Operative vs Nonoperative Treatment of Acute Cholecystitis in Older Adults With Multimorbidity

Importance: Acute cholecystitis in older patients with multimorbidity is associated with a high risk of morbidity and mortality. Debate exists as to whether operative or nonoperative treatment is the most appropriate approach. Objectives: To compare the effectiveness of operative and nonoperative treatment in older adults with multimorbidity who are hospitalized emergently with acute cholecystitis. Design, Setting, and Participants: This was a nationwide retrospective comparative effectiveness research study conducted in the US from 2016 to 2018 that used both an inverse propensity weight analysis and an instrumental variable analysis. The study participants were Medicare beneficiaries with multimorbidity hospitalized emergently with acute cholecystitis. Previously validated qualifying comorbidity sets were used to identify multimorbidity. Data were analyzed from April 1, 2016, to December 31, 2018. Exposures: Treatment assignment of operative or nonoperative treatment for acute cholecystitis. Main Outcomes and Measures: The primary outcome was 30- and 90-day mortality. Secondary outcomes included readmission rates, emergency department (ED) revisit rates, and cost. A preference-based instrumental variable approach was used to isolate circumstances for which the decision to operate is in clinical equipoise. Our hypothesis was that operative treatment would be associated with decreased mortality compared with nonoperative management. Results: Among the 32 527 included patients, the median age was 78.8 years (IQR, 72.4-85.2 years), and 21 728 patients (66.8%) underwent cholecystectomy. Of the 10 799 patients (33.2%) who received nonoperative treatment, 3462 (32.1%) received a percutaneous cholecystostomy tube. Among all patients, operative treatment was associated with a lower risk of 30-day mortality (risk difference [RD], -0.03; P < .001) and 90-day mortality (RD, -0.04; P < .001) compared with nonoperative treatment. Among patients for whom the treatment decision was in clinical equipoise, mortality was similar for the operative and nonoperative treatment groups; operative treatment was associated with a lower risk of 30-day readmissions (RD, -0.15; P < .001) and 90-day readmissions (RD, -0.23; P < .001) as well as a lower risk of 30-day ED revisits (RD, -0.09; P < .001) and 90-day ED revisits (RD, -0.12; P < .001). The risk-adjusted cost of operative treatment was higher at the index hospitalization (+$2870.84; P < .001) and lower at 90 days (-$5495.38; P < .001) and 180 days (-$9134.66; P < .001) compared with nonoperative treatment. Conclusions and Relevance: The findings of this comparative effectiveness research study suggest that risk-adjusted operative treatment of acute cholecystitis in older patients with multimorbidity was associated with lower rates of 30- and 90-day readmissions and ED revisits compared with nonoperative treatment and a lower cost by 90 days. These findings further suggest that when uncertainty exists regarding the most appropriate treatment approach for this challenging population, strong consideration should be given to operative treatment.