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Health Technology Assessment of Scheduled Procedures: Referral Thresholds for Haemorrhoid Procedures Health Information and Quality Authority Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority Health Technology Assessment of Scheduled Procedures Referral thresholds for haemorrhoid procedures November 2014 Safer Better Care Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority About the Health Information and Quality Authority The Health Information and Quality Authority (HIQA) is the independent Authority established to drive high quality and safe care for people using our health and social care services. HIQA’s role is to promote sustainable improvements, safeguard people using health and social care services, support informed decisions on how services are delivered, and promote person-centred care for the benefit of the public. The Authority’s mandate to date extends across the quality and safety of the public, private (within its social care function) and voluntary sectors. Reporting to the Minister for Health and the Minister for Children and Youth Affairs, the Health Information and Quality Authority has statutory responsibility for: Setting Standards for Health and Social Services – Developing person- centred standards, based on evidence and best international practice, for those health and social care services in Ireland that by law are required to be regulated by the Authority. Supporting Improvement – Supporting health and social care services to implement standards by providing education in quality improvement tools and methodologies. Social Services Inspectorate – Registering and inspecting residential centres for dependent people and inspecting children detention schools, foster care services and child protection services. Monitoring Healthcare Quality and Safety – Monitoring the quality and safety of health and personal social care services and investigating as necessary serious concerns about the health and welfare of people who use these services. Health Technology Assessment – Ensuring the best outcome for people who use our health services and best use of resources by evaluating the clinical and cost effectiveness of drugs, equipment, diagnostic techniques and health promotion activities. Health Information – Advising on the efficient and secure collection and sharing of health information, evaluating information resources and publishing information about the delivery and performance of Ireland’s health and social care services. 3 Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority 4 Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority Table of Contents ABOUT THE HEALTH INFORMATION AND QUALITY AUTHORITY ............. 3 1 HAEMORRHOID PROCEDURES ..................................................... 6 1.1 Scope of this health technology assessment ..................................... 6 1.2 Background ............................................................................ 6 1.3 Surgical options, alternatives and potential complications .................... 7 1.4 Current practice in Ireland .......................................................... 9 2 CLINICAL REFERRAL/TREATMENT THRESHOLD ........................... 13 2.1 Review of the literature ............................................................ 13 2.2 Clinical evidence ..................................................................... 14 2.3 Cost-effectiveness evidence ....................................................... 18 2.4 Budget impact and resource implications ....................................... 19 2.5 Advice on clinical referral/treatment threshold ................................. 21 3 DISCUSSION ........................................................................... 22 4 REFERENCES ........................................................................... 24 APPENDICES ................................................................................. 27 Appendix 1.1 – HIPE ICD-10AM/ACHI list of intervention codes for haemorrhoidectomy procedures ................................................................... 27 Appendix 1.2 Evidence table summarising the data extracted from the economic evaluation literature .................................................................................... 28 5 Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority 1 Haemorrhoid procedures 1.1 Scope of this health technology assessment This health technology assessment (HTA) evaluates the appropriateness and potential impact of introducing clinical referral and treatment thresholds for people who may require haemorrhoidectomy in Ireland. The effectiveness of this intervention may be limited unless undertaken within strict clinical criteria. This report is one of a series of HTAs of scheduled procedures. Details of the background to the request and general methodology are provided in the separate ‘Background and Methods’ document. (1) The scope of this HTA is to investigate clinical referral and treatment thresholds that can be used in the assessment, referral and diagnosis of adults who potentially require haemorrhoidectomy. Inputs from an Expert Advisory Group along with a review of the clinical and cost-effectiveness literature were used to inform the criteria. Additionally, the budget impact and resource implications were assessed, as appropriate. 1.2 Background Haemorrhoids result from swelling of blood vessels (the ‘anal cushions’) in the lower anal canal. These blood vessels are supported by connective tissue which, when weakened, leads to descent or ‘prolapse’ of the haemorrhoids. (2) There are two types of haemorrhoids, external and internal; these are classified based on their location relative to the dentate line which lies at the junction of the upper two thirds and lower one third of the anal canal; internal haemorrhoids are located above this line, while external haemorrhoids arise below it. The majority of haemorrhoidal symptoms arise from enlarged internal haemorrhoids, with painless rectal bleeding in association with bowel movement as the most common presenting symptom. As these haemorrhoids prolapse through the anal canal, the tissue can become traumatised and friable, leading to bleeding. The bleeding is typically bright red in colour. (3) In addition to bleeding, internal haemorrhoids tend to also cause a sensation of incomplete evacuation, tissue protrusion and mucous discharge. External haemorrhoids, meanwhile, are typically associated with anal discomfort with engorgement, pain with thrombosis, and (4) itching. 6 Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures Health Information and Quality Authority Fifty percent of the population will experience symptomatic haemorrhoid disease at some point in their lives, with the peak incidence of symptomatic disease between the ages of 45 and 65 years. (3) Factors that increase intra-abdominal pressure (for example, prolonged straining, constipation, pregnancy, ascites) contribute to the development of haemorrhoids. 1.3 Surgical options, alternatives and potential complications The differential diagnosis of haemorrhoids includes anal fissure, perirectal abscess, anal fistula, anal stenosis (narrowing of the anal opening), malignancy, inflammatory bowel disease (inflammatory bowel disease [IBD], Crohn’s disease and ulcerative colitis), anal condyloma (‘warts’), pruritus ani, rectal prolapse, hypertrophied anal papilla, and skin tags. (4) It is therefore important that these other conditions are ruled out before a diagnosis of haemorrhoids is arrived upon. Internal haemorrhoids are graded based on their appearance and degree of prolapse; this is known as Goligher’s classification: First-degree haemorrhoids (grade I): Bleeding, but without prolapse. Second-degree haemorrhoids (grade II): The anal cushions prolapse through the anus on straining, but reduce spontaneously. Third-degree haemorrhoids (grade III): The anal cushions prolapse through the anus on straining or exertion and require manual replacement into the anal canal. Fourth-degree haemorrhoids (grade IV): The prolapse stays out at all times and is irreducible. The type and extent of treatment depends on the extent of prolapse. Non-operative strategies may be employed in the first instance, and are particularly appropriate to the management of first-degree haemorrhoids. These include: avoiding constipation avoiding straining to evacuate the rectum increasing dietary fibre oral laxatives topical combination creams containing local anaesthetics with steroid. There are a number of interventional approaches available for management of proven haemorrhoids, which remain symptomatic despite conservative treatment. These include rubber band ligation, injection sclerotherapy, open and stapled haemorrhoidectomy and haemorrhoidal artery ligation surgery (HALS). Although the relative comparison of these techniques is beyond the scope of this present work, a brief description of common interventions is provided below. 7 Health Technology Assessment of Scheduled Procedures: Referral thresholds for haemorrhoid procedures
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