The European Journal of Health Economics

, Volume 13, Issue 5, pp 549–560 | Cite as

Cost-effectiveness of open versus laparoscopic appendectomy: a multilevel approach with propensity score matching

  • Laura HaasEmail author
  • Tom Stargardt
  • Jonas Schreyoegg
Original Paper



To compare postoperative complications and cost of treatment of laparoscopic (LA) versus open appendectomy (OA) and to identify the most cost-effective treatment method.


Patients treated for appendectomy in US veterans health administration (VHA) hospitals in 2005 were included into our study. Direct medical cost and postoperative complications during hospitalization were used as outcomes. Propensity score matching was employed to adjust for baseline imbalances between treatment groups. It was adjusted for the severity of appendicitis, comorbidities according to Charlson Comorbidity Index, and demographic variables. 1:1 optimal matching with replacement was performed. Based on the matched samples, we estimated generalized linear mixed regression models for costs (gamma model) and postoperative complications (logit model). Besides patients’ covariates, predictors of hospital resource use and quality of care at the hospital level were considered as explanatory variables.


The total study population comprised of 1,128 patients (370 LA, 758 OA) from 95 VHA hospitals. Type of appendectomy had a significant influence on total costs (P = 0.005), with predicted costs for LA being 17.1% lower in comparison to OA (OA: 10,851 US$ [95%CI: 9,707 US$; 12,131 US$] vs. LA: 8,995 US$ [95%CI: 8,073 US$; 10,022 US$]). Differences in the predicted overall postoperative complication were not significant between LA and OA (P = 0.6311). Severity of appendicitis had a significant impact on costs and postoperative complications.


Predicted costs for LA were 1,856 US$ lower than for OA while the postoperative complication rate did not differ significantly. Thus, LA is the treatment of choice from a provider’s perspective.


Cost-effectiveness Laparoscopic appendectomy Veterans health administration Administrative data Propensity score matching 

JEL Classification

I19 E17 C2 


  1. 1.
    Sporn, E., Petroski, G.F., Mancini, G.J., Astudillo, J.A., Miedema, B.W., Thaler, K.: Laparoscopic appendectomy—is it worth the cost? Trend analysis in the US from 2000 to 2005. J. Am. Coll. Surg. 208, 179–185 (2009)PubMedCrossRefGoogle Scholar
  2. 2.
    Reissfelder, C., Mc Cafferty, B., von Frankenberg, M.: Open appendectomy: When do we still need it? Chirurg 80, 602–607 (2009)PubMedCrossRefGoogle Scholar
  3. 3.
    Eriksson, S., Granstrom, L.: Randomised controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis. Br. J. Surg. 82, 166–169 (1995)PubMedCrossRefGoogle Scholar
  4. 4.
    Chiarugi, M., Buccianti, P., Celona, G., Decanini, L., Martino, M.C., Goletti, O., Cavina, E.: Laparoscopic compared with open appendectomy for acute appendicitis: a prospective study. Eur. J. Surg. 162, 385–390 (1996)PubMedGoogle Scholar
  5. 5.
    Semm, K.: Endoscopic appendectomy. Endoscopy 15, 59–64 (1983)PubMedCrossRefGoogle Scholar
  6. 6.
    Guller, U., Hervey, S., Purves, H., Muhlbaier, L.H., Peterson, E.P., Eubanks, S., Pietrobon, R.: Lapraoscopic versus open appendectomy—outcomes comparison based on a large administrative database. Ann. Surg. 239, 43–52 (2004)PubMedCrossRefGoogle Scholar
  7. 7.
    Kehagias, I., Karamanakos, S.N., Panagiotopoulos, S., Panagopoulos, K., Kalfarentzos, F.: Laparoscopic versus open appendectomy: which way to go? World J. Gastroenterol. 14, 4909–4914 (2008)PubMedCrossRefGoogle Scholar
  8. 8.
    Long, K.H., Bannon, M.P., Zietlow, S.P., Helgeson, E.R., Harmsen, W.S., Smith, C.D.: A prospective randomized comparison of laparoscopic appendectomy with open appendectomy: clinical and economic analyses. Surgery 129, 390–400 (2001)PubMedGoogle Scholar
  9. 9.
    Maxwell, J.G., Tyler, B.A., Rutledge, R., Brinker, C.C., Maxwell, B.G., Covington, D.L.: Deriving the indications for laparoscopic appendectomy from a comparison of the outcomes of laparoscopic and open appendectomy. Am. J. Surg. 182, 687–692 (2001)PubMedCrossRefGoogle Scholar
  10. 10.
    Fingerhut, A., Millat, B., Borrie, F.: Laparoscopic versus open appendectomy: time to decide. World J. Surg. 23, 835–845 (1999)PubMedCrossRefGoogle Scholar
  11. 11.
    Garbutt, J.M., Soper, N.J., Shannon, W.D., Botero, A., Littenberg, B.: Meta-analyses of randomized controlled trials comparing laparoscopic and open appendectomy. Surg. Laparosc. Endosc. 9, 17–26 (1999)PubMedCrossRefGoogle Scholar
  12. 12.
    Wei, B., Qi, C.L., Chen, T.F., Zheng, Z.H., Huang, J.L., Hu, B.G., Wei, H.B.: Laparoscopic versus open appendectomy for acute appendicitis: a metaanalysis. Surg. Endosc. 4, 1–10 (2011)CrossRefGoogle Scholar
  13. 13.
    Sauerland, S., Lefering, R., Holthausen, U., Neugebauer, E.A.M.: Laparoscopic versus conventional appendectomy—a meta-analysis of randomised controlled trials. Langenbecks Arch. Surg. 383, 289–295 (1998)PubMedCrossRefGoogle Scholar
  14. 14.
    Wu, H.S., Lai, H.W., Kuo, S.J., Lee, Y.T., Chen, D.R., Chi, C.W., Huang, M.H.: Competitive edge of laparoscopic appendectomy versus open appendectomy: a subgroup comparison analysis. J. Laparoendosc. Adv. Surg. Tech. 21, 197–202 (2011)CrossRefGoogle Scholar
  15. 15.
    Tiwari, M.M., Reynoso, J.F., High, R., Tsang, A.W., Oleynikov, D.: Safety, efficacy, and cost-effectiveness of common laparoscopic procedures. Surg. Endosc. 25, 1–9 (2011)CrossRefGoogle Scholar
  16. 16.
    Heikkinen, T., Haukipuro, K., Hulkko, A.: Cost-effective appendectomy. Surg. Endosc. 12, 1204–1208 (1998)PubMedCrossRefGoogle Scholar
  17. 17.
    Bresciani, C., Perez, R.O., Habr-Gama, A., Jacob, C.E., Ozaki, A., Batagello, C., Proscurshim, I., Gama-Rodrigues, J.: Laparoscopic versus standard appendectomy outcomes and cost comparisons in the private sector. J. Gastrointest. Surg. 9, 1174–1180 (2005)PubMedCrossRefGoogle Scholar
  18. 18.
    Ignacio, R.C., Burke, R., Spencer, D., Bissell, C., Dorsaonvil, C., Lucha, P.A.: Laparoscopic versus open appendectomy: what is the real difference? Results of a prospective randomized double-blinded trial. Surg. Endosc. 18, 334–337 (2004)PubMedCrossRefGoogle Scholar
  19. 19.
    Lintula, H., Kokki, H., Vanamo, K., Valtonen, H., Mattila, M., Eskelinen, M.: The costs and effects of laparoscopic appendectomy in children. Arch. Pediatr. Adolesc. Med. 158, 34–37 (2004)PubMedCrossRefGoogle Scholar
  20. 20.
    Yaisawarng, S., Burgess Jr, J.F.: Performance-based budgeting in the public sector: an illustration from the VA health care system. Health Econ. 15, 295–310 (2006)PubMedCrossRefGoogle Scholar
  21. 21.
    Schreyoegg, J., Stargardt, T.: The trade-off between costs and outcomes: the case of acute myocardial infarction. Health Serv. Res. 45, 1585–1601 (2010)CrossRefGoogle Scholar
  22. 22.
    Carey, K., Burgess, J.F.: Hospital costing: experience from the VHA. Financ. Account. Manag. 16, 289–308 (2000)CrossRefGoogle Scholar
  23. 23.
    Schreyoegg, J., Stargardt, T., Tiemann, O.: Costs and quality of hospitals in different health care systems: a multi-level approach with propensity score matching. Health Econ. 20, 85–100 (2011)CrossRefGoogle Scholar
  24. 24.
    Hale, D., Molloy, M., Pearl, R., Schutt, D., Jaques, D.: Appendectomy: a contemporary appraisal. Ann. Surg. 225, 252–261 (1997)PubMedCrossRefGoogle Scholar
  25. 25.
    Kazemier, G., Bijness, A.B., Schilthuis, M.S., Kazemier, G., Bijness, A.B., Schilthuis, M.S.: Appendicitis and pelvic inflammatory disease. In: Van Lanschot, J., Gouma, D., Jansen, P., Jones, E.A., Pinedo, H.M., Schouten, W.R., Tytgat, G. (eds.) Integrated medical and surgical gastroenterology, pp. 338–345. Thieme Medical Publishers, New York (2004)Google Scholar
  26. 26.
    Deyo, R.A., Cherkin, D.C., Ciol, M.A.: Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J. Clin. Epidemiol. 45, 613–619 (1992)PubMedCrossRefGoogle Scholar
  27. 27.
    Li, B., Evans, D., Faris, P., Dean, S., Quan, H.: Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases. BMC Health Serv. Res. 8, 12 (2008)PubMedCrossRefGoogle Scholar
  28. 28.
    Quan, H., Sundararajan, V., Halfon, P., Andrew Fong, B., Burnand, B., Luthi, J., Saunders, L., Beck, C., Feasby, T., Ghali, W.: Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med. Care 43, 1130–1139 (2005)PubMedCrossRefGoogle Scholar
  29. 29.
    Sundararajan, V., Henderson, T., Perry, C., Muggivan, A., Quan, H., Ghali, W.: New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J. Clin. Epidemiol. 57, 1288–1294 (2004)PubMedCrossRefGoogle Scholar
  30. 30.
    Schreyoegg, J.: A micro-costing approach to estimating hospital costs for appendectomy in a Cross-European context. Health Econ. 17, 59–69 (2008)CrossRefGoogle Scholar
  31. 31.
    Schrag, D., Cramer, L., Bach, P., Cohen, A., Warren, J., Begg, C.: Influence of hospital procedure volume on outcomes following surgery for colon cancer. J. Am. Med. Assoc. 284, 3028–3035 (2000)CrossRefGoogle Scholar
  32. 32.
    Flood, A., Scott, W., Ewy, W.: Does practice make perfect? Part II: the relation between volume and outcomes and other hospital characteristics. Med. Care 22, 115–125 (1984)PubMedCrossRefGoogle Scholar
  33. 33.
    D’Agostino, R.B.: Tutorial in biostatistics: propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat. Med. 17, 2265–2281 (1998)PubMedCrossRefGoogle Scholar
  34. 34.
    Indurkhya, A., Mitra, N., Schrag, D.: Using propensity scores to estimate the cost-effectiveness of medical therapies. Stat. Med. 25, 1561–1576 (2006)PubMedCrossRefGoogle Scholar
  35. 35.
    Rubin, D.: The use of matched sampling and regression adjustment to remove bias in observational studies. Biometrics 29, 185–203 (1973)CrossRefGoogle Scholar
  36. 36.
    Greenland, S.: Modeling and variable selection in epidemiologic analysis. Am. J. Public Health 79, 340–349 (1989)PubMedCrossRefGoogle Scholar
  37. 37.
    Normand, S.L.T., Landrum, M.B., Guadagnoli, E., Ayanian, J.Z., Ryan, T.J., Cleary, P.D., McNeil, B.J.: Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores. J. Clin. Epidemiol. 54, 387–398 (2001)PubMedCrossRefGoogle Scholar
  38. 38.
    Snijders, T., Bosker, R.: Multilevel analysis: an introduction to basic and advanced multilevel modeling. Sage, New York (1999)Google Scholar
  39. 39.
    Grieve, R., Nixon, R., Thompson, S.G., Cairns, J.: Multilevel models for estimating incremental net benefits in multinational studies. Health Econ. 16, 815–826 (2007)PubMedCrossRefGoogle Scholar
  40. 40.
    Hauck, K., Street, A.: Performance assessment in the context of multiple objectives: a multivariate multilevel analysis. J. Health Econ 25, 1029–1048 (2006)PubMedCrossRefGoogle Scholar
  41. 41.
    Goldstein, H.: Multilevel models. In: Armitrage, P., Colton, C. (eds.) Encyclopedia of biostatistics, pp. 2725–2731. Wiley, Chichester (1998)Google Scholar
  42. 42.
    Diehr, P.: Methods for analyzing health care utilization and costs. Annu. Rev. Public Health 20, 125–144 (1999)PubMedCrossRefGoogle Scholar
  43. 43.
    Piskun, G., Kozik, D., Rajpal, S., Shaftan, G., Fogler, R.: Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis. Surg. Endosc. 15, 660–662 (2001)PubMedCrossRefGoogle Scholar
  44. 44.
    Yagmurlu, A., Vernon, A., Barnhart, D., Georgeson, K., Harmon, C.: Laparoscopic appendectomy for perforated appendicitis: a comparison with open appendectomy. Surg. Endosc. 20, 1051–1054 (2006)PubMedCrossRefGoogle Scholar
  45. 45.
    Severens, J.L., De Boo, T.M., Konst, E.M.: Uncertainty of incremental cost-effectiveness ratios. Int. J. Technol. Assess. Health Care 15, 608–614 (1999)PubMedCrossRefGoogle Scholar
  46. 46.
    Henderson, J.: Health economics & policy. South-Western Cengage Learning, Mason (2008)Google Scholar
  47. 47.
    Garber, A.M., Phelps, C.E.: Economic foundations of cost-effectiveness analysis. J. Health Econ. 16, 1–31 (1997)PubMedCrossRefGoogle Scholar
  48. 48.
    Cothren, C.C., Moore, E.E., Johnson, J.L., Moore, J.B., Ciesla, D.J., Burch, J.M.: Can we afford to do laparoscopic appendectomy in an academic hospital? Am. J. Surg. 190, 950–954 (2005)Google Scholar
  49. 49.
    Martin, L., Puente, I., Sosa, J., Bassin, A., Breslaw, R., McKenney, M., Ginzburg, E., Sleeman, D.: Open versus laparoscopic appendectomy. A prospective randomized comparison. Ann. Surg. 222, 256–262 (1995)PubMedCrossRefGoogle Scholar
  50. 50.
    Nakhamiyayev, V., Galldin, L., Chiarello, M., Lumba, A., Gorecki, P.: Laparoscopic appendectomy is the preferred approach for appendicitis: a retrospective review of two practice patterns. Surg. Endosc. 24:859–864 (2010)Google Scholar
  51. 51.
    Botha, A., Elton, C., Moore, E., Sauven, P.: Laparoscopic appendicectomy: a trainee’s perspective. Ann. R. Coll. Surg. Engl. 77, 259–262 (1995)PubMedGoogle Scholar
  52. 52.
    Macario, A., Vitez, T.S., Dunn, B., McDonald, T.: Where are the costs in perioperative care? Analysis of hospital costs and charges for inpatient surgical care. Anesthesiology 83, 1138–1144 (1995)PubMedCrossRefGoogle Scholar
  53. 53.
    Yeh, C.C., Wu, S.C., Liao, C.C., Su, L.T., Hsieh, C.H., Li, T.C.: Laparoscopic appendectomy for acute appendicitis is more favorable for patients with comorbidities, the elderly, and those with complicated appendicitis: a nationwide population-based study. Surg. Endosc. 25:2932–2942 (2011)Google Scholar
  54. 54.
    Katkhouda, N., Mason, R.J., Towfigh, S., Gevorgyan, A., Essani, R.: Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann. Surg. 242, 439–448 (2005)PubMedGoogle Scholar
  55. 55.
    Canty Sr., T.G., Collins, D., Losasso, B., Lynch, F., Brown, C.: Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice? J. Pediatr. Surg. 35, 1582–1585 (2000)PubMedCrossRefGoogle Scholar
  56. 56.
    Ball, C.G., Kortbeek, J.B., Kirkpatrick, A.W., Mitchell, P.: Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors. Surg. Endosc. 18, 969–973 (2004)PubMedCrossRefGoogle Scholar
  57. 57.
    Hoehne, F., Ozaeta, M., Sherman, B., Miani, P., Taylor, E.: Laparoscopic versus open appendectomy: is the postoperative infectious complication rate different? Am. Surg. 71, 813–815 (2005)PubMedGoogle Scholar
  58. 58.
    Scarborough, J.E., Pietrobon, R., Tuttle-Newhall, J.E., Marroquin, C.E., Collins, B.H., Desai, D.M., Kuo, P.C., Pappas, T.N.: Relationship between provider volume and outcomes for orthotopic liver transplantation. J. Gastrointest. Surg. 12, 1527–1533 (2008)PubMedCrossRefGoogle Scholar
  59. 59.
    Dimick, J.B., Birkmeyer, J.D., Upchurch, G.R.: Measuring surgical quality: what’s the role of provider volume? World J. Surg. 29, 1217–1221 (2005)PubMedCrossRefGoogle Scholar
  60. 60.
    Gordon, T.A., Bowman, H.M., Bass, E.B., Lillemoe, K.D., Yeo, C.J., Heitmiller, R.F., Choti, M.A., Burleyson, G.P., Hsieh, G., Cameron, J.L.: Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J. Am. Coll. Surg. 189, 46–56 (1999)PubMedCrossRefGoogle Scholar
  61. 61.
    Hughes, R.G., Hunt, S.S., Luft, H.S.: Effects of surgeon volume and hospital volume on quality of care in hospitals. Med. Care 25, 489–503 (1987)PubMedCrossRefGoogle Scholar
  62. 62.
    Lin, Y.Y., Shabbir, A., So, J.B.Y.: Laparoscopic appendectomy by residents: evaluating outcomes and learning curve. Surg. Endosc. 24, 125–130 (2010)PubMedCrossRefGoogle Scholar
  63. 63.
    Ali, A., Moser, M.A.J.: Recent experience with laparoscopic appendectomy in a Canadian teaching centre. Can. J. Surg. 51, 51–55 (2008)PubMedGoogle Scholar
  64. 64.
    Rosenbaum, P.R., Rubin, D.B.: The central role of the propensity score in observational studies for causal effects. Biometrika 70, 41–55 (1983)CrossRefGoogle Scholar
  65. 65.
    Rosenbaum, P.R.: Observational studies. Springer, New York (2002)Google Scholar
  66. 66.
    Smith, J., Todd, P.: Does matching overcome LaLonde’s critique of nonexperimental estimators? J. Econometrics 125, 305–353 (2005)CrossRefGoogle Scholar
  67. 67.
    Ho, D.E., Imai, K., King, G., Stuart, E.A.: Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Polit. Anal. 15, 199–236 (2007)CrossRefGoogle Scholar
  68. 68.
    Byford, S., Raftery, J.: Perspectives in economic evaluation. Br. Med. J. 316, 1529–1530 (1998)CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Laura Haas
    • 1
    Email author
  • Tom Stargardt
    • 1
    • 2
  • Jonas Schreyoegg
    • 1
    • 2
    • 3
  1. 1.Institute of Health Economics and Health Care ManagementHelmholtz Zentrum MuenchenNeuherberg/MunichGermany
  2. 2.Department for Health Services ManagementMunich UniversityMunichGermany
  3. 3.Center for Primary Care and Outcomes ResearchStanford UniversityStanfordUSA

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