Cost-effectiveness analysis of initial nonoperative management versus emergency laparoscopic appendectomy for acute complicated appendicitis in Japan

Abstract Background: Although evidence regarding the safety and efficacy of nonoperative management is growing, the best treatment strategy for acute complicated appendicitis remains controversial. In this study, we performed a cost-effectiveness analysis of operative management with emergency laparoscopic appendectomy (ELA) alone as the first-line therapy in complicated appendicitis patients in a municipal hospital in Japan. Methods: We constructed a Markov model to compare treatment strategies for complicated appendicitis with emergency laparoscopic appendectomy in otherwise-healthy adults. Health outcomes were measured in quality-adjusted life years (QALYs) gained, and cost-effectiveness was evaluated using an incremental cost effectiveness ratio (ICER). Model variables were abstracted from a literature review, and from data from the hospital records of Tochigi Medical Center. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of ¥12 million. Results: Operative management cost ¥677,570 per patient. Nonoperative management without interval laparoscopic appendectomy (ILA) cost ¥109,257 more than operative management and produced only 0.005 more QALYs. Nonoperative management without ILA cost ¥26,049 more than operative management, and also yielded only 0.005 additional QALYs. The ICER for both nonoperative managements were > ¥12 million/QALY in the probabilistic sensitivity analysis.Conclusions : Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Operative management remains the standard of care, but nonoperative management deserves serious consideration as a treatment option in complicated appendicitis.