Comparison of outcomes and cost-effectiveness of laparoscopic and open appendectomies in public health services

Abstract

Acute appendicitis is the leading cause of abdominal emergency surgery worldwide and appendectomy continues to be the definitive treatment of choice. This cost-effectiveness analysis evaluates laparoscopic versus open appendectomies performed in public health services in the state of Bahia (Brazil). We conducted a retrospective observational study using the database from the Department of Informatics of the Unified Health System (DATASUS). Available data on appendectomies between 2008 and 2019 were included, and we evaluated the temporal trend of hospital admissions, procedure-related mortality rates, length of stay, and costs. Statistical analysis was performed using the R-software (R Foundation, v.4.0.3) and the BioEstat software (IMDS, v. 5.3), considering p<0.05 as significant. During 2008-2019, 53,024 appendectomies were performed in the public health services in Bahia, of which 94.9% were open surgeries. The open technique was associated with a higher mortality rate (4.9/1,000 procedures; p<0.05) and a higher risk of death (RR=4.5; p<0.05) compared to laparoscopy (1.1/1,000 procedures). Laparoscopic appendectomy (median of 2.7 days) had a shorter length of stay compared to laparotomy (median of 4.15 days) (p<0.05). There was no difference in the medians of costs nor hospital services, per procedure (p=0.08 and p=0.08, respectively). Laparoscopic professional median costs were higher by US$ 1.39 (p<0.05). Minimally invasive surgery for appendicitis is a safe and efficacious procedure in Brazilian public health care services, as it provides advantages over the open method (including lower procedure-related mortality rate and earlier discharges), and it did not imply higher expenses for public service budgets in the state of Bahia.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States

“…The reported mortality after appendectomy in various countries is 0.1% to 0.5%. 23 A relative increase of 20% in odds of mortality between the countries (OR = 1.2) was considered clinically relevant. Assuming a baseline mortality incidence of 0.2% and a logistic regression analysis with 4 covariates, a sample size of 44,500 patients per group was required to detect a difference of 20% in the odds of mortality between the countries, with 80% power, a significance level of 0.016, and 2-sided testing.…”

“…[23][24][25] A study on >50,000 appendectomies in Brazil reported a mortality rate of 0.47%. 23 Analysis of about 40,000 appendectomies performed in >100 institutions in the United States found a 30-day mortality rate of 0.07% to 0.17%. 24 Reports comparing FTR between LMICs and HICs are extremely scarce.…”

“…International Appendectomy Outcomes Our results are in agreement with studies that have reported higher mortality rates after appendectomy in LMICs. [23][24][25] A study on >50,000 appendectomies in Brazil reported a mortality rate of 0.47%. 23 Analysis of about 40,000 appendectomies performed in >100 institutions in the United States found a 30-day mortality rate of 0.07% to 0.17%.…”

Análise comparativa entre a recuperação pós-operatória entre pacientes submetidos a cirurgia laparoscópica e aberta de apendicectomia

“…Por fim, a escolha entre as duas técnicas deve ser feita com base nas condições do paciente e na opinião do cirurgião. Em conclusão, as técnicas de apendicectomia têm vantagens e desvantagens únicas, e a escolha entre as duas depende das circunstâncias individuais de cada paciente (NASCIMENTO et al, 2021).…”

“…Prova disso são as constatações de melhor cicatrização, tolerância mais rápida às comidas e redução da dor pós-operatória, fato esse que diminui, inclusive, a necessidade de se adotar analgésicos após a cirurgia. Além disso, devido ao menor tempo de hospitalização, o retorno às atividades normais tende a ocorrer mais rapidamente naqueles pacientes submetidos à AL (NASCIMENTO et al, 2021).…”