The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children.
BACKGROUND
Several studies have demonstrated the safety and short-term success of nonoperative management in children with acute, uncomplicated appendicitis. Nonoperative management spares the patients and their family the upfront cost and discomfort of surgery, but also risks recurrent appendicitis.


METHODS
Using decision-tree software, we evaluated the cost-effectiveness of nonoperative management versus routine laparoscopic appendectomy. Model variables were abstracted from a review of the literature, Healthcare Cost and Utilization Project, and Medicare Physician Fee schedule. Model uncertainty was assessed using both one-way and probabilistic sensitivity analyses. We used a $100,000 per quality adjusted life year (QALY) threshold for cost-effectiveness.


RESULTS
Operative management cost $11,119 and yielded 23.56 quality-adjusted life months (QALMs). Nonoperative management cost $2277 less than operative management, but yielded 0.03 fewer QALMs. The incremental cost-to-effectiveness ratio of routine laparoscopic appendectomy was $910,800 per QALY gained. This greatly exceeds the $100,000/QALY threshold and was not cost-effective. One-way sensitivity analysis found that operative management would become cost-effective if the 1-year recurrence rate of acute appendicitis exceeded 39.8%. Probabilistic sensitivity analysis indicated that nonoperative management was cost-effective in 92% of simulations.


CONCLUSIONS
Based on our model, nonoperative management is more cost-effective than routine laparoscopic appendectomy for children with acute, uncomplicated appendicitis.


METHODS
Cost-Effectiveness Study: Level II.
Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, CHS 72-228, Los Angeles, CA, United States. Electronic address: JamesWu@mednet.ucla.edu.
James X
JX
Wu
Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, CHS 72-228, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, United States; Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA, United States.
Greg D
GD
Sacks
Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, CHS 72-228, Los Angeles, CA, United States; VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, United States; Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA, United States.
Aaron J
AJ
Dawes
Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, CHS 72-228, Los Angeles, CA, United States.
Daniel
D
DeUgarte
Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, CHS 72-228, Los Angeles, CA, United States; Department of Surgery, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, CA, United States.
Steven L
SL
Lee
D000208:Acute Disease / Q000191:economics; D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000191:economics; D001062:Appendectomy / Q000191:economics*; D001064:Appendicitis / Q000191:economics* / Q000601:surgery; D002648:Child; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D010535:Laparoscopy / Q000191:economics*; D007902:Length of Stay / Q000191:economics; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012008:Recurrence
D000900:Anti-Bacterial Agents
Acute appendicitis; Cost-effectiveness; Laparoscopic appendectomy; Nonoperative management; Pediatric