J. X. Wu1, A. J. Dawes1, G. D. Sacks1 1UCLA David Geffen School Of Medicine,Department Of General Surgery,Los Angeles, CALIFORNIA, USA
Introduction: Appendectomy remains the gold standard of treatment for acute uncomplicated appendicitis. Nonetheless, there is growing evidence that non-operative management is both safe and efficacious. Non-operative management avoids the initial cost and morbidity associated with an operation, but may result in longer hospital stays, increased readmissions, and higher risk of treatment failures. We hypothesized non-operative management of acute appendicitis is cost-effective.
Methods: We constructed a decision tree to compare non-operative management of acute uncomplicated appendicitis both with and without interval appendectomy (IA) to laparoscopic appendectomy at the time of diagnosis (Fig 1). Outcome probabilities, health utilities, and direct costs were abstracted from a review of the literature, Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Conservative estimates were used for operative costs and postoperative quality adjusted life-year (QALY) reductions to favor conventional operative management. Operative management was used as the reference group for cost-effectiveness comparisons. We performed Monte Carlo simulations using one-way and probabilistic sensitivity analyses to assess model parameters.
Results: Operative management had a mean cost of $12,386. Compared to the status quo, non-operative management without IA dominated as the most cost-effective management strategy, costing $1,937 less and yielding 0.04 additional QALY. Non-operative management with IA was the least cost effective strategy, requiring an additional $2,880 per patient with no additional health benefit. One-way sensitivity analysis revealed that operative management would become the dominant strategy if recurrence rate of acute appendicitis after non-operative management exceeds 42%, or if the total cost of operative management could be reduced below $5,568. Probabilistic sensitivity analysis revealed that non-operative management without IA was dominant in 100% of 10,000 iterations.
Conclusion: Non-operative management without IA is potentially the most cost-effective treatment for healthy adults with acute uncomplicated appendicitis, and deserves serious consideration as a treatment option for a disease long thought to be definitively surgical. Further studies are necessary to better characterize the health states associated with the various treatment outcomes.
