Journal of Surgical Research 171, e161e168 (2011) doi:10.1016/j.jss.2011.06.

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ASSOCIATION FOR ACADEMIC SURGERY Economics of Appendicitis: Cost Trend Analysis of Laparoscopic Versus Open Appendectomy from 1998 to 2008
Brian McGrath, M.D.,* Michelle T. Buckius, M.D.,* Rod Grim, M.A., Theodore Bell, M.S., and Vanita Ahuja, M.D.*,,1
*Department of Surgery, York Hospital, WellSpan Health, York, Pennsylvania; Emig Research Center, York Hospital, WellSpan Health, York, Pennsylvania; and Penn StateHershey, Hershey, Pennsylvania Originally submitted January 17, 2011; accepted for publication June 27, 2011

Background. Laparoscopic appendectomy (LA) has become more acceptable for the treatment of appendicitis over the last decade; however, its cost benet compared to open appendectomy (OA) remains under debate. The purpose of this study is to evaluate the utilization of LA and its cost effectiveness based on total hospital charges stratied by complexity of disease and complications compared to OA. Material and Methods. Nationwide Inpatient Sample data from 1998 to 2008 with the principal diagnosis of appendicitis were included. Appendicitis cases were divided by simple and complex (peritonitis or abscess) and subdivided by OA, LA, and lap converted to open (CONV). Total charges (2008 value), length of stay (LOS), and complications were assessed by disease presentation and operative approach. Results. Between 1998 and 2008, 1,561,518 (54.3%) OA, 1,231,643 (42.8%) LA, and 84,662 (2.9%) CONV appendectomies were performed. LA had shorter LOS (2 d) than OA (3 d) and CONV (5 d) (P < 0.001). CONV (7.4%) cases had more complications than OA (3.7%) and LA (2.6%). LA ($19,978) and CONV ($28,103) are costlier than OA ($15,714) based on normalized cost for simple and complex diseases (P < 0.001). Conclusions. LA is more prevalent but its cost is higher in both simple and complex cases. Cost and complications increase if the case is converted to open. OA remains the most cost effective approach for patients with acute appendicitis. 2011 Elsevier Inc. All
rights reserved.

INTRODUCTION

Key Words: appendicitis; laparoscopic appendectomy; open appendectomy; laparoscopic converted to open appendectomy; cost; normalized cost.

Appendicitis is the most frequent intra-abdominal emergency in the United States. The current incidence of appendicitis in Europe/America is about at 100 cases per 100,000 persons per year. Open appendectomy (OA) has remained the gold standard of care since the technique was rst described by McBurney [13] over a century ago. In 1983, Semm provided the initial description of a laparoscopic appendectomy (LA) [4]. The prevalence of LA has increased during the last decade. Research on whether the laparoscopic procedure is superior to the open approach has shown that LA may be the best approach with respect to reducing hospital length of stay (LOS) and time to return to work [5, 6]. Many randomized prospective trials and meta-analyses have been performed on the subject, but consensus on the superiority of LA has not been reached [710]. There remains a debate on the economic benet of LA versus OA. The cost of the surgery has been shown to be higher in the laparoscopic approach due to the operating room time [11]. However, OA may have higher complication rates, which may negate the cost benet [8, 12, 13]. Studies thus far have not broken down the cost differences with respect to simple versus complex (i.e., ruptured, abscess) appendicitis. The objective of this study is to evaluate the utilization of LA as well as the cost effectiveness based on total hospital charges, cost associated with complication rates, stratied by complexity of disease with comparison to OA and LA converted to OA (CONV).
METHODS
The present study was conducted using data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project

To whom correspondence and reprint requests should be addressed at Department of Surgery, York Hospital, 1001 South George Street, York PA 17403. E-mail: vahuja@wellspan.org.

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0022-4804/$36.00 2011 Elsevier Inc. All rights reserved.

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(HCUP), Agency for Healthcare Research and Quality from 1998 to 2008 [14]. The NIS database contains information on inpatient hospital stays from about 1000 hospitals in 22 states. Inclusion criteria were principal diagnoses at discharge for simple appendicitis (appendicitis, appendicitis without mention of peritonitis, and appendicitis unqualied) and complex cases (appendicitis with peritonitis and appendicitis with peritoneal abscess). Exclusion criteria were incidental appendectomy, incidental LA, and right hemicolectomy. Only persons with appendicitis who had appendectomy as the primary procedure, which excludes anyone with recurrent appendicitis or treated with nonoperative management, were included in the study. This is due to NIS being an administrative database and we cannot tell if patients had readmissions and/or had appendectomy at a later stage. The cases were divided between simple and complex, and then subdivided by procedure performed (OA, LA, and CONV). Weighting was applied to all of the analysis to account for patients who were not accounted for in the NIS data set. Charlson scores were calculated according to Charlson [15] and Deyo [16] validated with published methods. Statistical analysis was performed using descriptives, tests of proportions, Chi-square tests, t-tests, ANOVA with post-hoc tests, and multiple regressions. All hospital costs used in this study were adjusted to 2008 values to account for ination using the Consumer Price Index (Economic Evaluation of Public Health Preparedness and Response Efforts: Cost Analysis Tutorial. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services http:// www.cdc.gov/owcd/EET/Cost/1.html). Other parameters of interest were cost of operation with and without in-hospital complications. Postoperative complications studied were LOS, mortality, urinary tract infection (UTI), acute renal failure (ARF), abscess/wound infection, pulmonary embolism, pneumonia, and wound dehiscence. The complication frequencies were determined and the costs associated with each complication taken into account to further determine the overall cost of the specic surgery through the years 19982008. The multiple regression used costs as our predictor variable and type of surgery (OA, LA, or CONV), gender (male or female), age (in years), race (White, Black , Hispanic, or other), payer (Medicare, Medicaid, private, or other), hospital bed size (small, medium, or large), hospital location (urban or rural), hospital region (Northeast, Midwest, South, or West), teaching status of hospital (teaching or non-teaching), type of case (simple or complex), complications (yes or no), Charlson score (0, 1, 2, or !3), and length of stay (in days) as our covariates. Based on the multiple regression results, we were able to calculate a normalized cost associated with each type of surgery by year. Normalized cost for each type of operation refers to its costs after controlling for these covariates and adjusted for personperson variation.

FIG. 1. Percent of operations by type of appendectomy (open, laparoscopic, laparoscopic coverted to open) from 19982008.

Patient Characteristics by Type of Operation

Table 1 shows the patient characteristics over the period studied. Males received signicantly more appendectomy in OA, LA, and CONV approaches (P < 0.001). In terms of mean age in years, all surgery groups were significantly different from each other: OA (30.9 y), LA (32.5 y), and CONV (41.6 y) (P < 0.001). The predominant race was White followed by Hispanic population. Patients who had CONV cases were more likely to have a complex disease, and 37.5% of these patients had peritonitis. The mean LOS in days for all three surgery groups differed signicantly: OA (3.2 d), LA (2.3 d), and CONV (5.3 d) (P < 0.001). The total charges for all three surgery groups also differed signicantly: OA ($15,714), LA ($19,978), and CONV ($28,103) (P < 0.001).
Patient Characteristics by Disease Presentation

RESULTS

Between 1998 and 2008, 2,877,823 appendectomies were performed: 1,561,518 (54.3%) OA, 1,231,643 (42.8%) LA, and 84,662 (2.9%) CONV. LA was the preferred surgery for simple or complex cases toward the end of the study period. The frequency of LA increased from 20.6% in 1998 to 70.8% in 2008 (P < 0 .001) (Fig. 1). The trend for greater utilization of LA over OA was seen starting in 2005. The frequency of CONV cases increased slightly over the study period (1.8% to 3.7%, P < 0 .001), which follows the trend in increase of LA.

Table 2 shows the data examined by simple and complex presentation for appendicitis. OA was utilized significantly more for either simple or complex presentation (P < 0.001). Appendectomies performed for complex compared with simple cases had more complications (6.7% versus 2.0%) and longer mean LOS (5.2 d versus 2.0 d) (both P < 0.001). LA had signicantly shorter mean LOS (1.7 d) than OA (2.6 d) and CONV (3.7 d) for simple cases. LA also had signicantly shorter mean LOS (4.4 d) compared with OA (5.6 d) and CONV (6.2 d) for complex cases. The total charges for simple were signicantly less than for complex disease ($15,134 versus $24,847, P < 0.001).
Total Cost by Type of Operation

The cost for all types of appendectomies increased signicantly from 1998 ($13,596) to 2008 ($26,396,

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TABLE 1 Patient Characteristics for Open (OA), Laparoscopic (LA,) and Laparoscopic Converted to Open (CONV) from NIS 1998 to 2008
OA Count Gender Male Female Race White Black Hispanic Other Payer Medicare Medicaid Private including HMO Other Bed size of hospital Small Medium Large Location of hospital Rural Urban Teaching status of hospital Non-teaching Teaching Region of hospital Northeast Midwest South West Disease presentation Simple Complex With peritonitis With abscess In-hospital Complications Yes No Charlson 0 1 2 !3 Died during hospitalization Yes No Age in y at admission (mean) LOS (mean) Total charges (mean) % Count LA % Count CONV % P <0.001 <0.001

934,418 602,448 738,953 76,273 225,262 86,879 114,852 239,166 949,356 252,193 239,174 434,074 888,108 245,589 1,315,767 980,951 580,405 338,278 345,849 475,615 401,777 1,064,669 496,849 319,555 177,293 57,512 1,504,006 1,395,122 121,503 22,011 22,883 1927 1,559,219 30.9 3 15714

60.8% 39.2% 65.5% 6.8% 20.0% 7.7% 7.4% 15.4% 61.0% 16.2% 15.3% 27.8% 56.9% 15.7% 84.3% 62.8% 37.2% 21.7% 22.1% 30.5% 25.7% 68.2% 31.8% 20.5% 11.4% 3.7% 96.3% 89.3% 7.8% 1.4% 1.5% .1% 99.9%

647,806 560,005 638,899 53,594 171,361 65,193 76,380 155,765 807,735 188,961 155,891 352,687 723,041 135,344 1,096,275 739,913 491,706 233,304 238,179 439,012 321,147 965,795 265,848 186,898 78,950 31,583 1,200,059 1,092,678 105,203 15,618 18,145 618 1,230,899 32.5 2 19,978

53.6% 46.4% 68.8% 5.8% 18.4% 7.0% 6.2% 12.7% 65.7% 15.4% 12.7% 28.6% 58.7% 11.0% 89.0% 60.1% 39.9% 18.9% 19.3% 35.6% 26.1% 78.4% 21.6% 15.2% 6.4% 2.6% 97.4% 88.7% 8.5% 1.3% 1.5% .1% 99.9%

48,939 35,162 45,073 4424 9818 3781 10,886 9046 51,021 13,527 11,483 25,428 47,747 13,654 71,003 51,851 32,806 14,180 19,933 33,056 17,493 29,846 54,816 31,741 23,075 6301 78,361 69,107 10,818 2293 2443 116 84,525 41.6 5 28,103

58.2% 41.8% 71.4% 7.0% 15.6% 6.0% 12.9% 10.7% 60.4% 16.0% 13.6% 30.0% 56.4% 16.1% 83.9% 61.2% 38.8% 16.7% 23.5% 39.0% 20.7% 35.3% 64.7% 37.5% 27.3% 7.4% 92.6% 81.6% 12.8% 2.7% 2.9% 0.1% 99.9%

<0.001

<0.001

<0.001 <0.001 <0.001

<0.001 <0.001 <0.001 <0.001

<0.001 <0.001 <0.001 <0.001

P < 0.001). Figure 2 shows the cost associated with each procedure by year. In 2008, CONV ($28,103) costs were greatest, followed by LA ($19,978), and OA ($15,714). The cost for OA and LA for both simple and complex cases increased over the study period. In 2008, LA ($34,518) was less costly than OA ($37,889) for complex cases, while LA ($24,033) was more expensive than OA ($20,296, all P < 0.001) for simple appendicitis (Fig. 3).

Laparoscopic converted to open (CONV) remained the most expensive surgery in 2008 for both simple ($24,858) and complex ($34,703) cases.
In-Hospital Complications and Cost

Table 3 shows the complications during the hospitalization studied with numbers of cases in the database.

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TABLE 2 Patient Demographics by Disease Presentation (Simple or Complex Appendicitis) from NIS 1998 to 2008
Simple n Gender Male Female Race White Black Hispanic Other Surgery Open Lap Converted to open In-hospital complications Yes No Died during hospitalization Yes No Age in y at admission (mean) LOS (mean) Total charges (mean) % n Complex % P <0.001 <0.001

1,153,313 869,483 1,017,293 94,409 290,480 113,267 1,064,669 965,795 29,846 40,899 2,019,412 513 2,059,472 30.2 2.0 15,134

57.0% 43.0% 67.1% 6.2% 19.2% 7.5% 51.7% 46.9% 1.4% 2.0% 98.0% .0% 100.0%

477,850 328,131 405,631 39,881 115,961 42,586 496,849 265,848 54,816 54,497 763,015 2148 815,171

59.3% 40.7% 67.2% 6.6% 19.2% 7.0% 60.8% 32.5% 6.7% 6.7% 93.3% .3% 99.7% 36.0 5.2 24847

<0.001

<0.001 <0.001 <0.001 <0.001 <0.001

Table 4 shows mean number of complications with simple or complex and then by type of surgery, OA, LA, and CONV. OA, LA, and CONV had signicantly higher LOS with complication for simple or complex appendicitis. The charges increased for each surgical procedure regardless of simple or complex. Overall, complications for CONV (7.4%) are signicantly greater than OA (3.7%) and LA (2.6%) (P < 0.001). CONV cases had the highest wound infection/ abscess rate (3.4%), followed by OA (1.4%), then LA

FIG. 2. Mean cost of each type of operation from 19982008.

(0.6%) (P < 0.001). If there was a complication during the hospitalization, the cost rose signicantly for OA ($17,368 versus $40,005), LA ($21,525 versus $37,525), and CONV ($30,108 versus $44,940) (P < 0.001). Table 4 shows the overall charges, which were signicantly higher if there was a complication for OA, LA, and CONV for simple or complex appendicitis (Table 4). In simple cases, the OA cost with complication increased by $10,390; the cost for LA increased by $9,516; and the cost for CONV increased by $11,444. Similarly, data indicated increases in charges for complex cases were signicantly higher if there was a complication with OA by $23,878, for LA by $20,879, and CONV by $14,683 (P < 0.001). Multiple regression was performed to nd the contribution of comorbidity, LOS, type of hospital, region of hospital, payer status, and patient characteristics to the cost associated with appendectomy. The highest contributor found was laparoscopic operation as the average cost went up $7594 when laparoscopic surgery was performed, (Table 5). However, our study showed that LOS is longer in open operation, but the laparoscopy portion has a higher contribution to the cost. Figure 4 shows the normalized cost of the three surgery groups when the covariates, such as patient characteristics, disease presentation, hospital variation, and region, are controlled for over the study period. Overall, the trend for cost of CONV remains the highest. The cost of LA is signicantly higher than OA for both simple and complex disease when the cost is adjusted for

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FIG. 3. Mean cost of each type of operation by simple and complex from 19982008.

covariates (P < 0.001). Due to the high cost of laparoscopy, laparoscopic cost remained higher than the open operation through the study period.

DISCUSSION

Over the last decade, LA has become more prevalent in both the simple and complex appendicitis cases. Our data show that the trend for LA over OA starting in 2005. This increase in prevalence is most likely due to recent studies showing advantages of shorter hospital stay, lower complication rates, and return to work earlier. The preference for LA over OA may reect the shorter learning curve with LA for surgeons and

pressure from patients for minimal invasive procedures [9, 13]. In this study, the NIS database was examined to determine the cost benet of appendectomy by laparoscopic or open procedure and then with respect to disease presentation in regard to complex versus simple appendicitis. A total of 2,877,823 cases were examined in the database for appendicitis. From 1998 to 2008, overall costs for both open and LA doubled, which we hypothesize may be due to increasing medical costs, insurance, medication, equipment costs, and diagnostic testing like CT scans. In 2008, for simple appendectomies, our study shows that the open approach remains less costly even when there are complications. Since the base

TABLE 3 In-Hospital Complications

OA* Variable ARF UTI Abscess/wound infection PE Pneumonia Wound dehiscence ICD-9 code 997.5 590 998.59 415.11 997.3 998.3 n 7989 17,025 22,146 656 11,527 1321 % 0.5% 1.1% 1.4% 0.04% 0.7% 0.1% n 5427 13559 7021 331 6353 84 LA* % 0.4% 1.1% .6% .04% .5% .01% n 801 1486 2898 121 1212 113 CONV* % 0.9% 1.8% 3.4% 0.1% 1.4% 0.1% P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

*OA open appendectomy; LA laparoscopic appendectomy; CONV laparoscopic converted to open appendectomy.

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TABLE 4 Mean Number of Complications by Presentation (Simple and Complex) and Type of Surgery
Simple OA Length of stay w/o complications w/ complications Number of complications, mean Charges, CPI adjusted Overall 0 Complications 1 Complication 23 Complications LA CONV P <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.138 OA LA Complex CONV P <0.001 <0.001 <0.001 0.555 <0.001 0.775 0.003

2.1 4.8 1.03 $14,131 $13,924 $23,733 $43,878

1.7 3.7 1.02 $19,908 $19,726 $28,778 $49,897

3.5 6.6 1.05 $24,858 $24,233 $35,194 $45,117

5.2 10.0 1.07 $26,911 $25,150 $47,052 $77,716

4.2 8.2 1.06 $29,293 $28,247 $47,399 $77,926

5.9 9.1 1.05 $34,703 $33,425 $47,493 $59,855

OR cost of LA remains higher than for OA and also, laparoscopic approach may have longer operative time, which could contribute to the higher hospital cost. There have been arguments stating that lower cost of shorter hospital stay and earlier return to work may offset the base cost for laparoscopic surgery [17]. The lower cost for simple OA remains less but not signicantly when the patient experiences more than one complication. (Table 4) Katkhouda et al. [12] showed that the LOS is similar in both groups. Moore et al. [18] have performed a decision analysis, taking into account a potential complication, and demonstrated that the laparoscopic approach may be benecial if wound infection rate exceeds 23% in OA. When taking into account the complexity of the appendicitis, the cost of OA still remains less expensive when the appendicitis is complicated and however the
TABLE 5 Contribution of Each Variable in the Cost of Operation
Variable LAP Western region of US CONV Charlson score of 3 LOS Charlson score of 2 Simple case Hispanic race Charlson score of 1 Other race Black race Other payer Age Male gender Teaching hospital Medicaid payer Medicare payer Medium size hospital Northeast region Small sized hospital Midwest region of US Contribution ($) adds or subtracts 7594 7353 4892 4688 4591 3866 3019 2276 1484 993 993 100 61 13 75 154 206 629 1075 1305 3301

cost benet disappears when adjusted for covariates. The cost benet of LA in complex disease has been controversial. While some randomized studies have shown reduced cost for LA with reduced pain, and earlier return to work [8], Sporn et al. showed that laparoscopic approach was 9% higher than OA in patients with complicated appendicitis [13]. This may be due to the high upfront cost of laparoscopy equipment, which may not still be offset by the increased LOS and higher complication rates for OA in complex cases. Also, our hospital data does not take into account readmission and posthospital cost. Additionally, when laparoscopic cases are converted, they have higher complication rates and longer length of stay. These patients tend to be older and have complex disease with peritonitis. Swank et al. also found that the only signicant risk factor for conversion was the presence of a generalized purulent peritonitis [19]. We were unable to examine if these patients had previous operations that increased their risk of conversion. However, previous abdominal surgery has not been a signicant factor. A limitation of the study is that it is a retrospective study and therefore the groups are not necessarily similar. Surgeon preference for laparoscopic versus open approach adds bias, as well as the rationale for determination of laparoscopic versus open based on patient characteristics, patient preference. It is possible that an open approach might have been deemed safe given patient/disease characteristics. Additionally, we are not able to examine if the surgeons laparoscopic volume or if advance training may have played a role in their results. Also, the data that NIS contains does not include readmission data or outpatient treatment of complications. One study showed a 4.6% rate of readmission, which would add to the costs this study is unable to measure [20]. In comparison between open and laparoscopic, Ninh et al. demonstrated a lesser readmission rate in the laparoscopic compared to the open

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FIG. 4. Normalized cost (adjusted for covariates) for open, laparoscopic, laparoscopic converted to open 19982008 by disease presentation.

(1.0% versus 1.3%) [21]. Many abscesses and other complications show up after a person is discharged and require readmission. Not accounting for rates and costs of complication related to readmissions makes it harder to draw conclusions about the general population. We did not study the 30-d global period and postoperative emergency visits, which can offset the initial hospitalization savings [22]. Our cost analysis does not examine earlier return to work, which may benet patients receiving LA. This nding remains inconclusive, since this may be dependent on patient demographics and work requirements, like farming or heavy lifting [5]. This cost analysis showed the open approach is less costly with simple appendicitis and this difference is present with in-hospital complications. The cost benet of laparoscopic approach remains unclear. It may be cheaper for complex appendicitis, but the difference disappears with adjustment to covariates. Additionally, the cost increases signicantly if the patient has to be converted open. A prospective study with 30-d followup period is needed to thoroughly demonstrate the economic benet of LA over OA.
ACKNOWLEDGMENTS
The authors would like to acknowledge Thomas Pierce and Jeffery Aspelmeier, Radford University, for statistical assistance.

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