New research findings published in the May issue of the Journal of the American College of Surgeons indicate that delaying cholecystectomy, the surgical removal of the gallbladder, in elderly patients with sudden inflammation of the organ often results in increased costs, morbidity and mortality.
Gallstone disease is the most costly digestive disease in the United States, with approximately 20 million people having the disorder. Annually, gallstone disease leads to more than one million hospitalizations, 700,000 operative procedures, and a cost of $5 billion. Furthermore, the prevalence of gallstones increases with age: 15 percent of men and 24 percent of women will have gallstones by age 70. As well, complications related to gallstones are more common in elderly patients, with the most common being acute cholecystitis, a sudden inflammation of the gallbladder, which can cause abdominal pain, nausea, vomiting, and fever.
"This is the first systematic study on how adherence to the recommendations for management of acute cholecystitis affects long-term outcomes and resource use," said Taylor S. Riall, MD, PhD, FACS, associate professor of surgery at the University of Texas Medical Branch in Galveston. "Our study helped identify both patients who are at high risk for not receiving definitive surgical treatment with cholecystectomy and those that are at high risk for being readmitted if they do not have cholecystectomy."
Researchers used a five percent sample of national Medicare claims data from 1996 to 2005 to identify a cohort of patients admitted to an acute care hospital with acute cholecystitis. By choosing patients from this period, researchers were able to evaluate comorbidities in the year before initial hospitalization and then follow all patients two years after their initial hospitalization for gallstone complications.
Between 1996 and 2005, 29,818 Medicare beneficiaries were admitted to acute care facilities for a first episode of acute cholecystitis. Of these patients, 75 percent (n=22,367) underwent cholecystectomy. The inpatient mortality rate was 2.7 percent in patients who did not undergo cholecystectomy, and 2.1 percent in patients who did (p = 0.001).
For the 25 percent of patients (n=7,451) who did not undergo cholecystectomy upon first hospitalization, 38 percent required gallstone related re-admission over the subsequent two years, compared to only four percent in patients who did undergo the surgery (P< 0.0001). Twenty-seven percent of patients who did not undergo definitive therapy (gallbladder removal) required subsequent cholecystectomy, often not performed electively, but associated with acute care re-admission. The gallstone-related readmissions were expensive for Medicare, leading to approximately $14,000 in total charges and greater than $7,000 in Medicare payments per readmission.
Additionally, patients who did not undergo cholecystectomy during initial hospitalization were 56 percent more likely to die two years after hospitalization discharge versus those who received immediate treatment (HR 1.56, 95 percent CI 1.47 to 1.65), even after controlling for patient demographics and comorbidities.
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