Outcomes of Nonoperative ManagementRichard G. Bachur, MD, Susan C. Lipsett, MD,of Michael Uncomplicated C. Monuteaux, ScD BACKGROUND AND OBJECTIVES:Appendicitis abstract Nonoperative management (NOM) of uncomplicated pediatric appendicitis has promise but remains poorly studied. NOM may lead to an increase in resource utilization. Our objective was to investigate the trends in NOM for uncomplicated appendicitis and study the relevant clinical outcomes including subsequent appendectomy, METHODS: complications, and resource utilization. Retrospective analysis of administrative data from 45 US pediatric hospitals. Patients <19 years of age presenting to the emergency department (ED) with appendicitis between 2010 and 2016 were studied. NOM was defined by an ED visit for uncomplicated appendicitis treated with antibiotics and the absence of appendectomy at the index encounter. The main outcomes included trends in NOM among children with uncomplicated appendicitis and frequency of subsequent diagnostic imaging, ED visits, hospitalizations, RESULTS: and appendectomy during 12-month follow-up. 99001 children with appendicitis were identified, with a median age of 10.9 years. Sixty-six percent were diagnosed with nonperforated appendicitis, of which 4190 (6%) were managed nonoperatively. An increasing number of nonoperative cases were observed over 6 years (absolute difference, +20.4%). During the 12-month follow-up period, NOM patients were more likely to have the following: advanced imaging (+8.9% [95% confidence interval (CI) 7.6% to 10.3%]), ED visits (+11.2% [95% CI 9.3% to 13.2%]), and hospitalizations (+43.7% [95% CI 41.7% to 45.8%]). Among patients managed nonoperatively, 46% had a CONCLUSIONS: subsequent appendectomy. A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy. WHANW T’s K O N ON THIS SUBJECT: Nonoperative Division of Emergency Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts management (NOM) of uncomplicated appendicitis has proven to be successful in select cases but remains Dr Bachur conceived and designed the study, analyzed and interpreted the data, and drafted and poorly studied. Although success rates may approach critically revised the manuscript; Dr Lipsett interpreted the data and drafted and critically revised 70% in limited prospective studies, premature adoption of the manuscript; Dr Monuteaux designed the study, acquired the data, analyzed and interpreted NOM may have unintended consequences on subsequent the data, and drafted and critically revised the manuscript; and all authors approved the final resource utilization. manuscript as submitted. Dr Monuteaux had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. WHAT THIS StUDY AddS: Among patients with uncomplicated appendicitis, NOM was associated with DOI: https:// doi. org/ 10. 1542/ peds. 2017- 0048 an increase in subsequent emergency department visits Accepted for publication Apr 11, 2017 and hospitalizations compared with those managed operatively. During 1-year follow-up, 46% of those managed Address correspondence to Richard G. Bachur, MD, Division of Emergency Medicine, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: [email protected] nonoperatively had a subsequent appendectomy. To cite: Bachur RG, Lipsett SC, Monuteaux MC. Outcomes of Nonoperative Management of Uncomplicated Appendicitis. Pediatrics. 2017;140(1):e20170048 Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 140, number 1, July 2017:e20170048 ARTICLE Appendectomy has been the hypothesize that patients managed appendicitis with peritonitis or standard practice for uncomplicated nonoperatively will have increased abscess (540.0, 540.1; K35.2, pediatric appendicitis across the rates of subsequent emergency K35.3). Children with any chronic33 United States. Although considered department (ED) visits and Datacomorbidities Assumptions were and excluded Data Integrity. routine and safe, appendectomy has hospitalizations as compared with a recognized risk of complications those with primary appendectomy. including postoperative abdominal As a consequence of the option Without clinical information, we wall infections, intraperitoneal for NOM, we also speculate that made the following assumptions: infections, and bowel obstruction1, 2 the diagnosis of appendicitis will diagnostic studies ordered for secondary to adhesions. For increase in the absence of a histologic ED patients were performed for those with complicated appendicitis standard. the purpose of evaluation of the associated with abscess or phlegmon, METHODS primary diagnosis. For evaluating the initial antibiotic treatment with a Data Source and Design frequency and outcomes of NOM, we delayed interval appendectomy3, 4 has classified patients as receiving NOM been shown to be effective, when 3 conditions were satisfied: (1) although the– need for the the patient had an ED encounter with This is a retrospective study using subsequent 5appendectomy8 has been the primary diagnosis of appendicitis data obtained from the Pediatric questioned. (nonperforated appendicitis Health Information System (PHIS), diagnostic codes), (2) parenteral Nonoperative management (NOM) an administrative database that – antibiotics were administered, and of acute appendicitis has been the contains inpatient, ED, ambulatory, (3) no appendectomy procedure code subject of recent investigations and observation encounter level was associated with the initial visit. and interest. Although previously data from 47 not-for-profit, tertiary To avoid the possibility of including practiced in remote locations care pediatric hospitals in the 9 10 ’ patients with a recent complication and during wartime, Coldrey United States. These hospitals are of an appendectomy as an index case in 1959 published the first large affiliated with the Children s Hospital of newly diagnosed appendicitis, we series of 471 adult patients treated Association (Overland Park, KS). Data removed any patients with a previous conservatively with antibiotics – quality and reliability are assured ’ diagnosis of appendicitis or who had alone. The more recent interest has through a joint effort between the 11 18 a previous appendectomy (on the grown from modern adult trials. Children s Hospital Association basis of available data for a minimum As demonstrated in a 2016 meta- and participating hospitals. For the 19 of 12 months before their ED visit). analysis, the 1-year success rate purposes of external benchmarking, of NOM of acute appendicitis in participating hospitals provide Data integrity was judged by testing adults is 63% without increased discharge or encounter data the following conditions: (1) all complications among treatment– including demographics, diagnoses, patients with acute nonperforated failures. Pediatric data are limited–20 23 and procedures. Forty-five of these appendicitis had an appendectomy to a 4 retrospective studies,24 27 hospitals also submit resource procedure or were treated with 4 prospective– case series, 4 utilization data (eg, pharmaceuticals, parenteral antibiotics at the index prospective28 31 comparative pediatric 32 imaging, and laboratory) into PHIS. visit (98.6%), and (2) all patients studies, and 1 randomized trial Data are deidentified at the time of with perforated appendicitis were with a reported 1-year success rate of data submission. administered antibiotics (99.3%). 58% to 79%. Patients with acute appendicitis that We investigated all children <19 were discharged from the ED without Despite the limited pediatric years of age with a primary diagnosis a parenteral dose of antibiotics would data, growing interest in medical of appendicitis in association with an be missed from the analysis, although management and the trend toward ED encounter from January 1, 2010, all the previous pediatric studies of shared decision making with through June 30, 2016. An encounter International NOM included at least a single dose informed patients and parents was classified as an appendicitis case – – Classification of Diseases of parental antibiotics before oral has led to early, and potentially if any of the following 20, 21, 23 27,29 32 Aantibioticsnalytic Plan. premature, adoption of nonoperative version 9 care. Herein, we sought to determine or 10 codes were assigned as the NOM Trends the frequency and outcomes primary diagnosis from the ED visit: of nonoperative treatment of ICD-9 540.0, 540.1, 540.9, 541, or uncomplicated appendicitis at major 542; ICD-10 K35.80, K35.89, K36, The frequency of NOM was displayed US pediatric institutions by using a or K37. Perforated appendicitis over time as a proportion of large administrative database. We was defined by diagnostic codes: nonperforated appendicitis cases. Downloaded from www.aappublications.org/news by guest on September 23, 2021 2 BACHUR et al TABLE 1 Study Population (N = 99 001) Age, y, median (interquartile 10.9 (8.1 to 13.8) To test for trends of NOM, we perforation (subsequent visit). range) estimated a multivariable logistic Failure of antibiotics during the Sex (male) 59 818 (60.4) regression model of nonoperative initial visit, defined