CHOLEDOCHOSCOPY - A COST-MINIMIZATION ANALYSIS

Although choledochoscopy for the prevention of retained bile duct stones has been postulated as cost effective, no economic evaluation exists to substantiate this claim. We performed a cost-minimization analysis on 287 patients who underwent choledochoscopy during operations for biliary tract calculi between 1981 and 1987 to assess the economic impact of choledochoscopy versus noncholedochoscopic alternatives in obtaining a stone-free duct. Common duct exploration was positive for calculi in 75% of patients. Choledochoscopy detected residual stones after duct exploration in 10% of patients. Residual stones were more frequent after positive (12.5%) than negative (2.7%) duct explorations. Retained stones occurred in 4.5% of patients after operation. Sensitivity, specificity, and negative predictive values of choledochoscopy were 67%, 100%, and 95%, respectively. Cost-minimization analysis showed that total cost of either selective ($75,250) or routine ($110,450) choledochoscopy significantly exceeded the total cost of obtaining a stone-free duct for patients with retained stones via either extraction through a T-tube tract ($17,545) or by endoscopic papillotomy ($45,675). Because choledochoscopy was not economically competitive with noncholedochoscopic, nonoperative alternatives, reduction of choledochoscopy fees was implemented to economically justify continued use of choledochoscopy. We conclude that choledochoscopy is clinically efficacious in obtaining a stone-free duct, but endorsement of either routine or selective choledochoscopy by cost-minimization analysis requires careful assessment of fee structure to make choledochoscopy competitive economically.