Gastroenterologist and nurse management of symptoms after pelvic radiotherapy for cancer: An economic evaluation of a clinical randomized controlled trial (the ORBIT study)

Background: Over 20 distressing gastrointestinal symptoms affect many patients after pelvic radiotherapy, but in the United Kingdom few are referred for assessment. Algorithmic-based treatment delivered by either a consultant gastroenterologist or clinical nurse specialist has been shown in a randomised trial to be statistically and clinically more effective than provision of a self-help booklet. In this study we assessed cost-effectiveness. Methods: Outcomes were measured at baseline (pre randomisation) and six months. Change in quality adjusted life years (QALY) was the primary outcome for the economic evaluation; a secondary analysis used change in the bowel subset score of the modified Inflammatory Bowel Disease Questionnaire (IBDQ-B). Intervention costs, British pounds 2013, covered visits with the gastroenterologist or nurse, investigations, medications and treatments. Incremental outcomes and incremental costs were estimated simultaneously using multivariate linear regression. Uncertainty was handled non-parametrically using bootstrap with replacement. Results: The mean (SD) cost of treatment was £895 (499) for the nurse, £1101 (567) for the consultant. The nurse was dominated by usual care which was cheaper and achieved better outcomes. The mean cost per QALY gained from the consultant, compared to usual care, was £250,455; comparing the consultant to the nurse, it was £25,875. Algorithmic care produced better outcomes compared to the booklet only, as reflected in the IBDQ-B results, at a cost of approximately £1,000. Conclusion: Algorithmic treatment of radiation bowel injury by consultant or nurse results in significant symptom relief for patients, but was not found to be cost-effective according to the NICE criteria.