title: A cost-effectiveness analysis of early vs late reconstruction of iatrogenic bile duct injuries.
abstract: BACKGROUND
  Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair.
  
  
  METHODS
  A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters.
  
  
  RESULTS
  The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.
  
  
  CONCLUSIONS
  This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-4753, USA.
authors.forename: Leigh Anne
authors.initials: LA
authors.lastname: Dageforde
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Landman
authors.forename: Irene D
authors.initials: ID
authors.lastname: Feurer
authors.forename: Benjamin
authors.initials: B
authors.lastname: Poulose
authors.forename: C Wright
authors.initials: CW
authors.lastname: Pinson
authors.forename: Derek E
authors.initials: DE
authors.lastname: Moore
mesh_terms: D001649:Bile Duct Diseases / Q000191:economics / Q000209:etiology / Q000601:surgery*; D001652:Bile Ducts / Q000293:injuries* / Q000601:surgery; D001662:Biliary Tract Surgical Procedures / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007049:Iatrogenic Disease / Q000191:economics*; D018803:Models, Economic; D011183:Postoperative Complications; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D019651:Plastic Surgery Procedures / Q000191:economics* / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome