operating costs only	0.90 (0.805, 0.996); 0.04	10%	$2362.72	$236.27 ($89.67–$304.28)
Developed economies (exclude developing economies^15)	0.88 (0.81, 0.95); 0.002	12%	$2220.32	$266.44 ($107.60–$365.14)
Imputation of Hallgrimsson et al.^13, 2008 SD based on Hozo et al.^21, 2005 methods	0.90 (0.82, 0.98); 0.01	10%	$2292.70	$229.27 ($89.67–$304.28)
All costs converted to 2015 Euros	0.89 (0.84, 0.95); 0.0002	11%	$2292.70	$252.20 ($98.63–$334.71)
Exclusion of studies requiring SD imputation^12^,^13	0.94 (0.888, 0.996); 0.03	6%	$2275.49	$136.53 ($53.80–$182.57)
Inclusion of Defechereux et al.^28, 2003 in primary analysis	0.90 (0.84, 0.97); 0.007	10%	$2154.80	$215.48 ($89.67–$304.28)
Exclusion of study with non-overlapping CI^12	0.92 (0.88, 0.97); 0.004	8%	$2371.04	$189.68 ($71.73–$243.43)
Primary analysis conducted using a Fixed Effects model	0.87 (0.86, 0.89); <0.00001	13%	$2292.70	$298.05 ($116.56–$395.57)

CI, Confidence Interval; RoM, Ratio of Means; RoGM, Ratio of Geometric Means; SD, Standard Deviation.

*A random effects model was applied.

Figure 4. Forest plot of ratio of means summary effect estimates for included sensitivity analyses.

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