title: MRCP is not a cost-effective strategy in the management of silent common bile duct stones.
abstract: BACKGROUND
  Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis.
  
  
  METHODS
  Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables.
  
  
  RESULTS
  The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome.
  
  
  CONCLUSIONS
  LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.
authors.affiliation: Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA. irene.epelboym@gmail.com
authors.forename: Irene
authors.initials: I
authors.lastname: Epelboym
authors.forename: Megan
authors.initials: M
authors.lastname: Winner
authors.forename: John D
authors.initials: JD
authors.lastname: Allendorf
mesh_terms: D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance / Q000191:economics*; D017081:Cholecystectomy, Laparoscopic; D042883:Choledocholithiasis / Q000175:diagnosis* / Q000191:economics* / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D003953:Diagnosis-Related Groups / Q000191:economics; D006760:Hospitalization / Q000191:economics; D006801:Humans; D006278:Medicare / Q000191:economics; D009518:New York; D011336:Probability; D012680:Sensitivity and Specificity; D012984:Software; D014481:United States