• Charles de Mestral, Jeffrey S Hoch, Andreas Laupacis, Harindra C Wijeysundera, Ori D Rotstein, Aziz S Alali, and Avery B Nathens.
• 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.
• J. Am. Coll. Surg. 2016 Feb 1; 222 (2): 185-94.

BackgroundThe 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.Study DesignA 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.ResultsEarly 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.ConclusionsThis 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.Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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