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.
“Our study will be relevant to policy issues such as episode of care reimbursement and determination of quality of care at the patient, physician, and hospital level,” said Dr. Riall of the University of Texas Medical Branch at Galveston. “Locally, we have already used these data to implement a pathway to maximize cholecystectomy rates during initial emergency admission.”
Dr. Riall 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.
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. Of the 21,907 who had the surgery and were discharged alive, 1.6% (352 patients) 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 (27%) were later rehospitalized for gallbladder problems and 1,604 (22%) died in the 2 years following initial hospitalization. The Kaplan-Meier 2-year readmission rate was 38%, after adjustment for patient deaths. Of the patients readmitted for gallstone-related problems, 1,372 (19% of the discharged group) underwent a cholecystectomy and 608 (8%) did not. The median Medicare payment for readmission was $7,000. Another 694 patients (9.6%) had a later cholecystectomy on an outpatient basis.
Mortality rates during 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. “The survival difference was significant even after controlling for patient comorbidities; patients who did not undergo cholecystectomy were 56% more likely to die,” Dr. Riall said.
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,” she said.
Several factors significantly influenced whether surgery was performed during the initial hospitalization. Every 5 years of advancing age decreased by 17% the chance that a patient would have surgery. Black patients were 32% less likely to have the operation than were white patients, and women were 6% less likely than men. Patients admitted by a gastroenterologist were 48% less likely to have surgery than those admitted by a surgeon.
Disclosures: Dr. Riall did not have any relevant financial disclosures.