Cost-Effectiveness of Elective Laparoscopic Cholecystectomy Versus Observation in Older Patients Presenting with Mild Biliary Disease

Abstract

INTRODUCTION Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. METHODS We built a decision model of elective cholecystectomy vs. observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5% national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. RESULTS Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (−0.10 QALYs) and had an increased cost of $3,422.83 per patient at two years follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3%. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7%. CONCLUSION An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.

Cost-effectiveness of emergencyversusdelayed laparoscopic cholecystectomy for acute gallbladder pathology

“…The primary outcome measure was the QALY, which is a composite measure of the length and quality of life; 1 QALY is defined as 1 year lived in perfect health. Following the approach used by Morris and co‐workers to identify the most appropriate utility values, a review of the Cost‐effectiveness Analysis Registry was conducted and 20 studies identified. The utility scores in this analysis were taken from a single study ( Table S3 , supporting information).…”

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

“…7 8 In contrast, the study conducted by Parmar et al reported that observation was the most CE approach. 44 Similarly, three other studies comparing the cost-effectiveness of LC with OC also favoured laparoscopic surgery as it was less costly and more effective, concluding that LC dominates OC. 10 39 40 Contrastingly, Teerawattananon and Mugford found that LC was not CE compared with OC.…”

“…Most studies (N=11, 39.29%) adopted the payer perspective, followed by the health system perspective (N=10, 35.71%). Four studies adopted a societal perspective,24 29 42 43 and the remaining three studies did not mention the study perspective 13 35 44…”

Hospital readmission after emergency room visit for cholelithiasis

“…Early intervention for symptomatic gallstones has been demonstrated to be cost-effective, 12 yet insurance status has been shown to play a role in care of patients with gallstone disease. 13,14 Patients without insurance are more likely to present with complex disease and have cholecystectomy done on an emergent basis, resulting in longer hospital stays and further increasing health costs.…”