title: Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis.
abstract: BACKGROUND
  The application of early cholecystectomy for acute cholecystitis remains inconsistent across hospitals worldwide. Given the constrained nature of health care spending, careful consideration of costs relative to the clinical consequences of alternative treatments should support decision making. We present a cost-utility analysis comparing alternative time frames of cholecystectomy for acute cholecystitis.
  
  
  METHODS
  A Markov model with a 5-year time horizon was developed to compare costs and quality-adjusted life-years (QALY) gained from 3 alternative management strategies for the treatment of acute cholecystitis: early cholecystectomy (within 7 days of presentation), delayed elective cholecystectomy (8 to 12 weeks from presentation), and watchful waiting, where cholecystectomy is performed urgently only if recurrent symptoms arise. Model inputs were selected to reflect patients with uncomplicated acute cholecystitis-without concurrent common bile duct obstruction, pancreatitis, or severe sepsis. Real-world outcome probability and cost estimates included in the model were derived from analysis of population-based administrative databases for the province of Ontario, Canada. The QALY values were derived from utilities identified in published literature. Parameter uncertainty was evaluated through probabilistic sensitivity analyses.
  
  
  RESULTS
  Early cholecystectomy was less costly (C$6,905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8,511; 4.18 QALYs per person) or watchful waiting (C$7,274; 3.99 QALYs per person). Probabilistic sensitivity analysis showed early cholecystectomy was the preferred management in 72% of model iterations, given a cost-effectiveness threshold of C$50,000 per QALY.
  
  
  CONCLUSIONS
  This cost-utility analysis suggests early cholecystectomy is the optimal management of uncomplicated acute cholecystitis. Furthermore, deferring surgery until recurrent symptoms arise is associated with the worst clinical outcomes.
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada. Electronic address: charles.demestral@mail.utoronto.ca.
authors.forename: Charles
authors.initials: C
authors.lastname: de Mestral
authors.affiliation: Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Hoch
authors.affiliation: Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Harindra C
authors.initials: HC
authors.lastname: Wijeysundera
authors.affiliation: Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Ori D
authors.initials: OD
authors.lastname: Rotstein
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Aziz S
authors.initials: AS
authors.lastname: Alali
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada; Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000328:Adult; D002763:Cholecystectomy / Q000191:economics*; D041881:Cholecystitis, Acute / Q000601:surgery*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008390:Markov Chains; D009864:Ontario; D019057:Quality-Adjusted Life Years; D061665:Time-to-Treatment / Q000191:economics*; D016896:Treatment Outcome; D057832:Watchful Waiting / Q000191:economics