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Operative delay to laparoscopic cholecystectomy: Racking up the cost of health care
Diane A Schwartz1, Adil A Shah, Cheryl K Zogg
1From the Department of Surgery (D.A.S., A.A.S., C.K.Z., C.G.V., D.T.E., E.B.S.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management (L.H.N.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center for Surgery and Public Health (A.A.S., C.K.Z., E.B.S., A.H.H.), Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
Background:
Health care providers are increasingly focused on cost containment. One potential target for cost containment is in-hospital management of acute cholecystitis. Ensuring cholecystectomy within 24 hours for cholecystitis could mitigate costs associated with longer hospitalizations. We sought to determine the cost consequences of delaying operative management.
Methods:
The Nationwide Inpatient Sample (2003-2011) was queried for adult patients (≥16 years) who underwent laparoscopic cholecystectomy for a primary diagnosis of acute cholecystitis. Patients who underwent open procedures or endoscopic retrograde cholangiopancreatography were excluded. Generalized linear models (GLMs) were used to analyze costs for each day's delay in surgery. Multivariable analyses adjusted for patient demographics, hospital descriptors, Charlson comorbidity index, mortality, and length of stay.
Results:
We analyzed 191,032 records. Approximately 65% of the patients underwent surgery within 24 hours of admission. The average cost of care for surgery on the admission day was $11,087. Costs disproportionately increased by 22% on the second hospital day ($13,526), by 37% on the third day ($15,243), by 52% on the fourth day ($16,822), by 64% on the fifth day ($18,196), by 81% on the sixth day ($20,125), and by 100% on the seventh day ($22,250) when compared with the cost of care for procedures performed within 24 hours of admission. Subset analysis of patients discharged 24 hours or earlier from the time of surgery demonstrated similar trends.
Conclusion:
After controlling for patient- and hospital-related factors, we noted significant costs associated with each day's delay in operative management. Cost containment practices for acute cholecystitis justify consideration of same-day or next-day surgery where the diagnosis is straightforward.
Level Of Evidence:
Economic and value-based analysis, level III.
