Cost-Effectiveness of Rubber Band Ligation Versus Hemorrhoidectomy for the Treatment of Grade III Hemorrhoids: Analysis Using Evidence From the HOLLAND Randomized Controlled Trial

BACKGROUND: Hemorrhoids significantly impact quality of life and health care costs. Although rubber band ligation and hemorrhoidectomy are common treatments for grade III hemorrhoids, comparative cost-effectiveness data are limited. OBJECTIVE: To assess the cost-effectiveness and cost-utility of rubber band ligation compared to hemorrhoidectomy from a societal perspective within the context of the HOLLAND trial. DESIGN: Cost-effectiveness and cost-utility analyses using data from a multicenter, randomized controlled trial. SETTINGS: Ten Dutch hospitals participating in the HOLLAND trial. PATIENTS: Adults with symptomatic grade III hemorrhoids randomly assigned to receive rubber band ligation or hemorrhoidectomy treatment. INTERVENTIONS: Rubber band ligation (up to 2 sessions) or excisional hemorrhoidectomy. MAIN OUTCOME MEASURES: Cost per quality-adjusted life year gained and cost per recurrence avoided over 24 months from a societal perspective. RESULTS: Seventy-nine patients were analyzed (33 for hemorrhoidectomy and 46 for rubber band ligation). Hemorrhoidectomy resulted in better clinical outcomes with a quality-adjusted life year difference of 0.08 (95% CI, 0.04-0.13) and a recurrence difference of 33.5% (95% CI, 15.3%-51.7%). Hospital costs were higher for hemorrhoidectomy (€1364; 95% CI, 895-1834; p < 0.001), as were societal costs (€1984; 95% CI, -132 to 4101; p = 0.066). The incremental cost-utility ratio for hemorrhoidectomy was €24,042 per quality-adjusted life year gained, and the incremental cost-effectiveness ratio was €5918 per recurrence avoided. The probability of hemorrhoidectomy being cost-effective was 45.5% at €20,000 per quality-adjusted life year and 83.9% at €50,000 per quality-adjusted life year. For recurrence avoidance, probabilities were 98.3% and 99.8%, respectively. LIMITATIONS: The small sample size may limit generalizability and the ability to detect rare but costly complications. Procedural costs were based on average hospital prices, which is a pragmatic approach but is less detailed than bottom-up costing. CONCLUSIONS: In patients with grade III hemorrhoids, hemorrhoidectomy provides better long-term clinical outcomes, including higher quality of life and lower recurrence rates compared to rubber band ligation. However, its cost-effectiveness varies depending on societal willingness-to-pay thresholds. Caution is warranted before discarding it as a first-line treatment solely based on health care costs or limited operating room availability.