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Cost‐effectiveness of same‐admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial. BJS 2016; 103: 1695-1703.

Published: 12th August 2016

Authors: D. W. da Costa, L. M. Dijksman, S. A. Bouwense, N. J. Schepers, M. G. Besselink, H. C. van Santvoort et al.

Background

Same‐admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone‐related complications, but its impact on overall costs is unclear. This study analysed the cost‐effectiveness of same‐admission versus interval cholecystectomy after mild gallstone pancreatitis.

Method

In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same‐admission cholecystectomy) or cholecystectomy after 25–30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis‐related absence from work. Cost‐effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months.

Results

All 264 trial participants were included in the present analysis, 128 randomized to same‐admission cholecystectomy and 136 to interval cholecystectomy. Same‐admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone‐related complications from 16·9 to 4·7 per cent (P = 0·002). Mean total costs from a societal perspective were €234 (95 per cent c.i. –1249 to 738) less per patient in the same‐admission cholecystectomy group. Same‐admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost‐effectiveness ratio of –€1918 to prevent one readmission for gallstone‐related complications.

Conclusion

In mild biliary pancreatitis, same‐admission cholecystectomy was more effective and less costly than interval cholecystectomy.

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2 Comments

Roberto de la Plaza Llamas

3 years ago

Sir,

We congratulate da Costa et al. on their cost-effectiveness analysis of same-admission versus interval cholecystectomy after mild gallstone pancreatitis (1). The authors carry out their analysis from societal and healthcare perspectives. They conclude that “in mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy”.

Mean total costs from a societal perspective were €234 less per patient in the same-admission cholecystectomy group. However, in the economic assessment from a social perspective (i.e. of the indirect costs) the costs were only calculated on the basis of lost hours of work/productivity, leaving aside other costs that patients and families or the Social Services are obliged to cover, as well as those induced in other sectors. If these costs had been taken into account, the difference recorded would have been greater.

In the same-admission group the duration of admission following randomization was 0.3 days longer and healthcare costs were €144 higher. The authors attribute these results to the fact that an interval of 72h after randomization was established for the cholecystectomy, and to the difference in length of hospital stay. Other studies have demonstrated lower costs and effectiveness in the same-admission group (2-3).

According to da Costa et al., “if same-admission cholecystectomy is implemented successfully in daily practice” – or more exactly if a specific clinical process is established – hospital stay can be shortened.

Same-admission cholecystectomy is a right for patients, because of the complications and readmissions it may avoid, and an obligation for healthcare providers, in view of the costs savings. 

R de la Plaza Llamas
JM Ramia Ángel
V Arteaga Peralta
AJ López Marcano

Department of Surgery
Hospital Universitario de Guadalajara
Calle del Donante de sangre s/n.
19002 Guadalajara
Spain
rdplazal@sescam.jccm.es

References:
1. da Costa DW, Dijksman LM, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, et al. Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial. Br J Surg 2016; 103: 1695–1703.
2. Morris S, Gurusamy KS, Patel N, Davidson BR. Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis. Br J Surg 2014; 101: 828–835.
3. Sutton AJ, Vohra RS, Hollyman M, Marriott PJ, Buja A, Alderson D, et al. Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology. Br J Surg 2017; 104: 98–107.

BJS admin

3 years ago

We welcome your comments on our cost-effectiveness analysis and your plea for same-admission rather than interval cholecystectomy.

While we believe our results to be a sufficiently reliable representation of the cost difference from a societal perspective, we again would like to confirm the limitations of our study (1). The PONCHO trial (Pancreatitis of biliary origin: Optimal timiNG of CHOlecystectomy) was designed to investigate a difference in readmissions for recurrent gallstone complications following mild pancreatitis (2). As our economic assessment was one of several secondary objectives, we chose to limit the societal perspective to what we considered the primary cost drivers: healthcare costs in the hospital and loss of productivity. A full economic evaluation would ideally follow a more comprehensive approach including, for instance, general practitioner costs and out-of-pocket expenses for health-related travel and informal care. In view of the scope of the main study and limited resources on our part, this did not prove feasible. Considering that main cost drivers were selected, it is conceivable that the observed cost difference between the two groups would be affected only to a limited extent and that the current underestimation, if any, of the difference in favour of same-admission cholecystectomy is small.

The clinical and cost-effectiveness outcomes of the PONCHO trial confidently indicate the advantages of same-admission cholecystectomy over interval cholecystectomy. Furthermore, our results reinforce the findings of previous studies directed at the economic effects of the two strategies except for a shorter hospital stay, as we have discussed in our paper (3,4).

David da Costa
Hein Gooszen
Marcel Dijkgraaf
on behalf of the Dutch Pancreatitis Study Group

Department of Radiology
St Antonius Hospital
Nieuwegein
The Netherlands
dwdacosta@gmail.com

References:
1. da Costa DW, Dijksman LM, Bouwense SA, et al. Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial. Br J Surg 2016; 103: 1695–1703.
2. da Costa DW, Bouwense SA, Schepers NJ, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386: 1261–1268.
3. Monkhouse SJ, Court EL, Dash I, Coombs NJ. Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br J Surg 2009; 96: 751–755.
4. Morris S, Gurusamy KS, Patel N, Davidson BR. Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis. Br J Surg 2014; 101: 828–835.