Common bile duct stones are especially prevalent in the elderly population.
The standard of care for stone removal is endoscopic retrograde cholangiography with sphincterotomy.
However, the clinician's decision to refer a patient for cholecystectomy after endoscopic retrograde cholangiography with sphincterotomy depends on several factors.
These factors include the potential for future biliary symptoms and complications, and morbidity and mortality related to cholecystectomy.
Costs associated with referral for cholecystectomy versus a conservative approach also influence the clinician's referral decisions.
Dr Miguel Arguedas and colleagues explored the economic implications of 2 treatment strategies in elderly patients with common bile duct stones.
The research team used decision analysis to assess these factors after endoscopic retrograde cholangiography with sphincterotomy in patients aged 60 years and over.
A decision tree was constructed to estimate the costs and outcomes associated with the 2 treatment strategies.
|Total costs of cholecystectomy were $5259 vs $1173 with expectant management|
|American Journal of Gastroenterology|
The team derived probabilities for potential complications and outcomes from the medical literature.
Cost reflected Medicare reimbursement rates at the researcher's institution.
The time horizon of the analysis was 2 years.
The team found that elective cholecystectomy was associated with total costs of $5259 with 94% of the cohort alive at 2 years.
However, expectant management was associated with total costs of $1173 with 95% of the cohort alive.
The researchers noted that the results were sensitive to the probability of recurrent biliary symptoms in patients treated conservatively.
Compared to elective cholecystectomy, expectant management became less effective at a yearly probability of recurrent symptoms greater than 40%.
In addition, the researchers observed that expectant management became more expensive at a yearly probability of recurrent symptoms greater than 90%.
Dr Arguedas' team concludes, “In patients aged 60 and older, expectant management after endoscopic retrograde cholangiography with sphincterotomy for common bile duct stones is a reasonable approach.”
“However, the economic attractiveness of this strategy is highly dependent on the probability of recurrent symptoms.”