Sceats LA, et al. - Researchers investigated the efficacy of nonoperative management of appendicitis in a national retrospective cohort of 58,329 patients with uncomplicated appendicitis. In this work, nonoperative management of appendicitis was associated with worse short-term outcomes compared with appendectomy despite a very low overall failure rate. Patients treated nonoperatively had higher rates of abscess and readmission and higher overall cost of care.

Methods

• Researchers used claims data from a private insurance database for this national retrospective cohort study; a comparison was performed of patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management.
• They reduced imbalance between groups via applying coarsened exact matching before multivariate analysis.
• From February 12 through May 1, 2018, they performed data analysis.
• Patients underwent appendectomy (control arm) or nonoperative management (treatment arm).
• Emergency Department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections were assessed as the short-term primary clinical outcomes.
• Small-bowel obstructions, incisional hernias, and appendiceal cancers were assessed as the long-term primary clinical outcomes.
• Hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure defined the nonoperative management failure.
• Number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care were included in the secondary outcome measures.
• Age, sex, region, insurance plan type, admission year, and Charlson comorbidity index were the included covariates.

Results

• Uncomplicated appendicitis was identified in 58,329 patients (52.7% men; mean [SD] age, 31.9 [16.5] years); among these, 55,709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management.
• Patients in the nonoperative management group displayed a tendency of having appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and of developing an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02).
• In the nonoperative management group, patients required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted −$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003).
• During a mean (SD) of 3.2 (1.7) years of follow-up, 101 patients (3.9%) displayed failure of nonoperative management; median time to recurrence was 42 days (interquartile range, 8-125 days).
• Treatment failure in 44 patients was noted within 30 days.