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COST-EFFECTIVENESS ANALYSIS OF EARLY SURGERY VERSUS PERCUTANEOUS DRAIN PLACEMENT WITH INTERVAL SURGERY FOR COMPLICATED DIVERTICULITIS WITH ABSCESS FORMATION
Gabriela Esnaola
*1, Kurt Schultz
3, Miranda Moore
2, Haddon Pantel
3, Eric B. Schneider
1, Ira Leeds
31Yale University School of Medicine, New Haven, CT; 2MEDSUR Center for Health Services & Outcome Research, New Haven, CT; 3Yale University Department of Surgery, New Haven, CT
Background:
The optimal timing of non-emergent resection for patients with complicated diverticulitis remains controversial. Early surgery is associated with increased rates of stoma formation and surgical morbidity. In contrast, interval surgery following an image-guided percutaneous drainage strategy, when inflammation has decreased, prolongs disease management and is subject to repeat diverticulitis flares. This study performed a cost-effectiveness analysis of early surgery compared to percutaneous drain placement with interval surgery for diverticulitis with abscess formation.
Methods:
A tree-based decision analysis model was constructed for a reference case patient undergoing early surgery versus interval surgery for complicated diverticulitis with abscess formation. Probabilities and utilities (quality-adjusted life years, QALYs) were sourced from secondary literature and Merative MarketScan healthcare claims data (2017-2022). Costs were obtained using Merative MarketScan healthcare claims data. "Early surgery" was defined as a non-emergent sigmoid colectomy performed within 30 days of index admission. "Interval surgery" was defined as a sigmoid colectomy performed over 30 and under 120 days from index admission following a percutaneous drainage procedure. Three surgical procedure types were considered: Hartmann procedure (HP) and primary anastomosis with or without diverting loop ileostomy (PADLI/PA). Outcomes assessed include total discounted economic costs, effectiveness (QALYs), and incremental cost effectiveness ratio (ICER, cost per QALY gained). A probabilistic sensitivity analysis was performed to account for uncertainty.
Results:
Early surgery was the more cost-effective strategy. Expected total costs for early surgery were $10,080 less than interval surgery, and early surgery yielded 0.62 more QALYs per patient. This relationship held true for all procedure types, with lower costs and higher QALYs attained for early HP (-$29,996, +0.5 QALYs), early PADLI (-$31,303, +0.89 QALYs), and early PA (-$13,472, +1.09 QALYs) compared to interval surgery. Sensitivity analysis satisfied this conclusion in 97.7% of cases. The threshold QALY decrement from percutaneous drainage to maintain cost-effectiveness favoring the early surgery strategy was as low as 0.032 (out of 1 QALY).
Conclusion:
Early surgery was the dominant strategy for surgical management of complicated diverticulitis. The superiority of early surgery was challenged in conditions where temporary percutaneous drain placement did not impact patient quality of life. Therefore, interval surgery may represent the optimal option in patients who have an external strong preference to delay intervention. This threshold for strategy variation emphasizes the importance of shared decision-making with patients around timing of surgery in cases of complicated diverticulitis with abscess formation.
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