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Early cholecystectomy for acute cholecystitis offers the best outcomes at the least cost: a model-based cost-utility analysis

de Mestral C, Hoch JS, Laupacis A, Winjeysundera HC, Rotstein OD, Alali AS, Nathens AB. J Am Coll Surg. 2016; 222(2):185-94. Epub 2015 Nov 24.


Background — The application of early cholecystectomy for acute cholecystitis remains inconsistent across hospitals worldwide. Given the constrained nature of healthcare spending, careful consideration of costs relative to the clinical consequences of alternative treatments should support decision making. We present a cost-utility analysis comparing alternative timeframes of cholecystectomy for acute cholecystitis.

Study Design — A Markov model with a 5 year time horizon was developed to compare costs and quality-adjusted life-years (QALY) gained from three alternative management strategies for the treatment of acute cholecystitis: early cholecystectomy (within 7 days of presentation), delayed elective cholecystectomy (8 to 12 weeks from presentation) and watchful waiting, where cholecystectomy is performed urgently only if recurrent symptoms arise. Model inputs were selected to reflect patients with uncomplicated acute cholecystitis – without concurrent common bile duct obstruction, pancreatitis or severe sepsis. Real-world outcome probability and cost estimates included in the model were derived from analysis of population-based administrative databases for the province of Ontario, Canada. QALY values were derived from utilities identified in published literature. Parameter uncertainty was evaluated through probabilistic sensitivity analyses.

Results — Early cholecystectomy was less costly (C$6,905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8,511; 4.18 QALYs per person) or watchful waiting (C$7,274; 3.99 QALYs per person). Probabilistic sensitivity analysis showed early cholecystectomy was the preferred management in 72% of model iterations given a cost-effectiveness threshold of C$50,000 per QALY.

Conclusion — This cost-utility analysis suggests early cholecystectomy is the optimal management of uncomplicated acute cholecystitis. Furthermore, deferring surgery until recurrent symptoms arise is associated with the worst clinical outcome.

Keywords: Health care costs Surgery Health care evaluation

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