JAMA Internal Medicine: Gastrointestinal Surgery- Stomach, small bowel, colorectal Topic Collection

Charge Variability for Acute Appendicitis: Is the Problem Overstated?

Epelboym I, Flory J. — Mon, 22 Oct 2012 00:00:00 GMT

We read the article by Dr Hsia and colleagues, as well as the related publication in the New York Times, with great interest. This article illustrates important concerns about charge variability in health care. A median charge of $33 611 is notably high, and a range from $1529 to $182 955 is extraordinary. However, we believe the article may somewhat overstate the scope of the problem, at least in the specific case of acute appendicitis. We would like to draw attention to several areas that would benefit from additional discussion.

Of Appendectomies, Markets, and Fictional Charges

Weeks WB. — Mon, 22 Oct 2012 00:00:00 GMT

In the article “Health care as a ‘market good’?” Hsia et al found substantial variation in total hospital charges among 19 368 appendectomy patients in California. The article engendered angst and claims of evidence of market failure. But before impugning the market mechanism, it is important to understand 2 market realities found in capitalist systems, whether customers buy health services or an apple at the store.

Appendicitis: The Great Masquerader

Maa J. — Mon, 22 Oct 2012 00:00:00 GMT

Hsia et al reported a wide range of costs for appendectomy. However, the results of their study are not surprising, given the tremendous variability in presentation and treatment of this disease. Known as the “great masquerader,” appendicitis can mimic many other diseases, leading to diagnostic challenges, particularly in pregnant women. Acute appendicitis can range from minimal inflammation, suppuration, gangrene, perforation, abscess, and systemic sepsis. Treatment may involve either admission for observation, operation, or interventional radiologic procedures to drain abscesses, with possible intensive care unit stay and mechanical ventilation. Over the decades, it has been debated whether patients with acute nonperforated appendicitis can be discharged home with antibiotics and offered surgical intervention if they return with appendiceal perforation. Advanced cases of perforation with pelvic abscess can be treated with antibiotics and a percutaneous drain, and the patients can be discharged for elective interval appendectomy weeks later. For patients requiring immediate surgery, a question arises whether surgery should be performed via the open or laparoscopic route, and the answer will vary with patient preference and surgeon expertise. Another highly variable factor is the length of time a patient waits to undergo appendectomy, which is mediated by operating room availability and other hospital capacity factors that affect length of stay.

Basic Health Care Is Not a “Market Good”

Potyk D, Graham J. — Mon, 22 Oct 2012 00:00:00 GMT

We read the article by Hsia et al about charges for appendectomy in California hospitals with interest. The wide variation in charges was remarkable but not surprising given prior publications. Two topics regarding this article are worthy of amplification. First, we assert that the data presented warrant more incisive conclusions. Second, we inquire about further analyses.