The impact of surgeon choice on the cost of performing laparoscopic appendectomy.
BACKGROUND
While laparoscopic appendectomy (LA) can be performed using a myriad of techniques, the cost of each method varies. The purpose of this study is to analyze the effects of surgeon choice of technique on the cost of key steps in LA.


METHODS
Surgeon operative notes, hospital invoice lists, and surgeon instrumentation preference sheets were obtained for all LA cases in 2008 at Cambridge Health Alliance (CHA). Only cases (N = 89) performed by fulltime staff general surgeons (N = 8) were analyzed. Disposable costs were calculated for the following components of LA: port access, mesoappendix division, and management of the appendiceal stump. The actual cost of each disposable was determined based on the hospital's materials management database. Actual hospital reimbursements for LA in 2008 were obtained for all payers and compared with the disposable cost per case.


RESULTS
Disposable cost per case for the three portions analyzed for 126 theoretical models were calculated and found to range from US $81 to US $873. The surgeon with the most cost-effective preferred method (US $299) utilized one multi-use endoscopic clip applier for mesoappendix division, two commercially available pretied loops for management of the appendiceal stump, and three 5-mm trocars as their preferred technique. The surgeon with the least cost-effective preferred method (US $552) utilized two staple firings for mesoappendix division, one staple firing for management of the appendiceal stump, and 12/5/10-mm trocars for access. The two main payers for LA patients were Medicaid and Health Safety Net, whose total hospital reimbursements ranged from US $264 to US $504 and from US $0 to US $545 per case, respectively, for patients discharged on day 1.


CONCLUSIONS
Disposable costs frequently exceeded hospital reimbursements. Currently, there is no scientific literature that clearly illustrates a superior surgical method for performing these portions of LA in routine cases. This study suggests that surgeons should review the cost implications of their practice and to find ways to provide the most cost-effective care without jeopardizing clinical outcome.
Chu
Thomas
T
Tufts University School of Medicine, Boston, MA, USA.
Chandhoke
Ryan A
RA
Smith
Paul C
PC
Schwaitzberg
Steven D
SD
D001062:Appendectomy / Q000191:economics* / Q000295:instrumentation; D001064:Appendicitis / Q000191:economics / Q000601:surgery; D002755:Choice Behavior; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D004209:Disposable Equipment / Q000191:economics* / Q000706:statistics & numerical data; D004210:Dissection / Q000191:economics / Q000295:instrumentation; D013502:General Surgery; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data*; D010535:Laparoscopy / Q000191:economics*; D008404:Massachusetts; D008484:Medicaid / Q000191:economics; D008483:Medical Assistance / Q000191:economics; D017057:Medically Uninsured; D010818:Practice Patterns, Physicians' / Q000191:economics*; D013525:Surgical Instruments / Q000191:economics / Q000706:statistics & numerical data; D013537:Sutures / Q000191:economics; D014481:United States