Laird Harrison

November 05, 2014

SAN FRANCISCO — Surgery is more cost-effective than antibiotics for acute appendicitis, a new study suggests.

"Laparoscopic appendectomy carries lower costs per quality of life-year in unselected patient populations," said Vincent Chong, MD, from the University of California, San Francisco.

Dr Chong presented the finding here at the American College of Surgeons 2014 Clinical Congress.

Although appendectomy remains the gold standard for treating acute appendicitis, antibiotics have been used since 1945, Dr Chong said.

Antibiotics can be used successfully when surgery is not possible, such as in remote locations or when the patient is frail. Although research shows that some cases of appendicitis are self-limiting, perforation is no longer considered inevitable. Treatment with antibiotics also eliminates the risks related to surgery.

However, appendicitis recurs in about one-third of patients treated with antibiotics.

Knowing which therapy to use is important because appendicitis is so common, said Dr Chong. The lifetime risk for appendicitis is 8%, and 300,000 appendectomies are performed every year in the United States, at a cost of $3 billion in hospital charges.

Controversial Question

Some randomized controlled trials have explored which treatment is better, but the results are controversial.

In their study, Dr Chong and his team looked at the issue from another angle, and assessed the cost-effectiveness of the two strategies.

They evaluated data from four randomized controlled trials and multiple observational studies.

As their base case, they used an otherwise healthy woman of reproductive age with uncomplicated appendicitis. They calculated direct and opportunity costs on the basis of Medicare reimbursement in 2010 dollars.

The outcome options for appendectomy were that the patient could return home healthy, die in the hospital, suffer a small bowel obstruction, suffer an organ space surgical-site infection, or suffer a superficial surgical-site infection.

The outcome options for antibiotic therapy were that the patient would recover permanently, recover but suffer a recurrence leading to surgery, or die.

The model did not include postoperative complications or missed malignancy and colonoscopy.

In the unselected patient population, the cost per quality of life-adjusted year was lower for appendectomy than for antibiotic therapy. However, Dr Chong emphasized, the circumstances of individual patients should determine the choice of treatment.

Table. Outcomes With Appendectomy and Antibiotics

Outcome Appendectomy Antibiotics
Length of stay (days) 2.00 2.75
Sick leave (days) 9 7
Mortality (%) 0.1 0.1
Small bowel obstruction (%) 0.64
Surgical-site infection (%) 2.7
Abscess (%) 1.5
Treatment failure (%) 9.4
Recurrent appendicitis (%) 14
Quality of life-adjusted years 27.84 27.93
Total cost $10,805 $11,340
Cost per quality of life-adjusted years $388.11 $406.02


"It seems like the upfront costs of surgery would be much greater," said Greg Sacks, MD, a surgery resident at the University of California, Los Angeles, who said he is surprised by the results.

"What really drove the increased cost in the antibiotics arm was the recurrence rate," Dr Chong explained.

Session moderator Shimul Shah, MD, associate professor of surgery at the University of Cincinnati, said he wonders whether the timing of the appendectomy would affect the costs.

Dr Chong, Dr Sacks, and Dr Shah have disclosed no relevant financial relationships.

American College of Surgeons (ACS) 2014 Clinical Congress. Presented October 27, 2014.


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