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ASSOCIATION FOR ACADEMIC SURGERY Economics of Appendicitis: Cost Trend Analysis of Laparoscopic Versus Open Appendectomy from 1998 to 2008
Brian McGrath, M.D.,* Michelle T. Buckius, M.D.,* Rod Grim, M.A.,† Theodore Bell, M.S.,† and Vanita Ahuja, M.D.*,‡,1
*Department of Surgery, York Hospital, WellSpan Health, York, Pennsylvania; †Emig Research Center, York Hospital, WellSpan Health, York, Pennsylvania; and ‡Penn State–Hershey, Hershey, Pennsylvania Originally submitted January 17, 2011; accepted for publication June 27, 2011
Background. Laparoscopic appendectomy (LA) has become more acceptable for the treatment of appendicitis over the last decade; however, its cost beneﬁt compared to open appendectomy (OA) remains under debate. The purpose of this study is to evaluate the utilization of LA and its cost effectiveness based on total hospital charges stratiﬁed by complexity of disease and complications compared to OA. Material and Methods. Nationwide Inpatient Sample data from 1998 to 2008 with the principal diagnosis of appendicitis were included. Appendicitis cases were divided by simple and complex (peritonitis or abscess) and subdivided by OA, LA, and lap converted to open (CONV). Total charges (2008 value), length of stay (LOS), and complications were assessed by disease presentation and operative approach. Results. Between 1998 and 2008, 1,561,518 (54.3%) OA, 1,231,643 (42.8%) LA, and 84,662 (2.9%) CONV appendectomies were performed. LA had shorter LOS (2 d) than OA (3 d) and CONV (5 d) (P < 0.001). CONV (7.4%) cases had more complications than OA (3.7%) and LA (2.6%). LA ($19,978) and CONV ($28,103) are costlier than OA ($15,714) based on normalized cost for simple and complex diseases (P < 0.001). Conclusions. LA is more prevalent but its cost is higher in both simple and complex cases. Cost and complications increase if the case is converted to open. OA remains the most cost effective approach for patients with acute appendicitis. Ó 2011 Elsevier Inc. All
Key Words: appendicitis; laparoscopic appendectomy; open appendectomy; laparoscopic converted to open appendectomy; cost; normalized cost.
Appendicitis is the most frequent intra-abdominal emergency in the United States. The current incidence of appendicitis in Europe/America is about at 100 cases per 100,000 persons per year. Open appendectomy (OA) has remained the gold standard of care since the technique was ﬁrst described by McBurney [1–3] over a century ago. In 1983, Semm provided the initial description of a laparoscopic appendectomy (LA) . The prevalence of LA has increased during the last decade. Research on whether the laparoscopic procedure is superior to the open approach has shown that LA may be the best approach with respect to reducing hospital length of stay (LOS) and time to return to work [5, 6]. Many randomized prospective trials and meta-analyses have been performed on the subject, but consensus on the superiority of LA has not been reached [7–10]. There remains a debate on the economic beneﬁt of LA versus OA. The cost of the surgery has been shown to be higher in the laparoscopic approach due to the operating room time . However, OA may have higher complication rates, which may negate the cost beneﬁt [8, 12, 13]. Studies thus far have not broken down the cost differences with respect to simple versus complex (i.e., ruptured, abscess) appendicitis. The objective of this study is to evaluate the utilization of LA as well as the cost effectiveness based on total hospital charges, cost associated with complication rates, stratiﬁed by complexity of disease with comparison to OA and LA converted to OA (CONV).
The present study was conducted using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project
To whom correspondence and reprint requests should be addressed at Department of Surgery, York Hospital, 1001 South George Street, York PA 17403. E-mail: firstname.lastname@example.org.
0022-4804/$36.00 Ó 2011 Elsevier Inc. All rights reserved.
6 d) and CONV (6. Patient Characteristics by Disease Presentation RESULTS Between 1998 and 2008. Agency for Healthcare Research and Quality from 1998 to 2008 . complications (yes or no).714). and CONV). P < 0 .2 d versus 2. Charlson scores were calculated according to Charlson  and Deyo  validated with published methods.html). 1.9 y).001).103) (P < 0.7 d) than OA (2. and 37. This is due to NIS being an administrative database and we cannot tell if patients had readmissions and/or had appendectomy at a later stage.978). hospital location (urban or rural).847.6 y) (P < 0. Other parameters of interest were cost of operation with and without in-hospital complications. OA was utilized significantly more for either simple or complex presentation (P < 0. The cases were divided between simple and complex.8% to 3. t-tests.001). DECEMBER 2011 (HCUP). All hospital costs used in this study were adjusted to 2008 values to account for inﬂation using the Consumer Price Index (Economic Evaluation of Public Health Preparedness and Response Efforts: Cost Analysis Tutorial. or CONV).001). and right hemicolectomy. LA also had signiﬁcantly shorter mean LOS (4. The trend for greater utilization of LA over OA was seen starting in 2005.8%) LA. LA.gov/owcd/EET/Cost/1.877. race (White.7 d) for simple cases. 1. Males received signiﬁcantly more appendectomy in OA.0 d) (both P < 0. 1).001). 1. and 84.cdc. Based on the multiple regression results. or large). 171. Department of Health and Human Services http:// www. and length of stay (in days) as our covariates. Statistical analysis was performed using descriptives.2 d). P < 0.518 (54. and CONV (5. appendicitis without mention of peritonitis. LA. Normalized cost for each type of operation refers to its costs after controlling for these covariates and adjusted for personperson variation.7%. urinary tract infection (UTI).001).231.001). Patient Characteristics by Type of Operation Table 1 shows the patient characteristics over the period studied. LA. LA (32. Hispanic. Appendectomies performed for complex compared with simple cases had more complications (6. type of case (simple or complex). Postoperative complications studied were LOS. private. Table 2 shows the data examined by simple and complex presentation for appendicitis.S. which follows the trend in increase of LA. Midwest. .134 versus $24.5% of these patients had peritonitis. The frequency of LA increased from 20. mortality. The total charges for simple were signiﬁcantly less than for complex disease ($15. which excludes anyone with recurrent appendicitis or treated with nonoperative management. or !3). incidental LA.396.823 appendectomies were performed: 1. Inclusion criteria were principal diagnoses at discharge for simple appendicitis (appendicitis. laparoscopic.7% versus 2.3 d). Charlson score (0. medium. payer (Medicare. In terms of mean age in years. and then subdivided by procedure performed (OA. FIG. we were able to calculate a normalized cost associated with each type of surgery by year. and appendicitis unqualiﬁed) and complex cases (appendicitis with peritonitis and appendicitis with peritoneal abscess). NO. acute renal failure (ARF).3 d) (P < 0. ANOVA with post-hoc tests.3%) OA.001).4 d) compared with OA (5.561. Total Cost by Type of Operation The cost for all types of appendectomies increased signiﬁcantly from 1998 ($13. all surgery groups were significantly different from each other: OA (30. LA was the preferred surgery for simple or complex cases toward the end of the study period. The frequency of CONV cases increased slightly over the study period (1.662 (2. and wound dehiscence. Patients who had CONV cases were more likely to have a complex disease. hospital region (Northeast. abscess/wound infection. or other). The predominant race was White followed by Hispanic population. Medicaid. South. and CONV approaches (P < 0. The multiple regression used costs as our predictor variable and type of surgery (OA.5 y). 2. Centers for Disease Control and Prevention. pulmonary embolism. Exclusion criteria were incidental appendectomy. The complication frequencies were determined and the costs associated with each complication taken into account to further determine the overall cost of the speciﬁc surgery through the years 1998–2008. and CONV (41. LA ($19. or West). 2. The NIS database contains information on inpatient hospital stays from about 1000 hospitals in 22 states. LA (2.643 (42.8% in 2008 (P < 0 .001). gender (male or female). tests of proportions. 2.001) (Fig. The mean LOS in days for all three surgery groups differed signiﬁcantly: OA (3. Only persons with appendicitis who had appendectomy as the primary procedure. Weighting was applied to all of the analysis to account for patients who were not accounted for in the NIS data set. U. LA had signiﬁcantly shorter mean LOS (1. or other). pneumonia.0%) and longer mean LOS (5. and CONV ($28. teaching status of hospital (teaching or non-teaching). Black .6 d) and CONV (3.596) to 2008 ($26. Percent of operations by type of appendectomy (open. Chi-square tests. and multiple regressions. hospital bed size (small.6% in 1998 to 70.2 d) for complex cases.e162 JOURNAL OF SURGICAL RESEARCH: VOL. laparoscopic coverted to open) from 1998–2008. were included in the study. The total charges for all three surgery groups also differed signiﬁcantly: OA ($15.9%) CONV. age (in years).
006 1.074 888.589 1.950 31. Laparoscopic (LA.886 9046 51.203 15.4% 12.8% 1.001 <0.0% 6.5% 6.011 22.230.8% 18.7% 2.527 11.4% 68.162 45.2% 21.275 739.) and Laparoscopic Converted to Open (CONV) from NIS 1998 to 2008 OA Count Gender Male Female Race White Black Hispanic Other Payer Medicare Medicaid Private including HMO Other Bed size of hospital Small Medium Large Location of hospital Rural Urban Teaching status of hospital Non-teaching Teaching Region of hospital Northeast Midwest South West Disease presentation Simple Complex With peritonitis With abscess In-hospital Complications Yes No Charlson 0 1 2 !3 Died during hospitalization Yes No Age in y at admission (mean) LOS (mean) Total charges (mean) % Count LA % Count CONV % P <0.166 949.765 807.849 475.7% 68.852 239.315.5 2 19. In-Hospital Complications and Cost Table 3 shows the complications during the hospitalization studied with numbers of cases in the database.3% 89.483 25.525 41.9% <0.851 32. 3).816 31.147 965.898 78.6% 97.583 1.5% 25.021 13.001 <0.304 238.4% 7.5% 1.4% 2.559.001 934.293 57.795 265.395.McGRATH ET AL.615 401.7% 8.879 114.939 35.849 319.361 65.503 22.777 1.2% 31.8% 71.9% 0.899 53.7% 65.001 <0.978 53.0% 15.4% 61.361 69.3% 35.0% 60.4% 88.145 618 1.9% 48.4% 3.001 <0.3% 27.883 1927 1.806 14.9% 647.2% 41.9% 19.356 252.493 29.9% 61.846 54.2% 15.8% 2.0% 20.4% 21. In 2008.001 <0.4% 1.219 30.001 P < 0.767 980.001) for simple appendicitis (Fig. Figure 2 shows the cost associated with each procedure by year.5% 27.001 <0.193 76.8% 20. LA ($34.064.806 560.6% 58. CONV ($28.714).953 76.073 4424 9818 3781 10.6% 46.001 <0.: ECONOMICS OF APPENDICITIS e163 TABLE 1 Patient Characteristics for Open (OA).180 19.6% 12.678 105.512 1.012 321.033) was more expensive than OA ($20.7% 60.075 6301 78.7% 28.4% 7.7% 35.0% 13.858) and complex ($34. The cost for OA and LA for both simple and complex cases increased over the study period.889) for complex cases.3% 1.7% 7.891 352.056 17.594 171.6% 26.1% 39.428 47.555 177.4% 16.5% 11.041 135.059 1.1% 78.103 58.3% 7.103) costs were greatest.179 439.273 225.122 121.687 723.1% 99.518) was less costly than OA ($37.741 23.6% 81.3% 64.1% 83.706 233.4% 15.848 186.296.8% 56.978).0% 56.003 51.6 5 28.8% 37.096. all P < 0.913 491.174 434.278 345.2% 6.818 2293 2443 116 84.7% 23.001 <0.200.5% .6% 15.0% 89.005 638.1% 99.001 <0.8% 16.2% 38.504.405 338.0% 7.618 18.7% 84.8% 20.5% .703) cases.9% 15.5% 39.380 155. followed by LA ($19. and OA ($15.4% 92.3% 62.899 32.7% 37. while LA ($24.961 155.2% 12.448 738.8% 5.001 <0.6% 6.001).262 86.0% 12.669 496.9% 18. In 2008.933 33.7% 11.1% 30.0% 16.418 602.7% 96.1% 99.344 1. Laparoscopic converted to open (CONV) remained the most expensive surgery in 2008 for both simple ($24.654 71.092.001 <0.2% 65.4% 16.001 <0.193 239.001 <0.9% 10.8% 39.735 188. .6% 30.747 13.9 3 15714 60.3% 7.7% 22.951 580.7% 15.108 245.107 10.
131 405. OA.4% 2.6% 19.9% 1.848 54.0% 67.0% .2% 6.313 869.0% 43. our study showed that LOS is longer in open operation.0% 477.001 <0. Similarly.2 24847 <0. data indicated increases in charges for complex cases were signiﬁcantly higher if there was a complication with OA by $23.2% 7. and the cost for CONV increased by $11. In simple cases. 171.267 1.4%).001 <0.001).015 2148 815. CONV cases had the highest wound infection/ abscess rate (3.516. LA. and CONV by $14. for LA by $20.3% 40.171 59.846 40. 2. DECEMBER 2011 TABLE 2 Patient Demographics by Disease Presentation (Simple or Complex Appendicitis) from NIS 1998 to 2008 Simple n Gender Male Female Race White Black Hispanic Other Surgery Open Lap Converted to open In-hospital complications Yes No Died during hospitalization Yes No Age in y at admission (mean) LOS (mean) Total charges (mean) % n Complex % P <0.881 115.483 1.816 54.134 57.7% 93.153. which were signiﬁcantly higher if there was a complication for OA. the trend for cost of CONV remains the highest.7% 46.e164 JOURNAL OF SURGICAL RESEARCH: VOL.0 5. LA.586 496.412 513 2.8% 32.7% 36. Multiple regression was performed to ﬁnd the contribution of comorbidity. but the laparoscopy portion has a higher contribution to the cost.878.001 <0.001 <0.390.850 328.525 versus $37.001 <0.005).409 290.5% 51.001).6%) (P < 0. payer status.017. However. The highest contributor found was laparoscopic operation as the average cost went up $7594 when laparoscopic surgery was performed. hospital variation.001).940) (P < 0.001 <0.108 versus $44. LOS.683 (P < 0.7% 6. (0.669 965. The charges increased for each surgical procedure regardless of simple or complex. disease presentation.0% 98. Overall.368 versus $40. If there was a complication during the hospitalization.293 94.6%) (P < 0. NO.497 763. and CONV for simple or complex appendicitis (Table 4).849 265.525). and region.3% .001).2% 19.5% 6.4%) are signiﬁcantly greater than OA (3. the OA cost with complication increased by $10.019. LA. Overall. LA ($21. region of hospital.0 15. The cost of LA is signiﬁcantly higher than OA for both simple and complex disease when the cost is adjusted for . Mean cost of each type of operation from 1998–2008.2 2. followed by OA (1. are controlled for over the study period. such as patient characteristics.064. the cost for LA increased by $9.631 39. OA. and patient characteristics to the cost associated with appendectomy. and CONV ($30.899 2.1% 6.3% 99.480 113.795 29.0% 100.961 42. complications for CONV (7. type of hospital.7%) and LA (2.444. and CONV had signiﬁcantly higher LOS with complication for simple or complex appendicitis. Figure 4 shows the normalized cost of the three surgery groups when the covariates. then LA FIG.0% 60.001 1.472 30. the cost rose signiﬁcantly for OA ($17.879.001 Table 4 shows mean number of complications with simple or complex and then by type of surgery. and CONV. 2.7% 67. Table 4 shows the overall charges. (Table 5).4%).2% 7.059.
3. overall costs for both open and LA doubled. This increase in prevalence is most likely due to recent studies showing advantages of shorter hospital stay.1% n 5427 13559 7021 331 6353 84 LA* % 0. which we hypothesize may be due to increasing medical costs. In 2008. Since the base TABLE 3 In-Hospital Complications OA* Variable ARF UTI Abscess/wound infection PE Pneumonia Wound dehiscence ICD-9 code 997.001 <0. LA ¼ laparoscopic appendectomy. From 1998 to 2008.5 590 998. equipment costs. medication. .McGRATH ET AL.9% 1.527 1321 % 0.1% 1.001 <0.001 <0.001 <0. our study shows that the open approach remains less costly even when there are complications.3 n 7989 17.001 *OA ¼ open appendectomy. A total of 2. for simple appendectomies.8% 3.877. The preference for LA over OA may reﬂect the shorter learning curve with LA for surgeons and pressure from patients for minimal invasive procedures [9.3 998. lower complication rates.823 cases were examined in the database for appendicitis. In this study. Mean cost of each type of operation by simple and complex from 1998–2008.025 22.04% .59 415.4% 0. and diagnostic testing like CT scans.1% . insurance.001).7% 0.04% 0.4% 0. the NIS database was examined to determine the cost beneﬁt of appendectomy by laparoscopic or open procedure and then with respect to disease presentation in regard to complex versus simple appendicitis. LA has become more prevalent in both the simple and complex appendicitis cases. laparoscopic cost remained higher than the open operation through the study period.11 997.1% 1.001 <0.1% P <0.: ECONOMICS OF APPENDICITIS e165 FIG.146 656 11.5% .4% 1. DISCUSSION Over the last decade. 13]. covariates (P < 0. CONV ¼ laparoscopic converted to open appendectomy. and return to work earlier. Due to the high cost of laparoscopy. Our data show that the trend for LA over OA starting in 2005.6% .01% n 801 1486 2898 121 1212 113 CONV* % 0.4% 0.5% 1.
demonstrated a lesser readmission rate in the laparoscopic compared to the open .775 0. A limitation of the study is that it is a retrospective study and therefore the groups are not necessarily similar. While some randomized studies have shown reduced cost for LA with reduced pain. We were unable to examine if these patients had previous operations that increased their risk of conversion. the data that NIS contains does not include readmission data or outpatient treatment of complications. The cost beneﬁt of LA in complex disease has been controversial. Additionally.001 <0. Sporn et al.425 $47. Moore et al.  have performed a decision analysis. as well as the rationale for determination of laparoscopic versus open based on patient characteristics.131 $13. Swank et al.194 $45. the cost of OA still remains less expensive when the appendicitis is complicated and however the TABLE 5 Contribution of Each Variable in the Cost of Operation Variable LAP Western region of US CONV Charlson score of 3 LOS Charlson score of 2 Simple case Hispanic race Charlson score of 1 Other race Black race Other payer Age Male gender Teaching hospital Medicaid payer Medicare payer Medium size hospital Northeast region Small sized hospital Midwest region of US Contribution ($) adds or subtracts 7594 7353 4892 4688 4591 3866 3019 2276 1484 993 993 100 61 13 À75 À154 À206 À629 À1075 À1305 À3301 cost beneﬁt disappears when adjusted for covariates.003 2. patient preference.778 $49. and demonstrated that the laparoscopic approach may be beneﬁcial if wound infection rate exceeds 23% in OA.5 6.001 0.2 10. Also. mean Charges. (Table 4) Katkhouda et al. also found that the only signiﬁcant risk factor for conversion was the presence of a generalized purulent peritonitis . laparoscopic approach may have longer operative time.1 4.911 $25.001 <0.001 0.05 $24.7 3.138 OA LA Complex CONV P <0.02 $19. which could contribute to the higher hospital cost. It is possible that an open approach might have been deemed safe given patient/disease characteristics.6% rate of readmission.07 $26.052 $77.399 $77.878 1.733 $43. However.924 $23.6 1. previous abdominal surgery has not been a signiﬁcant factor. NO. There have been arguments stating that lower cost of shorter hospital stay and earlier return to work may offset the base cost for laparoscopic surgery . Ninh et al. The lower cost for simple OA remains less but not signiﬁcantly when the patient experiences more than one complication. showed that laparoscopic approach was 9% higher than OA in patients with complicated appendicitis . our hospital data does not take into account readmission and posthospital cost.926 5.  showed that the LOS is similar in both groups. Surgeon preference for laparoscopic versus open approach adds bias.001 <0.9 9.247 $47.1 1.716 4.0 1.293 $28. 171.703 $33. CPI adjusted Overall 0 Complications 1 Complication 2–3 Complications LA CONV P <0.233 $35. One study showed a 4. Also.001 0. we are not able to examine if the surgeon’s laparoscopic volume or if advance training may have played a role in their results. which may not still be offset by the increased LOS and higher complication rates for OA in complex cases.001 <0.726 $28.858 $24. These patients tend to be older and have complex disease with peritonitis.908 $19.855 OR cost of LA remains higher than for OA and also.03 $14. When taking into account the complexity of the appendicitis.2 1.555 <0.897 3. Additionally.05 $34.001 <0. DECEMBER 2011 TABLE 4 Mean Number of Complications by Presentation (Simple and Complex) and Type of Surgery Simple OA Length of stay w/o complications w/ complications Number of complications.001 <0.150 $47. and earlier return to work . when laparoscopic cases are converted.06 $29. taking into account a potential complication.493 $59. This may be due to the high upfront cost of laparoscopy equipment.2 8.e166 JOURNAL OF SURGICAL RESEARCH: VOL.001 <0. 2. In comparison between open and laparoscopic.7 1. which would add to the costs this study is unable to measure .8 1. they have higher complication rates and longer length of stay.117 5.
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