Abstracts
1999 Digestive Disease Week

# 2182 INCIDENTAL APPENDECTOMY IN THE ERA OF LAPAROSCOPY
H T Wang, H C Sax, Univ of Rochester Med Ctr, Rochester, NY

Appendicitis and its complications remain a major cause of morbidity with a lifetime risk of 8%. A study done in the pre-laparoscopic era, without stratifying by sex or age, demonstrated no cost benefit for routine incidental appendectomy. With the onset of laparoscopy, both patient comfort and cost increased with minimal change in morbidity. As capitation contracts become more prevalent, a re-analysis of the role of incidental appendectomy is warranted. The goal of this study is to evaluate the cost-effectiveness of incidental appendectomy both by age and by type of surgery (open versus laparoscopic). Methods: Financial data from 251 patients undergoing appendectomy for acute appendicitis without complication at a single institution were identified. Age specific epidemiology data from the Center for Disease Control, Atlanta, on incidence of appendectomy were used in calculations. The following assumptions were made: incidental appendectomy patients would have had a similar incidence of acute appendicitis as the general population had their appendix not been taken out; and, complications related to incidental appendectomy were the same or less when compared to the acute situation and did not significantly change cost. Cost of one case of acute appendectomy = average total hospital cost (including operating room (OR) cost) + average surgeon billing + average anesthesia. Cost of incidental appendectomy = (cost of 10 extra minutes of OR and anesthesia time + cost of equipment + surgeon's bill) X number of incidental appendectomy needed to prevent one case of acute appendectomy. The amount saved in preventing one case of acute appendectomy = cost of one case of acute appendectomy minus cost of incidental appendectomies needed to prevent one acute appendectomy. Costs were extrapolated to the population as a whole stratified by sex and age. Data were computed at various surgeons' billing for incidental appendectomy (0, 10, or 50% of full reimbursement). Results: Laparoscopic appendectomy increased OR cost compared to open appendectomy (±113 vs. ±76, mean±SEM, t-test p<0.001) with no significant difference in hospital cost (±217 vs. ±157, p>0.05) respectively. At 10% surgeon reimbursement, open incidental appendectomy saved from to ,300 per prevented case in those under 25 years of age. Applied to the general population, open incidental appendectomy in those under 25 years represented savings of to per 10,000 population per year. Under a capitated system (0% surgeon fee), similar findings were noted with savings extending to those under 35 years of age. A surgeon's fee of 50% or laparoscopic incidental appendectomy accrued no savings in any age groups with cost exceeding ,000 per case prevented in those aged 70 years or older. Conclusions: Open incidental appendectomy at low or no surgeon reimbursement is a cost-effective procedure for patients under 25-35 years of age (depending on billing practices). Due to higher equipment costs, laparoscopic incidental appendectomy is not cost-effective in any age group.

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