Cost‐effective surgery for better outcomes. BJS 2018; 105: 11-12.

Published: 19th December 2017

Authors: S. Paterson‐Brown

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Humza Malik

10 months ago

We welcome Mr. Paterson-Brown’s response to our paper (1). At the heart of contention is inguinal hernia repair for minimally symptomatic patients. Long-term follow-up from short-term trials have indicated that 32% of patients can be appropriately managed with watchful-waiting (2). Although applying this figure to the current national cohort requires assumptions, it does establish an understanding of the opportunity associated with de-adoption of this intervention (3).

By offering watchful-waiting over an intermediate timescale a surgeon would be able to decipher patients who would gain most from repair. This method is advocated by the Canadian Association of General Surgeons (4).

Index Cholecystectomy for acute gallstone pathologies should be debated less. Since December 2015 NICE recommends that cholecystectomy is performed within 2 weeks of acute cholecystitis as it provides best patient-related outcomes (5). Cited obstacles such as reduced theatre availability, lack of radiological and endoscopic support must be tackled in order to offer optimal treatment (1).

This illustrates the importance of clinical leadership.

The Choosing Wisely UK guidance contains valuable insights from other specialties on overuse of medical interventions with the notable absence of any surgical procedure (6). Getting It Right First Time (GIRFT) and Right Care are programmes committed to delivering optimal care to patients, making the NHS’s money travel further and bettering patient outcomes by tackling overuse/underuse of resources. Surgeons should instigate change with the primary goal of maintaining high quality care whilst achieving cost-effectiveness as an added benefit. To claim that surgical procedures are opportunities for ‘bargain-basement shoppers’ as Mr. Paterson-Brown does, is ill-informed at best.

H Malik
J Marti
A Darzi
E Mossialos

1. Paterson-Brown, S., Cost-effective surgery for better outcomes. Br J Surg, 2018. 105(1): p. 11-12.
2. Fitzgibbons, R.J., Jr., et al., Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg, 2013. 258(3): p. 508-15.
3. Malik, H.T., et al., Savings from reducing low-value general surgical interventions. Br J Surg, 2018. 105(1): p. 13-25.
4. (CAGS), C.A.o.G.S. Choosing Wisely Canada. 2013 27/12/2017].
5. NICE , N.I.f.H.c.a.E. Gallstone Disease – NICE. Dec 2015 [cited 2017 27/12/2017].
6. Academy of Royal Colleges, U. Choosing Wisely UK. [cited 2016 01/11/2016]; Choosing Wisely UK Guidance].