Patient Selection Key in Nonoperative Appendicitis Care

Jennifer Garcia

November 14, 2018

Nonoperative management of acute uncomplicated appendicitis (AUA) can be successful. However, over time, complication and readmission rates were higher among medically managed patients compared with those who underwent appendectomy, according to results of a large retrospective study.

The data, published online November 14 in JAMA Surgery, also suggest that the risk for recurrence persists for several years after the index event.

"Although the overall failure rate of nonoperative management of appendicitis was very low, nonoperative management was associated with worse short-term outcomes compared with appendectomy," write Lindsay A. Sceats, MD, from the Department of Surgery, Stanford University, California, and colleagues.

Sceats and colleagues evaluated claims data from 58,329 patients admitted for appendicitis from January 1, 2008, through December 31, 2014. Patients designated on the basis of International Classification of Diseases, Ninth Revision codes as having AUA underwent either nonoperative management with antibiotic therapy (n = 2620; 4.5%) or appendectomy (n = 55,709; 95.5%). Laparoscopic surgery was performed in the majority of patients (83%) who underwent appendectomy.

The researchers found that patients in the nonoperative group were more likely to have appendicitis-related readmissions (2.6% vs 1.2%; P < .001) and were more likely to develop an abdominal abscess (2.3% vs 1.3%; P < .001) in comparison with patients who underwent appendectomy.

The researchers note that patients in the nonoperative group were older (mean age, 34.2 years vs 31.8 years, P < .001), had more comorbid conditions (Charlson comorbidity index, .37 vs .26, P < .001), and were more likely to have high-deductible insurance compared with those in the appendectomy group (9.0% vs 6.5%,).

Further, the study authors note that risk for recurrence persisted as long as 4 years following the index event, a finding that had not been noted previously in other studies with shorter follow-up periods. The investigators suggest that this may lead "to a positively skewed assumption about the success of nonoperative management.”

When assessing the economic impact of surgical vs nonsurgical management, Sceats and colleagues found that although patients in the nonoperative group had lower index hospitalization costs, the total cost of care was higher, owing to outpatient follow-up visits, readmissions, or recurrence within 1 year after diagnosis (unadjusted mean, $14,934 vs $14,186; adjusted +$785; P = .003).

The researchers acknowledge the inherent limitations of evaluating administrative claims data, including the potential for misclassifications, and that the insured population in the present study may be different from uninsured or government-insured patients.

Given the increased risk for readmission and overall increased cost of care, "these data do not support the use of nonoperative management as first-line therapy for uncomplicated appendicitis until more conclusive randomized clinical trial data become available," conclude Sceats and colleagues.

In an accompanying editorial, Katherine M. Reitz, MD, and Brian S. Zuckerbraun, MD, from the Department of Surgery, University of Pittsburgh, in Pennsylvania, write: "The notion of surgery is daunting for many patients, and short-term consequences can often be seen with more clarity than longer-term consequences, thus contributing to the appeal of nonoperative options.”

Although Reitz and Zuckerbraun acknowledge that the study data support both conservative and surgical approaches to AUA, they emphasize that "the subsequent recommendation for operative or nonoperative management should be tempered by whichever strategy is most likely to achieve the additional goals and priorities of the patient beyond cure."

Support for the study was provided by the National Center for Advancing Translational Science Clinical and Translational Science Awards. Internal funding was provided by Stanford University. The authors and editorialists have disclosed no relevant financial relationships.

JAMA Surg. Published online November 14, 2018. Full text

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