Operative Versus Nonoperative Management of Appendicitis: A Long-TermCost Effectiveness Analysis

摘要

>Background. Recent clinical trials suggest that nonoperative management (NOM) of patients with acute, uncomplicated appendicitis is an acceptable alternative to surgery. However, limited data exist comparing the long-term cost-effectiveness of nonoperative treatment strategies. >Design. We constructed a Markov model comparing the cost-effectiveness of three treatment strategies for uncomplicated appendicitis: 1) laparoscopic appendectomy, 2) inpatient NOM, and 3) outpatient NOM. The model assessed lifetime costs and outcomes from a third-party payer perspective. The preferred strategy was the one yielding the greatest utility without exceeding a $50,000 willingness-to-pay threshold. >Results. Outpatient NOM cost $233,700 over a lifetime; laparoscopic appendectomy cost $2500 more while inpatient NOM cost $7300 more. Outpatient NOM generated 24.9270 quality-adjusted life-years (QALYs), while laparoscopic appendectomy and inpatient NOM yielded 0.0709 and 0.0005 additional QALYs, respectively. Laparoscopic appendectomy was cost-effective compared with outpatient NOM (incremental cost-effectiveness ratio $32,300 per QALY gained); inpatient NOM was dominated by laparoscopic appendectomy. In one-way sensitivity analyses, the preferred strategy changedwhen varying perioperative mortality, probability of appendiceal malignancy orrecurrent appendicitis after NOM, probability of a complicated recurrence, andappendectomy cost. A two-way sensitivity analysis showed that the rates of NOMfailure and appendicitis recurrence described in randomized trials exceeded thevalues required for NOM to be preferred. >Limitations. There arelimited NOM data to generate long-term model probabilities. Health stateutilities were often drawn from single studies and may significantly influencemodel outcomes. >Conclusion. Laparoscopic appendectomy is acost-effective treatment for acute uncomplicated appendicitis over a lifetimetime horizon. Inpatient NOM was never the preferred strategy in the scenariosconsidered here. These results emphasize the importance of considering long-termcosts and outcomes when evaluating NOM.