191 Comparing Cost, Risk Factors, and Rates of Return in Immediate versus Delayed Cholecystectomy for Emergency Department Patients with Biliary Colic Using Statewide Linked Datasets

Abstract

Approximately 700,000 patients present annually with biliary colic to United States emergency departments (EDs) and providers must decide whether patients should be admitted for immediate cholecystectomy or can be discharged for outpatient management. Despite the prevalence of biliary colic, the timing of surgery varies greatly and this decision is based on factors such as cost, the risk of ED re-visits (EDRs) and clinical prognosis that are not well-defined. The primary objective of this study was to compare the patient characteristics, the costs and the risks of EDRs in ED patients with biliary colic who are allocated to different treatment options including immediate cholecystectomy, delayed cholecystectomy or no cholecystectomy. Patients who presented to an ED in the state of Maryland were identified in the State ED Database (SEDD) using the ICD-10 code for cholelithiasis (K80) and then followed for one year using unique identifiers in the SEDD, the State Ambulatory Surgery Database (SASD), and the State Inpatient Database (SID) for 2016-18. Hospital admissions, outpatient surgeries, and EDRs were identified for each patient. Patients that died on their index ED visit or from a cause unrelated to cholelithiasis were excluded from the analysis, and only charts that contained a K80 diagnosis were included. Following index visit, ED patients were analyzed based on the following categories: (1) Admit and immediate cholecystectomy, (2) Discharge and delayed cholecystectomy as an outpatient, (3) No cholecystectomy, and (4) Discharge and repeat ED visit for return immediate cholecystectomy. Costs were estimated using Medicare Relative Value Units (RVUs) and Healthcare Cost and Utilization Project Cost-Charge Ratio files, and a multivariate logistic regression analysis was performed on the four clinical pathways. Of the 4069 patients identified and followed for a year, 67% underwent immediate surgery, 6% delayed surgery, 27% no surgery, and 1% return immediate surgery. Patients who received immediate surgery had fewer EDRs (0.01 vs 0.05, p<10-9) and was associated with higher average costs compared to all discharged patients ($11,100 vs $7500, p<10-36). Of all patients initially discharged from the ED, 81% did not undergo cholecystectomy within one year. Biliary colic described as “inflammatory” was significantly associated with cholecystectomy, while increased age and ischemic heart disease were strongly associated with both discharge and no surgery after discharge (Table 1). Race, sex, and insurance status were not associated with differences in cholecystectomy allocation. The majority of patients who present to the ED undergo immediate cholecystectomy (67%) which is associated with lower EDRs (0.01 vs 0.05) but higher cost ($11,100 vs $7500). For patients discharged from the ED, 81% never receive a cholecystectomy within one year. Inflammatory biliary colic was associated with increased likelihood of both immediate and delayed surgery, while increasing age was associated with a decreased likelihood of both immediate and delayed surgery. More research is needed to understand how to balance the increased cost of immediate cholecystectomy with the increased risk ED returns from a delayed approach.