James X Wu1, Steven L Lee2, Daniel A DeUgarte3. 1. David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, UCLA, Los Angeles, CA. 2. David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, UCLA, Los Angeles, CA; Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; LA Biomed, Torrance, CA. 3. David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, UCLA, Los Angeles, CA; Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA; LA Biomed, Torrance, CA. Electronic address: ddeugarte@mednet.ucla.edu.
Abstract
INTRODUCTION: Compared to operative fascial closure, nonoperative flap and/or skin-closure repair for gastroschisis has several potential advantages: avoidance of anesthesia, decreased pain, and improved cosmesis. Disadvantages include a higher risk of hernia. We hypothesized that routine nonoperative closure results in cost savings versus conventional management in uncomplicated gastroschisis. METHODS: A decision tree was constructed to compare three different strategies for the management of uncomplicated gastroschisis: nonoperative closure, primary closure, and routine silo. Model variables were abstracted from a literature review and the Medicare Physician Fee schedule. Uncertainty surrounding model parameters was assessed via one-way and probabilistic sensitivity analyses. RESULTS: According to our model, the nonoperative strategy for uncomplicated gastroschisis was the least costly, with an expected cost of $198,085 per patient. Primary closure cost $208,763 per patient. Routine silo placement was the most costly, $239,038 per patient. One-way sensitivity analysis suggested the cost of primary closure would be less costly than nonoperative management if the initial success rate of nonoperative management was less than 35.4% or if the initial success rate of primary operative closure was greater than 87.8%. Probabilistic sensitivity analysis found that nonoperative management was the least costly strategy among 97.4% of 10,000 Monte Carlo simulations. CONCLUSIONS: A nonoperative strategy for uncomplicated gastroschisis with routine attempted flap and/or skin closure repair is less costly than strategies using routine primary closure and routine silo placement. Given the expected cost savings and other potential advantages of the nonoperative strategy (including avoidance of general anesthesia), more studies examining outcomes of the flap and/or skin closure are indicated.
INTRODUCTION: Compared to operative fascial closure, nonoperative flap and/or skin-closure repair for gastroschisis has several potential advantages: avoidance of anesthesia, decreased pain, and improved cosmesis. Disadvantages include a higher risk of hernia. We hypothesized that routine nonoperative closure results in cost savings versus conventional management in uncomplicated gastroschisis. METHODS: A decision tree was constructed to compare three different strategies for the management of uncomplicated gastroschisis: nonoperative closure, primary closure, and routine silo. Model variables were abstracted from a literature review and the Medicare Physician Fee schedule. Uncertainty surrounding model parameters was assessed via one-way and probabilistic sensitivity analyses. RESULTS: According to our model, the nonoperative strategy for uncomplicated gastroschisis was the least costly, with an expected cost of $198,085 per patient. Primary closure cost $208,763 per patient. Routine silo placement was the most costly, $239,038 per patient. One-way sensitivity analysis suggested the cost of primary closure would be less costly than nonoperative management if the initial success rate of nonoperative management was less than 35.4% or if the initial success rate of primary operative closure was greater than 87.8%. Probabilistic sensitivity analysis found that nonoperative management was the least costly strategy among 97.4% of 10,000 Monte Carlo simulations. CONCLUSIONS: A nonoperative strategy for uncomplicated gastroschisis with routine attempted flap and/or skin closure repair is less costly than strategies using routine primary closure and routine silo placement. Given the expected cost savings and other potential advantages of the nonoperative strategy (including avoidance of general anesthesia), more studies examining outcomes of the flap and/or skin closure are indicated.
Authors: Melissa Wong; Assaf P Oron; Anna Faino; Susan Stanford; Jennifer Stevens; Claudia S Crowell; Patrick J Javid Journal: Am J Surg Date: 2020-03-09 Impact factor: 2.565