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Date: May 6th, 2019
Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018
Guest Skeptic: Dr. Robert Leeper is an assistant professor of surgery at Western University and the London Health Sciences Centre. His practice is in trauma, emergency general surgery, and critical care with an academic interest in ultrasound and medical simulation.
Case: An 18-year-old woman presents with a Grade 1 appendicitis (Tominaga et al J Trauma Acute Care Surg 2016).
Background: The first documented appendectomy was done by Claudius Amyand in 1735. The standard treatment for acute appendicitis has been appendectomy ever since Charles McBurney described it in 1889.
Omar et al (2008) showed just how safe laparoscopic appendectomies have become. They found in a study of over 230,000 UK patients under the age of 49 there were no deaths.
Being that there are doctors out there without scalpels, and that diverticulitis has often been treated successfully with antibiotics. Some clinicians have hypothesized that perhaps acute appendicitis could also be treated successfully with antibiotics.
Two meta-analyses have been done and they looked at nearly the same studies on “uncomplicated” acute appendicitis and came up with two opposite conclusions. This is an example of why things in evidence-based medicine can be “complicated” (SGEM#115 and SGEM#180
Clinical Question: Operative treatment or non-operative treatment of acute Grade 1 (uncomplicated) appendicitis?
Reference: Sceats et al. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surgery 2018
- Population: Adult patients admitted to hospital with a diagnosis of acute uncomplicated (Grade I) appendicitis.
- Exclusion: Patients with co-occurring diagnosis or procedure codes consistent with complicated appendicitis and patients lacking appendectomy codes.
- Exposure: Non-operative management of appendicitis
- Comparison: Operative management of appendicitis
- Outcome:
- Primary Outcomes:
- Short Term (<30 days) Complications: ED visits, all-cause readmissions, appendicitis-associated readmissions, rate of abdominal abscess and C. difficile.
- Long Term (>30 days) Complications: Readmission for small-bowel obstruction, diagnosis of incisional hernia, and diagnosis of appendiceal cancer.
- Secondary Outcomes: “Length of stay during index hospitalization, cost of index hospitalization, number of follow-up visits required in the following year, and the total cost of appendicitis-associated care in the year after diagnosis. Total cost of appendicitis-associated care was determined by summing the total cost for every in-patient and outpatient encounter associated with appendicitis for the following year, including the index hospitalization.”
- Post Hoc Analysis: Rates of non-operative management failure (<30 days) and rates of appendicitis recurrence (>29d days) as well as timing of the failure or recurrence.
- Primary Outcomes:
Authors’ Conclusions: “According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.”
Quality Checklist for Observational Study:
- Did the study address a clearly focused issue? Yes
- Did the authors use an appropriate method to answer their question? Yes
- Was the cohort recruited in an acceptable way? Unsure
- Was the exposure accurately measured to minimize bias? Unsure
- Was the outcome accurately measured to minimize bias? Unsure
- Have the authors identified all-important confounding factors? Unsure
- Was the follow up of subjects complete enough? Yes
- How precise are the results? The results seem fairly precise.
- Do you believe the results? Yes
- Can the results be applied to the local population? Unsure
- Do the results of this study fit with other available evidence? No
Key Results: Their database search found 58,329 patients with a primary admission diagnosis of uncomplicated (Grade 1) acute appendicitis. There were slightly more men than women in the cohort. The mean age was 32 years. The vast majority (95.5%) underwent appendectomy with only a few (4.5%) treated nonoperatively. Of those who had an appendectomy, 83% were done laparoscopically and the rate increased over the duration of the study.
The patients in the nonoperative group were statistically significantly older (34 vs. 32), had more comorbidity and lived in the Northeast or South USA. There were also differences observed on insurance plans with the nonoperative patients more likely to have a high-deductible.
There were less short-term complications with operative management vs. nonoperative management.
No statistical difference was found in long-term complications except for patients to be diagnosed more often with appendiceal cancer.
- Secondary Outcomes: Length of stay was 0.15 days longer in the appendectomy group while those in the nonoperative group had more follow-up visits. Costs are listed in the original paper and will not apply outside the USA.
- Post Hoc Analysis: A total of 101 cases (3.9%) were considered failure of nonoperative management (1.7% in 30 days and 2.2% after 30 days).
1. ICD-9 Codes: Has this been validated as an accurate way to measure exposure and outcomes? We were not able to find any publication that quantified using this tool and the authors provided no reference. They also assumed that if the patient had appendectomies the did have appendicitis. We know that there is a small number of patients that will have a negative appendectomy.
2. Patient Satisfaction: It would have been nice to know how satisfied patients were with their management. Would those in the operative group liked to have been treated nonoperatively and visa versa.
3. Complications and Failures: The short-term complication rate was higher in the nonoperative group. The absolute difference was 1% for abscesses. The increase in readmit and appendicitis associated readmit rates would be associated with this complication. Are patients willing to accept a 1% abscess rate to avoid a surgery in the short therm.
In addition, the overall “failure” rate was just under 4%. If you wanted to promote the nonoperative management protocol you could say it has a 96% success rate. The cohort is skewed because 96% of patients were in the operative management cohort.
Another important point is that this 4% “failure” rate is lower than has been previously reported in randomized trials. It could be that privately insured patients in the USA are different than patient included in randomized control trials and therefore limit the external validity of these findings to other populations.
There is an ENORMOUS selection bias. Of course, when providers and patient use the full extent of their good judgement to choose treatment options we should expect them to be able to bias the results towards the good. The lower rate of failure simply tells us that providers and patients were choosing wisely.
4. Missed Cancer: They highlight the small difference in missed cancers. They correctly point out that the incidence was so small the study is underpowered for this complication. However, a more important question would be whether or not a delay in identifying an appendicular cancer resulted in a worse patient-oriented outcome.
5. Asked the Wrong Question: We want to know if it is better to cut or not to cut in patients with uncomplicated appendicitis. Only a well-designed, blinded randomized trial could provide the answer. Their retrospective study design could have unmeasured confounders influencing the results. We need to be careful not to over interpret their findings.
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions. The last sentence could have also been written: “These data suggest that nonoperative management [may or] may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.”
SGEM Bottom Line: Nonoperative management of acute uncomplicated appendicitis may be better than we thought in selected patients but comes with a cost of a small absolute increase in some complications.
Case Resolution: She chooses to have her appendix removed, does well and is discharged home that night.
Dr. Rob Leeper
Clinical Application: Empower appropriately selected patients with the evidence and your clinical judgment. Engage them in shared decision making and ask about their preference.
What Do I Tell My Patient? You are lucky because there are two pretty good options to treat appendicitis. Option one is to take your appendix out and you will be home later tonight and you should never have trouble again. The rate of a successful operation is really, really high. The price you will pay is three small holes in your belly and some pain over the next week or so. The other option, if you prefer, is to take oral antibiotics for one week. There is about a 95% success rate with a small risk of bouncing back to the hospital with appendicitis or an abscess. I think either option would work well for you.
Keener Kontest: There were lots of keeners last week but no winner. Many people thought the patent for insulin was sold for $1 in 1923. However, the correct answer is $3. Frederick Banting, Charles Best, and James Collip, the team that first discovered and refined insulin therapy, agreed to receive $1 each in exchange for giving their patent rights to the Board of Governors of the University of Toronto in 1923.
Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.
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