Our calculations showed that the standard treatment costs for steam ablation were lower than those for vein stripping. In addition, we found that patients treated with steam ablation had shorter sickness absence, resumed daily and sporting activities sooner, and experienced fewer days with limitations in daily activities.
We calculated costs related to personnel and premises based on estimated time use in our own clinic. The need for training of healthcare personnel affects time use, and it is not always possible to streamline a clinic in the manner achieved by some institutions reporting short procedure times for vein stripping (6). Training requirements for surgeons affect the operating time and will have the greatest impact on vein stripping, which involves the most personnel. We have tried to compensate for this by assuming that only a single surgeon is used. Since endovenous steam ablation is a new procedure at our clinic, it is possible that our personnel have not yet reached the top of the learning curve and may therefore require more time to perform the procedure. Lower staffing requirements and shorter treatment times may lead to reductions in the cost of steam ablation in the long term, which will further increase the differential cost in favour of steam ablation. Time use in our department is considered comparable to that of other institutions, both for vein stripping and for steam ablation (6).
We found that costs related to disposable materials were higher for steam ablation than for vein stripping, due to the price of the steam catheter. Some studies have found this cost to be the deciding factor with respect to which treatment method is cheaper (12, 13).
Costs were calculated for a standardised intervention, a method that has been used previously (14). Recording the use of resources for each operation would have provided information on variation in time use and costs, but was beyond the scope of this study. We found the cost of steam ablation to be lower than that of vein stripping, but there is reason to believe that the cost may vary as a result of local conditions related to anaesthesia and operating techniques, labour costs, organisation, and personnel allocation. This may be one explanation for why another Norwegian study found the cost of vein stripping to be somewhat lower than we did (15).
Expenditure on post-treatment health care should usually be taken into account too, but was omitted from our study as there has been little reported need for healthcare provision after varicose vein treatment (11, 12). In our study, however, several procedure-related symptoms and complications were reported in patients who underwent vein stripping. Future studies examining the cost of varicose vein treatment should include these costs in addition.
We defined daily activities as simple, personal activities such as dressing and undressing, whereas others have also included more complex activities such as childcare and driving a car (16). We found that patients who underwent vein stripping resumed daily activities after a median of four days and reported limitations in daily activities for ten days. Patients treated with steam ablation resumed daily activities on the first postoperative day and reported limitations for two days, in line with other studies (10), (17–19).
Median sickness absence was 14 days in our patients who underwent vein stripping. Others have reported sickness absence ranging from 4 to 26 days following vein stripping; this variation may reflect differences in sickness benefit schemes, in people's expectations, and in surgical techniques (10, 12, 13, 19)(19–26). Our patients who were treated with steam ablation resumed work after a median of 2 days; a substantial difference versus vein stripping of 12 days (uncorrected). As an illustration, 12 days may mean a cost saving for society in the order of NOK 27 000 if we assume an annual salary of NOK 518 000 (27). This gain would come in addition to the lower hospital costs associated with the use of steam ablation.
As our study design did not include randomisation and blinding, we cannot fully exclude the possibility that the observed differences in sickness absence and resumption of activities reflect other, unknown factors. Sampling bias may also have occurred as we recruited patients continuously. The results must therefore be interpreted in light of these factors. Strengths of the study include the structured way in which questions relating to daily activities, exercise and sickness absence were delivered, as well as the fact that the patients were familiar with the questions in advance. This applied equally to both groups.
The short follow-up time and absence of a measure of clinical efficacy mean that we cannot draw conclusions about clinical outcomes per se or about the potential need for further treatment in the future, and thus we cannot draw conclusions about economic differences over time either. The results of another study, however, suggest that vein stripping and steam ablation are likely to have similar clinical outcomes, and no statistically significant differences in recurrence have been reported (28).
Another strength of our study is that all patients who were treated over a particular period were given the opportunity to participate, and only three declined. The patients were followed up closely, and we achieved a response rate of 100 %. We therefore assume that the risks of recall bias, follow-up bias and attrition bias are low (29).
There is little research in general on the short and long-term efficacy of steam ablation, and there is a need for good randomised clinical trials. There is also a need for better economic data, as shown by the results of a modelling study (15).