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Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis
Peter C Minneci1, Justin B Mahida1, Daniel L Lodwick1
1Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio2Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio.
Insights
Nonoperative management is effective for uncomplicated appendicitis in children when chosen by families. This approach leads to less morbidity and lower healthcare costs compared to surgery.
Area of Science:
- Pediatric Surgery
- Clinical Effectiveness Research
Background:
- Current evidence supports nonoperative management for uncomplicated appendicitis.
- Effectiveness depends on medical outcomes and patient/family perspectives.
- Patient choice is increasingly recognized in pediatric care decisions.
Purpose of the Study:
- To evaluate the effectiveness of patient-choice nonoperative management versus surgery for uncomplicated appendicitis in children.
- To compare medical outcomes, disability days, and healthcare costs between management strategies.
Main Methods:
- Prospective cohort study of children (7-17 years) with uncomplicated appendicitis.
- Patients/families chose between nonoperative management (IV antibiotics, oral antibiotics) and urgent appendectomy.
- Primary outcome: 1-year success rate of nonoperative management (no appendectomy).
Main Results:
- Nonoperative management success rate was 89.2% at 30 days and 75.7% at 1 year.
- The nonoperative group had lower rates of complicated appendicitis (2.7% vs 12.3%).
- Children managed nonoperatively experienced fewer disability days and lower appendicitis-related costs.
Conclusions:
- Family-chosen nonoperative management is an effective treatment for uncomplicated appendicitis in children.
- This approach is associated with reduced morbidity and healthcare expenditures.
- Incorporating patient/family choice enhances treatment effectiveness and satisfaction.
Importance:
Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's perspective, goals, and expectations.
Objective:
To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children.
Design, Setting, And Participants:
Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy.
Interventions:
Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics.
Main Outcomes And Measures:
The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery.
Results:
A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01).
Conclusions And Relevance:
When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.
Trial Registration:
clinicaltrials.gov Identifier: NCT01718275.
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