HOT SPRINGS, VA. — Delaying gallbladder surgery in elderly patients with acute cholecystitis might save money in the short run, but it racks up a bigger bill later in health outcomes and cash outlay, judging by a Medicare claims database study.
Early surgery significantly reduced cholecystitis recurrence and emergency gallstone-related readmissions, saving Medicare $7,000 for each avoided readmission, Dr. Taylor S. Riall said at the annual meeting of the Southern Surgical Association.
Dr. Riall of the University of Texas Medical Branch at Galveston, and her colleagues tracked Medicare claims data for almost 30,000 elderly patients (mean age 78 years) who were admitted for acute cholecystitis from 1996 to 2005. They examined cost and health outcomes for 24 months after the admission.
Most patients (89%) were white. More than half of the admissions (64%) were emergent; 36% were urgent. About one-quarter were admitted by a surgeon.
The majority of the patients (75%) underwent cholecystectomy during their initial hospitalization, and 71% of the procedures were laparoscopic. The median length of stay was 5 days, and the median Medicare payment was $7,362. There was a 2% in-hospital mortality rate.
For the 25% of patients who did not undergo surgery during their initial hospitalization, the median hospital length of stay was 4 days and the median Medicare payment was $4,251. However, Dr. Riall said, surgical patients had significantly fewer rehospitalizations over the 24-month follow-up period than did nonsurgical patients. Among the 21,907 who had the surgery and were discharged alive, 1.6% were rehospitalized for gallstone-related problems and 2.5% (556 patients) for surgical complications. The overall Kaplan-Meier readmission rate in this group was 4.4% with all readmissions occurring in the first 60 days postoperatively; the median Medicare payment for each readmission was $5,000.
These measures were all significantly different among patients who initially did not undergo cholecystectomy. Among the 7,250 who were discharged alive, 1,980 were later rehospitalized for gallbladder problems and 1,604 died in the 2 years following initial hospitalization. The Kaplan-Meier 2-year readmission rate was 38%, after adjustment for patient deaths, as these patients were no longer at risk of readmission. Of the patients readmitted for gallstone-related problems, 1,372 (19% of the discharged group) underwent a cholecystectomy and 608 (8%) did not. The overall median Medicare payment for readmission was $7,000. Another 694 of the discharged patients (9.6%) also had a later cholecystectomy on an outpatient basis and did not require emergency readmission.
Mortality rates over the next 24 months also were significantly different between the groups: 15% for those who had surgery during initial hospitalization, vs. 29% for those who did not.
Although the survival difference was significant, Dr. Riall warned against making too many assumptions about mortality. “It's almost certain that most patients who did not undergo cholecystectomy were sicker and had a higher 2-year mortality without cholecystitis,” said Dr. Riall, who did not report having any conflicts of interest.