Costs and effectiveness of appendectomy in Sonla province general hospital

Journal of military pharmaco-medicine n08-2017

COSTS AND EFFECTIVENESS OF APPENDECTOMY
IN SONLA PROVINCE GENERAL HOSPITAL
Nguyen Duc Toan*; Pham Le Tuan**
SUMMARY
Objectives: To assess impact of costs and efficiency of appendectomy in Sonla Province
General Hospital. Subjects and methods: The research was conducted on 322 patients who
underwent laparoscopic appendectomy and open appendectomy at Sonla Province General
Hospital from 01 - 01 - 2012 to 30 - 12 - 2013. Sample selection error is controlled by
Propensity Score Matching (n = 109 pairs). Results and conclusions: The hospital stay in the
group of laparoscopic appendectomy (4.2 ± 2.3 days) was less than that of open appendectomy
(5.2 ± 2.2 days), but the difference did not have statistical significance (p > 0.05). The cost of
open appendectomy and laparoscopic appendectomy in cases with complications (5,918.7
thousand and 5,247.9 thousand VND) was higher than the group without complications (5,531.9
thousand and 5,126.3 thousand). The cost of treatment of open appendectomy was higher than
that of laparoscopic appendectomy, yet the effectiveness of laparoscopic appendectomy (96.3%)
was higher than that of open appendectomy (93.6%), (p > 0.05). Therefore, laparoscopic
appendectomy is the best choice for the patients with acute appendicitis.
* Keywords: Appendicitis; Laparoscopic appendectomy; Cost.

INTRODUCTION
Health economic evaluation is a systematic
approach designed to offer the policy
makers a wide variety of options. Cost,
effectiveness analysis is a form of
cost-benefit analysis. Analysis of cost
effectiveness has helped choose more
effective methods at the same cost or
equally effective ones at a lower cost [1, 2].
The cost - efficiency laparoscopic

appendectomy (LA) and open appendectomy
(OA) was one of many authors’ interest
[3, 4, 5, 6]. The study by Varela J.E et al.
(2008) [8] on 1,943 patients showed that
the hospital stay of LA group was shorter
than that of OA (3 days compared to 4 days)

and its complication rate was lower (LA:
9% compared with open surgery: 17%).
Incision infection rate was also lower
(1% vs. 3%). Obese patients treated with
LA had higher complication rate (27%
versus 18%) and the treatment cost was
also higher (16,600 dollars compared to
12,300 dollars). Lin K.B et al (2015) [7]
revealed that low income patients benefit
more from LA than OA due to reduced
hospitalization time, fewer complications
and fewer hospitalization for treatment of
complications. Therefore, this study was
conducted: To assess the impact of costs
and efficiency of appendectomy in Sonla
Province General Hospital.

* Sonla Province General Hospital
* Department of Health
Corresponding author: Nguyen Duc Toan ()
Date received: 21/08/2017
Date accepted: 29/09/2017

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Journal of military pharmaco-medicine n08-2017
Five prognosis factors are put into pair

SUBJECTS AND RESEARCH
METHODS

according to PSM method are age, time
from sickness until the surgery, time of

1. Subjects.
OA and LA surgery patients were enrolled
in Sonla Province General Hospital from
01 - 01 - 2012 to 30 - 12 - 2013.

hospital admission, the progression of
acute appendicitis and who pays the
costs.
- Tools, indicators and variables studied:

2. Method.
- Sample size: All patients were adults
who underwent OA and LA surgery in Sonla
Province General Hospital from 01 - 01 2012 to 30 - 1 - 2013.
- Research design: Descriptive horizontal
slicing analysis.
+ On the basis of factors related to
prognosis of cost-effectiveness of OA and

LA, to control the model selecting errors
we applied Propensity Score Matching (PSM).

patients interview about direct costs outside
health, indirect costs of households based
on sets of questions are available after
training.
- The data is handled by the method of
biological-medical statistics using IBM
SPSS 22.0 software. Descriptive statistics
with X ± SD. Differences are statistically
significant when p < 0.05 and highly
significant when p < 0.001.

RESULTS
Table 1: The length of hospital stays of patients with acute appendicitis.
Time (days)

OA (n = 109) (1)

LA (n = 109) (2)

The number of patients

93

97

X ± SD

5.1 ± 2.1

4.2 ± 2.4

The number of patients

16

12

X ± SD

6.0 ± 2.8

3.9 ± 0.9

> 0.05

> 0.05

5.2 ± 2.2

4.2 ± 2.3

p1-2

No complications (A)

With complications
(B)

pA-B
The total number

> 0.05

< 0.01

> 0.05

Table 1 shows the hospital stay of LA was less than OA, but the difference did not
have statistical significance (p > 0.05). For the group of acute appendicitis with
complication, time of hospitalization of LA was less than that of OA, the differences
are statistically significant (p < 0.01).
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Journal of military pharmaco-medicine n08-2017
Table 2: Cost of surgery for complicated acute appendicitis and uncomplicated cases.
(Unit: thousand VND)
Complications of acute appendicitis

OA (n = 109)

LA (n = 109)

p1-2

X ± SD

4,163.0 ± 2,749.0

3,965.0 ± 1,916.0

> 0.05

Median

3,686.6

4,352.2

X ± SD

4,259.7 ± 2,375.4

3,904.6 ± 1,478.1

Median

3,326.4

4,209.0

> 0.05

> 0.05

X ± SD

422.4 801.6

671.1 ± 388.0

Median

740.0

600.0

X ± SD

980.9 ± 382.0

705.8 ± 438.3

Median

970.0

535.0

> 0.05

> 0.05

X ± SD

567.3 ± 770.0

490.1 ± 593.5

Median

350.0

400.0

X ± SD

678.1 ± 926.2

637.5 ± 470.0

Median

425.0

775.0

> 0.05

> 0.05

X ± SD

5,531.9 ± 3,042.3

5,126.3 ± 2,465.8

Median

4,806.9

5,404.6

X ± SD

5,918.7 ± 2,966.0

5,247.9 ± 1,382.1

Median

4,980.9

5,462.8

> 0.05

< 0.05

(A)
The cost paid
to the hospital

> 0.05

Yes (B)

pA-B

> 0.05

(A)
Direct costs in
addition to
healthcare

> 0.05

Yes (B)

pA-B

> 0.05

(A)

Indirect costs

> 0.05

Yes (B)

pA-B

> 0.05

(A)
Total

< 0.05

Yes (B)

pA-B

(* Acute appendicitis with complications (OA: 16; LA: 12)
Table 2 shows the total costs of OA in the group of appendicitis with complication
was higher than that of LA group, the differences were statistically significant with
p < 0.05. In both groups, the total costs of the group of acute appendicitis with
complications was higher than the group without complication, the differences were
statistically significant (p < 0.05).
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Journal of military pharmaco-medicine n08-2017
Table 3: Cost of surgery for acute appendicitis according to the results of surgery.
(Unit: thousand VND)
OA (n = 109) (1)

LA (n = 109) (2)

102 (93.6%)

105 (96.3%)

5,623.1 ± 3,071.6

5,037.8 ± 2,157.2

Median
(QL25-QL75)

4,850.0
[3,759.1 - 6,775.9]

5,404.6
[2,938.9 - 6,325.6]

n (efficiency)

7 (6.4%)

4 (3.7%)

X ± SD (costs)

5,087.6 ± 2,262.0

7,814.3 ± 5,513.6

Median
(QL25-QL75)

4,264.4
[3,652.6 - 5,294.8]

5,508.3
[4,342 8-13.592, 0]

pA-B

> 0.05

< 0.001

n

109

109

X ± SD

5,588.7 ± 0 3.02

5,139.6 ± 2,366.6

Median

4,833.9

5,404.6

Results of surgery
n (efficiency)
Good (A)

Average (B)

The total cost

X ± SD (costs)

p1-2

> 0.05

< 0.05

< 0.05

We found that in the group with good surgical results, OA was more costly than LA, but
the differences were not statistically significant (p > 0.05). In the group of average
surgery results, the total cost of LA was greater than that of OA, the differences
were statistically significant (p < 0.05).
DISCUSSION
1. Cost impact.
In the OA group, total cost of the group
of acute appendicitis with complication
was VND 386.8 thousand higher than that
of the group without complication. For LA
patients, the total cost of acute appendicitis
with complication was VND 121.6 thousand,
higher than the group without complication,
the differences were statistically significant
(p < 0.05). Therefore, for complicated
cases of acute appendicitis, LA as well as OA
had higher expenditure compared to group
of uncomplicated acute appendicitis.

This result was similar to other authors’.
Dennett K.V et al (2012) [3] made a
comparison between direct and indirect

hospital cost of 61 households where
children with acute appendicitis were operated
promptly and unpromptly leading to appendicitis
perforation. Perforated patients had longer
hospital stay (9 days) than the group of
early surgery (7 days), (p = 0.02) and the
total cost of the hospital stay was also
significantly larger ($31.349 compared to
$21.323, p = 0.01). No significant difference
was seen in the number of school holidays
(9 days compared to 10 days, p = 0.23) and
adult holiday time for care (5 days versus
7 days, p = 0.18). The authors said that the
hospital stay in the group of acute
appendicitis and perforation was longer
with more costs, but indirect costs were
not higher than those were treated early.
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Journal of military pharmaco-medicine n08-2017
Research by Cárdenas-Salomon C.M
et al (2011) [1] showed hospitalization
time of OA group was higher than that of LA
(3.33 compared to 2.52 days, p < 0.0001).
The treatment cost of LA group was 25%

higher than open surgery (p = 0.0005).
The cost of LA without complication was
1.7 times higher compared to open surgery
(p < 0.0001). There was no difference in
terms of the cost of hospitalization and
surgery between groups with complications
(p = 0.5319).

medical costs are mainly the cost of
medicine and nursing costs.
2. Cost impact based on efficiency.
Research results showed that the hospital
stay in LA group (4.2 ± 2.3 days) was less
than OA (5.2 ± 2.2 days), but the difference
did not have statistical significance (p > 0.05).
In the surgery group with good results, the
total cost of OA (5,623.1 ± 3,071.6 thousand)
was higher than that of LA (5,037.8 ±
2,157.2 thousand) but not statistically
significant (p > 0.05). In the surgery group
with median results, the total cost of LA
(7,814.3 ± 5,513.6 thousand) was higher
than that of OA (5,087.6 ± 2,262.0 thousand),
the differences were statistically significant
with p < 0.05.

Dhupar R et al (2012) [4] carried out
the study on 453 patients with
appendectomy found that patients with
complication had hospital stays as much

as 2.3 times compared to the group
without complications (4.4 days versus
1.9 days; p < 0.001) and the average cost
was as high as 86% ($14.125 versus
$7.595; p < 0.001). The differences in

Based on the two criteria of cost and
efficacy of LA and OA, we found that OA
was more costly than LA, yet LA was
more effective. The cost-effectiveness
table was illustrated as below:

Table 4: Cost-effectiveness of LA and OA.
Cutting performance
appendix

The cost of the CRT
NS < MM

MM = NS

MM cost > NS

MM < NS

1: Increased costeffectiveness ratio

4: NS better than MM

7: NS better than MM

MM = NS

2: MM better than NS

5: Consider other factors

8: NS better than MM

MM > NS

3: MM better than NS

6: MM better than NS

9: Increased costeffectiveness ratio

We can see that LA outweighs OA. This is also similar to foreign authors’ research findings.
Dubois L et al (2010) [5] carried out study on 161 LA patients, the author found that
the proportion of patients treated early was 45% (72/161 patients) with mean surgery
time of 4.7 hours. The group of patients treated early had similar complication rate to
other groups (4.3% versus 7.1%), but the time of hospital stay in the recovery room
after surgery significantly reduced (4.7 hours compared with 16.2 hours, p < 0.001),
the average cost for a patient decreased $323.46. The authors said that if patients,
who were discharged from hospital soon after LA, the treatment cost would be reduced
45% of hospital bed demand, so we may save about 300 dollars per patient.
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According to Khan S.Y et al (2013) [6],
mean cost of LA (534 Oman riyal) was
higher than that of open surgery (343 Oman
riyal) (p < 0.001). The authors suggested
that cost of LA was more expensive than
open surgery, but similarly safe and does
not increase the rate of complications
or time of hospital stay. Costa-Navarro D
et al (2013) [2] did a research on 142
appendectomy cases (99 LA patients and
43 OA patients) also showed that net costs
for OA (1.799 euro) was higher than LA
(1.081 euros). The authors suggest that
LA technique should be chosen for the
treatment of acute appendicitis due to its
clinical and economic efficiency.
Hence, LA reduces the rate of
complications, time in hospital and also
reduce the costs not directly related to
health care and indirect costs. Therefore,
the total cost of the LA was lower than
that of OA, so LA is the best choice for
the patients with acute appendicitis.
CONCLUSION
- Time of the LA group (4.2 ± 2.3 days)
was less than OA (5.2 ± 2.2 days) .
- Cost of OA and LA in complicated
cases (5,918.7 thousand and 5,247.9
thousand) was higher than that of the
group without complication (5,531.9 thousand

and 5,126.3 thousand).
- The treatment cost of OA was higher
than that of LA, yet the effectiveness of
LA (96.3%) was higher than OA (93.6%),
(p > 0.05).

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2. Costa-Navarro d, Jiménez-Fuertes m and
i.-R. A. Laparoscopic appendectomy: quality
care and cost-effectiveness for today's economy.
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