James X Wu1, Aaron J Dawes2, Greg D Sacks2, F Charles Brunicardi3, Emmett B Keeler4. 1. Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. Electronic address: JamesWu@mednet.ucla.edu. 2. Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA. 3. Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA. 4. Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA; RAND Corporation, Santa Monica, CA.
Abstract
BACKGROUND: Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious. METHODS: We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses. RESULTS: Operative management cost $12,213 per patient. Nonoperative management without interval appendectomy (IA) was the dominant strategy, costing $1,865 less and producing 0.03 more quality-adjusted life-years (QALYs). Nonoperative management with IA cost $4,271 more than operative management, but yielded only 0.01 additional QALY. One-way sensitivity analysis suggested operative management would become the preferred strategy if the recurrence rate was >40.5% or the total cost of appendectomy was decreased to <$5,468. Probabilistic sensitivity analysis confirmed nonoperative management without IA was the preferred strategy in 95.6% of cases. CONCLUSION: Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical. Published by Elsevier Inc.
BACKGROUND: Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious. METHODS: We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses. RESULTS: Operative management cost $12,213 per patient. Nonoperative management without interval appendectomy (IA) was the dominant strategy, costing $1,865 less and producing 0.03 more quality-adjusted life-years (QALYs). Nonoperative management with IA cost $4,271 more than operative management, but yielded only 0.01 additional QALY. One-way sensitivity analysis suggested operative management would become the preferred strategy if the recurrence rate was >40.5% or the total cost of appendectomy was decreased to <$5,468. Probabilistic sensitivity analysis confirmed nonoperative management without IA was the preferred strategy in 95.6% of cases. CONCLUSION: Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical. Published by Elsevier Inc.
Authors: Lindsay A Sceats; Seul Ku; Alanna Coughran; Britainy Barnes; Emily Grimm; Matthew Muffly; David A Spain; Cindy Kin; Douglas K Owens; Jeremy D Goldhaber-Fiebert Journal: MDM Policy Pract Date: 2019-08-17