OBJECTIVES: This study explores to add carbon emissions to health economic evaluation of using stapler devices in China.

METHODS: We adapted a Cost-Effectiveness Analysis (CEA) and Budget Impact Analysis (BIA) to capture the health economic impact of manual endoscopic staplers compared with powered endoscopic staplers in surgery, by building a decision tree model and a BIA framework. Life cycle assessment (LCA) was used to track the carbon footprint of the manual and powered endoscopic staplers. This study introduced two approaches to add carbon emissions to the health economic evaluations. The first approach translated carbon footprint into health effects of CEA, while the second considered carbon footprint as an independent outcome indicator.

RESULTS: The carbon footprint for one manual and powered endoscopic stapler were 2.97 kg carbon dioxide equivalent (CO₂-eq), and 8.54 kg CO₂-eq, respectively. When the carbon footprint are converted to health costs, the CEA indicated the powered endoscopic staplers was dominated compared to manual endoscopic staplers, with a cost saving of 1656.83 yuan and a reduction in the anastomotic leak risk by 5%. The BIA showed the economic advantage of replacing manual endoscopic staplers with powered endoscopic staplers. When considering the carbon footprint as an independent outcome, compared to the manual counterpart, the powered staplers resulted in an increase of 1 kg CO₂-eq per case, while with 0.9% decrease of anastomotic leak risk and savings of 297.5 yuan. By 2027, the total incremental carbon footprint due to the gradual replacement of manual endoscopic staplers by powered endoscopic staplers was estimated to be 7,053 t CO₂-eq.

CONCLUSIONS: The use of powered staplers was cost-effective compared to manual staplers after adding carbon footprint of product itself to health economic evaluation. It is necessary to incorporate environmental, social and governance (ESG) perspective into health economic evaluation.