K. B. Ricci1, A. Diaz1, A. P. Rushing1, A. Z. Paredes1, A. M. Ingraham2, V. T. Daniel3, D. Ayturk3, H. E. Baselice1, S. A. Strassels1, H. P. Santry1 1The Ohio State University Wexner Medical Center,Surgery,Columbus, OH, USA 2University of Wisconin,Surgery,Madison, WI, USA 3University of Massachusetts Medical School,Surgery,Worcester, MA, USA
Introduction:
Appendectomy remains a frequently performed emergency general surgery (EGS) operation. Historically, the decision to operate was based on classic history and exam findings; however, the advent of modern imaging has led to more imaging prior to surgical consultation. The purpose of this study was to evaluate the association of CT scan resources on timing of appendectomy and outcomes.
Methods:
In 2015, we surveyed 2,811 US hospitals regarding EGS practices including diagnostic radiology structure and process measures (e.g., overnight radiology staff, time to read availability). 1,690 US hospitals completed surveys (60% response). Survey data were linked to 2015 State Inpatient Databases (SID) from 17 states (510 hospitals total) using American Hospital Association Unique Identifiers. In SID, we identified all emergent admissions for adults (≥18yrs) with a primary diagnosis of appendicitis who also underwent appendectomy. We compared differences in CT scan resources at treating hospitals for patients undergoing appendectomy on the date of admission (EARLY) to those undergoing appendectomy at a later date (LATE) using appropriate tests of association (e.g., Pearson chi2 test, Fisher Exact test, Student t-test, Wilcoxon Rank-Sum test). Multivariable logistic and linear regression models, adjusted for patient clinical and demographic characteristics and clustering of care within hospitals, were performed to measure the association between CT scan resources and timing of surgery. We also measured the association of LATE vs EARLY appendectomy on postoperative outcomes (systemic complications, surgical complications, and length of stay (LOS).
Results:
We identified a total of 8,873 patients who underwent appendectomy; 2.7% (N=242) of whom underwent a LATE operation. Compared to EARLY patients, patients undergoing LATE operation tended to be older (median 54 vs 44 yo), have more comorbidities (36% vs 15% with >3 comorbidities) and have undergone an open operation (18% vs 9.0%) (all p-value<0.001).The only measure that affected the timing of appendectomy was inconsistent access to radiology reads via teleradiology which reduced the adjusted odds of EARLY operation by 36% (aOR 0.64 [95%CI 0.44, 0.93]). However, LATE operation, even when accounting for patient factors, increased the odds of surgical complications (aOR 1.97 [95%CI 1.47, 2.64]) and systemic complications (aOR 2.01 [95%CI 1.43, 2.83]) while increasing LOS by ~4 days (4.0 [95%CI 3.6,4.3]).
Conclusion:
CT resources did not reliably lead to a higher odds of an early operation. However, a late operation comes with a number of costs in terms of increased odds of both major operative and systemic complications as well as LOS. This findings suggests that process changes in areas of care other than diagnostic radiology services are necessary to improve timing and outcomes for acute appendicitis.