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Operative delay to laparoscopic cholecystectomy

Racking up the cost of health care

Schwartz, Diane A. MD; Shah, Adil A. MBBS; Zogg, Cheryl K. MSPH, MHS; Nicholas, Lauren H. PhD; Velopulos, Catherine G. MD, MHS; Efron, David T. MD; Schneider, Eric B. PhD; Haider, Adil H. MD, MPH

Journal of Trauma and Acute Care Surgery: July 2015 - Volume 79 - Issue 1 - p 15–21
doi: 10.1097/TA.0000000000000699
EAST 2015 Plenary Papers
EAST Journal Club

BACKGROUND Health care providers are increasingly focused on cost containment. One potential target for cost containment is in-hospital management of acute cholecystitis. Ensuring cholecystectomy within 24 hours for cholecystitis could mitigate costs associated with longer hospitalizations. We sought to determine the cost consequences of delaying operative management.

METHODS The Nationwide Inpatient Sample (2003–2011) was queried for adult patients (≥16 years) who underwent laparoscopic cholecystectomy for a primary diagnosis of acute cholecystitis. Patients who underwent open procedures or endoscopic retrograde cholangiopancreatography were excluded. Generalized linear models (GLMs) were used to analyze costs for each day’s delay in surgery. Multivariable analyses adjusted for patient demographics, hospital descriptors, Charlson comorbidity index, mortality, and length of stay.

RESULTS We analyzed 191,032 records. Approximately 65% of the patients underwent surgery within 24 hours of admission. The average cost of care for surgery on the admission day was $11,087. Costs disproportionately increased by 22% on the second hospital day ($13,526), by 37% on the third day ($15,243), by 52% on the fourth day ($16,822), by 64% on the fifth day ($18,196), by 81% on the sixth day ($20,125), and by 100% on the seventh day ($22,250) when compared with the cost of care for procedures performed within 24 hours of admission. Subset analysis of patients discharged 24 hours or earlier from the time of surgery demonstrated similar trends.

CONCLUSION After controlling for patient- and hospital-related factors, we noted significant costs associated with each day’s delay in operative management. Cost containment practices for acute cholecystitis justify consideration of same-day or next-day surgery where the diagnosis is straightforward.

LEVEL OF EVIDENCE Economic and value-based analysis, level III.

From the Department of Surgery (D.A.S., A.A.S., C.K.Z., C.G.V., D.T.E., E.B.S.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management (L.H.N.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Center for Surgery and Public Health (A.A.S., C.K.Z., E.B.S., A.H.H.), Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham & Women’s Hospital, Boston, Massachusetts.

Submitted: December 1, 2014, Revised: February 16, 2015, Accepted: February 18, 2015.

The study was presented at the 28th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 13–17, 2015, in Lake Buena Vista, Florida.

Address for reprints: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Brigham and Women’s Hospital, 1620 Tremont St, One Brigham Circle, 4th Floor, Suite 4–020 Boston, MA 02120; email:

© 2015 Lippincott Williams & Wilkins, Inc.