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Cost-Effectiveness of Total Pancreatectomy With Islet Cell Autotransplantation for the Treatment of Small Duct Chronic Pancreatitis
Gregory C. Wilson*, Daniel E. Abbott, Daniel P. Schauer, Mark H. Eckman, Syed Ahmad
Surgery, University of Cincinnati, Cincinnati, OH
Introduction: Total pancreatectomy and islet cell autotransplantation (TPIAT) has gained popularity for managing chronic pancreatitis (CP), but a cost-benefit assessment has not been scientifically performed. We hypothesized that TPIAT decreases long-term resource utilization and improves quality-of-life, justifying the initial costs and risks of the procedure.
Methods: From 1999-2013, 46 patients with small duct CP and detailed treatment and outcomes data in the perioperative period (12 months before and after TPIAT) were analyzed. These data populated a Markov model comparing ongoing medical management versus TPIAT for small duct CP. The surgery cohort included perioperative mortality and complication rates, while CT imaging, insulin use, morphine equivalent (MEQ) and endoscopic procedure (EGD, EUS, ERCP) and readmissions were used in both surgical and medical cohorts. Survival (quality adjusted life years, QALY) and cost (based on Medicare payment, 2013 US$) were discounted at 3% per year.
Results: Median patient age was 36 years (range = 15-61) with a predominance of females (n=29, 63%). The etiologies of CP were primarily idiopathic (n=30, 65%) followed by genetic (n=12, 26%). In the 12 months prior to TPIAT (medical management cohort), annual mean per patient hospital admissions were 1.6 (range = 0-11), endoscopic procedures 1.3 (range = 0-6), and imaging (CT/MRI) 1.3 (range = 0-4). In the surgical cohort there were no perioperative deaths, with complication and 30-day readmission rates of 41% and 37%, respectively. 1 year after TPIAT, annual mean per patient admissions, endoscopic procedures and imaging had decreased to 0.9 (range = 0-4), 0.4 (range = 0-2) and 0.9 (range 0-5), respectively. Furthermore, monthly narcotic use in the surgical cohort decreased from 138 to 37 MEQ (p=0.012). Cost and survival for the TPIAT versus continued medical management were $153,576/14.9 QALYs and $196,042/11.5 QALYs, respectively. Sensitivity analyses with variable perioperative mortality rates, quality of life adjustment and TPIAT payment did not substantially change the cost-effectiveness analysis.
Conclusions: In patients with refractory small duct CP, TPIAT is associated with both decreased cost and increased quality-adjusted survival. Because TPIAT is a cost-effective treatment for small duct pancreatitis, tertiary care centers should look for opportunities to increase the use of TPIAT, and insurers should more enthusiastically embrace its use.
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