A. J. Rios Diaz1, D. Metcalfe2, C. L. Devin1, A. C. Berger1, F. Palazzo1 1Thomas Jefferson University Hospital,Department Of Surgery,Philadelphia, PA, USA 2University of Oxford, John Radcliffe Hospital,,Nuffield Department Of Orthopaedics, Rheumatology And Musculoskeletal Sciences (NDORMS),Oxford, OX3 9BU, United Kingdom
Introduction: A number of randomized controlled trials have suggested that non-operative treatment of acute appendicitis is an acceptable alternative to appendectomy. However, it is not yet clear what implications this has for patients or the healthcare system in the United States. We hypothesized that those treated non-operatively would have higher inpatient healthcare utilization after discharge.
Methods: All adult patients (≥ 18 years old) admitted with a ICD-9-CM diagnosis of acute appendicitis (with or without peritonitis, or with abscess) between 2010 and 2015 were identified from the Nationwide Readmission Database (NRD). Transfers between hospitals and incomplete follow up were excluded. The NRD is a nationally-representative database that permits longitudinal tracking of patients between hospital admissions. The outcomes were 30- and 180-day readmission, mortality, complications, and prolonged hospital length of stay (>75th percentile). Multivariable logistic regression models were used to adjust outcomes for differences in and hospital characteristics.
Results: Records from 406,478 with acute appendicitis were extracted, of which 96.3% were treated operatively and 3.7% non-operatively. The patients treated non-operatively were more likely to be older (49 vs. 43 years, p<0.01), be admitted to a teaching hospital (63.5% vs. 45%, p<0.01), have public insurance (Medicare/Medicaid; 38.2% vs. 28.5%, p<0.01), have comorbidities (Charlson Comorbidity Index >=2, 12.5% vs. 5.9%, p<0.01), present with peritonitis (29.6% vs. 18.8%) or abscess (36.6% vs. 13%, p<0.01). The non-operatively treated patients were less likely to be discharged home (87.2% vs. 94.9% p<0.01). Readmission rates between the two groups were 10.6% vs. 5.2% at 30 days and 24.2% vs. 9.5% at 180 days (all p<0.01). This trend persisted within multivariable regression models (30-day adjusted odds ratio [aOR] 1.55, 95% confidence interval [95% CI] 1.41-1.71; and 90-day aOR 2.24, 95% CI 2.09-2.41; see Table). Of those readmitted within 180 days, 20.3% were readmitted to a different hospital, and of those initially treated non-operatively, 14.5% underwent an interval procedure.
Conclusion: Non-operative treatment of acute appendicitis is utilized in only a small proportion of patients. This strategy may have substantial resource implications as these patients may experience significantly higher utilization of the healthcare system, as demonstrated by increased readmissions as long as 6-months post-discharge.
