S. W. Knight1, S. Scaife2, J. D. Mellinger1, S. Ganai1,3 1Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 2Southern Illinois University School Of Medicine,Center For Clinical Research,Springfield, IL, USA 3Southern Illinois University School Of Medicine,Population Science And Policy,Springfield, IL, USA
Introduction: Guidelines for management of gallstone pancreatitis (GSP) recommend cholecystectomy at the index admission to limit risk of readmission from recurrent pancreatitis, cholangitis or acute cholecystitis. It is uncertain whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy or stenting is sufficient management for this patient population. We hypothesized that index cholecystectomy (chole) for GSP would be the more cost-effective strategy using a time horizon of a single quality-adjusted life-year.
Methods: A retrospective cohort analysis was performed using the National Readmission Database (NRD) from 2013-2015 across 1st-3rd quarters to obtain full 90-day readmission data for all analyzed patients. Inclusion criteria identified adults admitted with pancreatitis and various cholelithiasis ICD-9 codes. Exposures were procedures (ERCP, cholecystectomy, none, or both) coded during the index hospitalization. Outcomes included cost, likelihood of 90-day readmission, and risk of death. A societal perspective framework for cost-effectiveness was used based on likelihood of readmission, median cost of each admission, mortality with intervention or readmission, and negative utility of a readmission (NUR), factoring the perceived impact of a 90-day readmission in respect to quality of life (QOL)..
Results: In total, 396,978 index admissions with a diagnosis of GSP were studied. Readmissions were noted in 32.8% of patients receiving no procedure (n=336393), 12.6% receiving chole (n=54917), 13.5% of patients receiving chole and ERCP (n=2260), and 38.6% of patients receiving ERCP (n=3408). Median cost for those who were not readmitted was $21k for no procedure, $55k for chole, $59k for chole/ERCP, and $41k for ERCP. Median cost for those who were readmitted was $72k for no procedure, $83k for chole, $149k for chole/ERCP, and $108k for ERCP. Readmission mortality was 1.45% for no procedure, nil for chole and chole/ERCP, and 0.85% for ERCP. Figure 1 models cost-benefit ratio using the above data controlling to the cost of a no procedure strategy across varying NUR.
Conclusion: Our cost-effectiveness analysis supports the hypothesis that cholecystectomy performed at the index admission for gallstone pancreatitis is superior to ERCP alone. ERCP is more favorable than ERCP/chole only when the expected surgical mortality is high or the NUR is less than 0.2 (<10 weeks of impaired QOL with readmission), primarily because of higher readmission rates and index+readmission mortality risk. ERCP alone prior to discharge is not an optimal strategy for an average-risk patient.
