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Cost-Effectiveness of Elective Cholecystectomy vs. Observation in Older Patients Presenting With Mild Biliary Disease
Abhishek Parmar*1,2, Mark Coutin1, Gabriela Vargas1, Nina Tamirisa1,2, Kristin Sheffield1, Taylor S. Riall1
1Department of Surgery, University of Texas- Medical Branch, Galveston, TX; 2Department of Surgery, UCSF-East Bay, Oakland, CA
INTRODUCTION: Cholecystectomy is the standard of care for younger patients with symptomatic cholelithiasis. However, older patients with mild biliary disease may have multiple competing risks and the optimal treatment strategy for these patients is not known. For these patients, cholecystectomy should ideally be performed in the subset of patients most likely to benefit. Our objective was to determine the threshold for probability of recurrent symptoms at which elective cholecystectomy is the more effective and cost-effective option.
METHODS: We built a decision model to evaluate the cost-effectiveness of elective cholecystectomy vs. observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis and not requiring initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications in these patients were determined from observed frequencies in a 5% national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Quality-adjusted life years (QALYs) for various health states were obtained from established literature estimates and the Tufts Cost-Effectiveness Analysis Registry. Threshold analyses was used to determine the probabilities of symptoms at which cholecystectomy became the more effective and cost-effective decision. Sensitivity analyses were also performed to account for variability in parameter estimates.
RESULTS: Compared to observation in all patients, elective cholecystectomy for this high-risk population was associated with slightly lower effectiveness (-0.09 QALYs) and had an increased cost of $3,320.44 per patient at two years follow-up. In the threshold analysis, elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 42.7%, with an additional cost of $2,236.99 per patient. Elective cholecystectomy was the both more effective and less costly when the probability for continued symptoms exceeded 80.8%. Our model was insensitive to wide variations in QALY measurements and costs.
CONCLUSION: These data can be used to guide shared decision-making in older patients presenting with symptomatic cholelithiasis. The development of models that accurately predict recurrent symptoms or complications from gallstones would allow practitioners to educate patients of the individual risks and benefits of observation versus elective cholecystectomy. This data driven, shared decision making approach has the potential to improve outcomes by increasing early elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimizing unnecessary cholecystectomy for patients unlikely to benefit.
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