Institutioning a clinical practice guideline to decrease the rate of normal appendectomies

With the advent of laparoscopic appendectomy, the rate of normal appendectomies increased at our institution. To decrease our rate of normal appendectomies, we instituted a clinical practice guideline in January 1999 for the preoperative evaluation and treatment of patients with possible acute appendicitis. The medical records of 464 consecutive patients who underwent either open or laparoscopic appendectomy with a preoperative diagnosis of acute appendicitis between January 1, 1997, and December 31, 2000, were reviewed. The decision of open versus laparoscopic appendectomy was made at the time of surgery by the attending surgeon. Two hundred twelve patients (116 females, 96 males) underwent an appendectomy for acute appendicitis (142 open, 70 laparoscopic) from January 1, 1997 through December 31, 1998, prior to the institution of the guideline. Two hundred fifty-two patients (117 females, 135 males) underwent an appendectomy for acute appendicitis (193 open, 59 laparoscopic) from January 1, 1999, through December 31, 2000 (after the guideline was instituted). Prior to the guideline, the normal appendectomy rate was 21.7 per cent (18.3% open, 28.6% laparoscopic). After the guideline was instituted, the normal appendectomy rate was 16.7 per cent (14.5% open, 23.7% laparoscopic). In females, the normal appendectomy rate prior to the guideline was 31.0 per cent (26.6% open, 36.5% laparoscopic) while the normal appendectomy rate after the guideline was 23.1 per cent (19.0% open, 31.6% laparoscopic), P = 0.172. In males, the normal appendectomy rate prior to the guideline was 10.4 per cent (11.5% open, 5.6% laparoscopic) while the normal appendectomy rate after the guideline was 11.1 per cent (11.4% open, 9.5% laparoscopic), P = 0.861. By instituting a guideline for the diagnosis and treatment of possible acute appendicitis, we were able to decrease our rate of normal appendectomies. Although statistical significance was not reached, there is a trend toward decreasing the rate of normal appendectomies in females after the guideline was instituted.