Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019.

INTRODUCTION: Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS: The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS: Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS: NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

The risks of failed nonoperative management of appendicitis in older adults.

BACKGROUND: The consequences of failed nonoperative management of appendicitis in older patients have not been described. METHODS: We used the 2004-2017 National Inpatient Sample to identify acute appendicitis patients managed nonoperatively (<65 years old: 32,469; ≥65 years old: 11,265). Outcomes included morbidity, length of stay (LOS), inpatient costs, and discharge to skilled facilities. Differences were estimated using propensity scores. RESULTS: For patients <65, nonoperative failure was associated with increased morbidity (7 â€‹% [95 â€‹% CI 6.9 â€‹%-8.1 â€‹%]), LOS (3 day [95 â€‹% CI 3-4]), costs ($9015 [95 â€‹% CI $8216- $9446]), and discharges to skilled facilities (1 â€‹% [95 â€‹% CI 0.9 â€‹%-1.6 â€‹%]) compared to successful nonoperative treatment. Patients ≥65 had differences in morbidity (14 â€‹% [95 â€‹% CI 13.6 â€‹%-16.2 â€‹%]), LOS (6 days [95 â€‹% CI 5-6]), costs ($15,964 [95 â€‹% CI $15,181- $17,708]), and discharges to skilled facilities (12 â€‹% [95 â€‹% CI: 10.0 â€‹%-13.3]) compared to nonoperative success. CONCLUSIONS: Nonoperative management of appendicitis should be approached cautiously for older adults.

Lessons learned from value-based pediatric appendectomy care: A shared savings pilot model.

PURPOSE: We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. METHODS: All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. RESULTS: 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (-57%) and patient satisfaction. No savings were realized because the cost reduction threshold (-9%) was not met during PP1 (+1.7%) or PP2 (-0.4%). CONCLUSIONS: Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs.

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BACKGROUND: Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS: A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS: A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION: This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications.

BACKGROUND: Despite unparalleled advances in perioperative medicine, surgical outcomes remain poor for racial minority patients relative to their white counterparts. Little is known about the excess costs to the health care system related to these disparities. METHODS: We performed a retrospective analysis of data from the Nationwide Inpatient Sample between 2001 and 2018. We included children younger than 18 years admitted with appendicitis who underwent an appendectomy during their hospital stay. We examined the inflation-adjusted hospital costs attributable to the racial disparities in surgical complications and perforation status, focusing on differences between non-Hispanic white patients and non-Hispanic Black patients. RESULTS: We included 100 639 children who underwent appendectomy, of whom 89.9% were non-Hispanic white and 10.1% were non-Hispanic Black. Irrespective of perforation status at presentation, surgical complications were consistently higher for Black compared with white children, with no evidence of narrowing of the racial disparity gap over time. Black children consistently incurred higher hospital costs (median difference: $629 [95% confidence interval: $500-$758; P < .01). The total inflation-adjusted hospital costs for Black children were $518 658 984, and $59 372 044 (11.41%) represented the excess because of the racial disparities in perforation rates. CONCLUSIONS: Although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden. We provide an empirical economic argument for sustained efforts to reduce racial disparities in pediatric surgical outcomes, notwithstanding that eliminating these disparities is simply the right thing to do.

Impact of implementing a fast-track protocol and standardized guideline for the management of pediatric appendicitis.

Background: In 2017, a provincial guideline was created to fast track and standardize care for pediatric appendicitis in Alberta. We conducted a study to determine the impact of implementation of the guideline at our institution on length of stay (LOS), antibiotic stewardship efforts and costs. Methods: We performed a retrospective review of the charts of all patients younger than 18 years of age who underwent appendectomy at our institution in 2 periods: before guideline implementation (Dec. 1, 2016, to May 31, 2017) and after implementation (Dec. 1, 2017, to May 31, 2018). We compared LOS, duration of antibiotic therapy, 30-day postdischarge complication rates and variable cost between the 2 cohorts. Results: Of the 276 total appendectomy procedures performed, 185 were for simple appendicitis (81 before guideline implementation and 104 after implementation), and 91 were for complicated appendicitis (44 and 47, respectively). The median LOS was shorter in the postimplementation cohort for both simple and complicated appendicitis (15.5 h [interquartile range (IQR) 12-19 h] v. 17.0 h [IQR 13-22 h], p = 0.03; and 3.0 d [IQR 2-4 d] v. 3.0 d [IQR 3-5 d], p = 0.05, respectively). Patients with complicated appendicitis had fewer antibiotic days after guideline implementation; the difference was statistically significant for patients without diffuse peritoneal contamination or abscess formation (p = 0.02). There were no differences between the cohorts with respect to 30-day rates of complications, including emergency department visits, readmission and surgical site infections. After guideline implementation, the average variable cost per patient was reduced by $230, equating to a total average annual cost savings of $75 842 for our institution. Conclusion: The implementation of a provincial guideline aimed at standardizing care in pediatric appendicitis at our institution was associated with shortened LOS, improved antibiotic stewardship efforts and reduced cost of care. Other institutions may replicate our model of a standardized pathway in the management of pediatric appendicitis in an effort to improve the quality of patient care and reduce health care costs.

Contexte: En 2017, des lignes directrices provinciales ont vu le jour en Alberta afin d'accélérer et de normaliser les soins pédiatriques pour appendicite. Notre étude visait à déterminer l'effet de leur application, par notre établissement, sur la durée du séjour, la gestion des antibiotiques et les coûts des soins. Méthodes: Nous avons examiné de façon rétrospective le dossier de tous les patients de moins de 18 ans ayant subi une appendicectomie à notre établissement avant l'application des lignes directrices (entre le 1er décembre 2016 et le 31 mai 2017) et après (entre le 1er décembre 2017 et le 31 mai 2018). Les données relatives à la durée du séjour, à la durée de l'antibiothérapie, au taux de complications 30 jours après le congé et aux coûts variables ont été comparées entre les 2 groupes. Résultats: Des 276 appendicectomies totales effectuées, 185 concernaient une appendicite simple (81 avant l'application des lignes directrices et 104 après), et 91, une appendicite compliquée (44 avant l'application et 47 après). La durée médiane du séjour était plus courte dans le groupe postapplication, tant pour l'appendicite simple (15,5 h [écart interquartile (EI) 12­19 h] c. 17,0 h [EI 13­22 h]; p = 0,03) que pour l'appendicite compliquée (3,0 j [EI 2­4 j] c. 3,0 j [EI 3­5 j]; p = 0,05). Les patients qui présentaient une appendicite compliquée avaient une antibiothérapie moins longue après l'application des lignes directrices; la différence était statistiquement significative chez les patients sans contamination péritonéale diffuse ou abcès (p = 0,02). Aucune différence n'a été observée entre les cohortes en ce qui a trait au taux de complications à 30 jours, qui comprenait les consultations à l'urgence, les réadmissions et les infections du site opératoire. L'application des lignes directrices a permis de réduire les coûts variables par patient de 230 $, ce qui représente une économie annuelle moyenne de 75 842 $ pour notre établissement. Conclusion: L'application des lignes directrices provinciales visant à normaliser les soins pédiatriques pour appendicite a été associée, dans notre établissement, à une réduction de la durée du séjour, à l'amélioration de la gestion des antibiotiques et à une diminution des coûts des soins. D'autres établissements pourraient reproduire ce modèle de soins normalisés pour améliorer la qualité et réduire les coûts.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

The impact of intravenous acetaminophen pricing on opioid utilization and outcomes for children with appendicitis.

BACKGROUND: In 2014, the price of intravenous acetaminophen more than doubled. This study determined whether increased intravenous acetaminophen cost was associated with decreased utilization and increased opioid use for children undergoing appendectomy. METHODS: A multicenter retrospective cohort study using the Pediatric Health Information System database between 2011 and 2017 was performed. Healthy children 2 to 18 years undergoing appendectomy at 46 children's hospitals in the United States were identified. Intravenous acetaminophen use, opioid use, and pharmacy costs were assessed. Multivariable mixed-effects modeling was used to determine the association between postoperative opioid use, intravenous acetaminophen use, and postoperative length-of-stay. RESULTS: Overall, 110,019 children undergoing appendectomy were identified, with 22.5% (N = 24,777) receiving intravenous acetaminophen. Despite the 2014 price increase, intravenous acetaminophen use increased from 3% in 2011 to 40.1% in 2017 (P < .001), but at a significantly reduced rate. After 2014, adjusted median pharmacy charges decreased from $3,326.5 (interquartile range: $1,717.5-$6,710.8) to $3,264.1 (interquartile range: $1,782.8-$5,934.7, P < .001) for children who received intravenous acetaminophen. In 94,745 children staying ≥1 day after surgery, postoperative opioid use decreased from 73.6% in 2011 to 58.6% in 2017 (P < .001). Use of intravenous acetaminophen alone compared to opioids alone after surgery resulted in similar predicted mean postoperative length-of-stay. CONCLUSION: In children undergoing appendectomy, intravenous acetaminophen use continued to rise, but at a slower rate after a price increase. Furthermore, adjusted pharmacy charges were lower for children receiving intravenous acetaminophen, possibly secondary to a concurrent decrease in postoperative opioid use. These findings suggest intravenous acetaminophen may be more broadly used regardless of perceived costs to minimize opioid use after surgery.

Single site versus conventional laparoscopic appendectomy: some pain for no gain?

INTRODUCTION: The optimal laparoscopic appendectomy approach is not clear, comparing single site laparoscopic appendectomy (SILA) to conventional 3-port appendectomy (CLA). We investigated outcomes in pediatric patients comparing SILA to CLA: length of operation, length of stay, time to resumption of regular diet, follow up, rehospitalization, and cost. METHODS: Data was collected from children 1 to 18 years with appendectomy at Loma Linda University from 2018 to 2020, operated by two surgeons. Analysis utilized two-sample T, chi-squared, and Fisher's exact tests. RESULTS: Of 173 patients, 77 underwent SILA and 96 had CLA. There was no gender, age, or race difference between groups. Mean WBC was 17.5 × 103/mL in SILA group, compared to 15.3 × 103/mL in CLA group (P = 0.004). Operative time was 47.0 SILA compared to 49.5 minutes CLA (P = 0.269). Of SILA cases, 55.8% were simple appendicitis, while 53.3% of the CLA cases were simple (P = 0.857). Regular diet was resumed after 1.7 days in the SILA group, 1.1 days in CLA (P = 0.018). Length of stay was 2.9 days for SILA, 2.4 days for CLA (P = 0.144). Seven children required hospital readmission, 5 SILA and 2 CLA (P = 0.244). Five of the children who returned had intra-abdominal abscesses, of whom 4 had SILA. There was no difference in cost. CONCLUSIONS: The operative techniques had similar outcomes and operative times. There was a trend toward more intra-abdominal abscesses in the SILA group. Further study and longer follow up is needed to determine if there is an advantage to one laparoscopic approach over another.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis.

BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Computed Tomography for Acute Appendicitis Diagnosis and Confirmation in Men : Trends and Cost Implications.

INTRODUCTION: The classic findings of acute appendicitis-right lower quadrant pain, anorexia, and leukocytosis-have been well known. However, emergency medicine and surgical providers continue to rely on imaging to confirm the diagnosis. We aimed to evaluate the increase in reliance on computed tomography (CT) scans for acute appendicitis diagnosis over time. METHODS: We conducted a retrospective study of patients ≥18 years presenting to UNC Hospitals with signs and symptoms of acute appendicitis who subsequently underwent appendectomy from 2011 to 2015. Demographic, clinical, laboratory, and pathologic data were reviewed. We evaluated the incidence of CT scans stratified by year, age, and sex. RESULTS: Within our male population, 55.2% (278/504) had classic appendicitis symptoms. Of the 278 male patients with classic appendicitis symptoms, 248 underwent CT imaging. Male patients <45 years of age were more likely to present with classic appendicitis symptoms (216/357, 60.5%) compared with patients aged 46-65 (52/108, 48.1%) or >65 (10/39, 25.6%). Of the male patients <45 years with classic appendicitis symptoms, the incidence of CT scans increased over time (68.3% in 2011, 84.2% in 2012, 92.3% in 2013, 93.9% in 2014, 92.3% in 2015). When considering the 216 CT scans that could have been avoided in our population, we calculate an approximate savings of $173 998.80 over 5 years. CONCLUSION: The incidence of CT scans for acute appendicitis confirmation has increased over time even in men. CT scans for the diagnosis or confirmation of acute appendicitis should rarely be indicated in men aged <45 years with classic appendicitis symptoms.

Cost-effectiveness analysis of initial nonoperative management versus emergency laparoscopic appendectomy for acute complicated appendicitis.

BACKGROUND: The evidence regarding the safety and efficacy of nonoperative management is growing. However, the best treatment strategy for acute complicated appendicitis remains controversial. We aimed to evaluate the cost-effectiveness of treatment strategies for complicated appendicitis patients. This study sought to determine the most cost-effective strategy from the health care-payer's perspective. METHODS: The primary outcome was an incremental cost effectiveness ratio (ICER) using nonoperative management with or without interval laparoscopic appendectomy (ILA) as the intervention compared with operative management with emergency laparoscopic appendectomy (ELA) alone as the control. Model variables were abstracted from a literature review, and from data obtained from the hospital records of Tochigi Medical Center. Cost-effectiveness was evaluated using an ICER. We constructed a Markov model to compare treatment strategies for complicated appendicitis in otherwise-healthy adults, over a time horizon of a single year. Uncertainty surrounding model parameters was assessed via one-way- and probabilistic-sensitivity analyses. Threshold analysis was performed using the willingness-to-pay threshold set at the World Health Organization's criterion of $107,690. RESULTS: Three meta-analysis were included in our analysis. Operative management cost $6075 per patient. Nonoperative management with interval laparoscopic appendectomy (ILA) cost $984 more than operative management and produced only 0.005 more QALYs, resulting in an ICER of $182,587. Nonoperative management without ILA cost $235 more than operative management, and also yielded only 0.005 additional QALYs resulting in an ICER of $45,123 per QALY. Probabilistic sensitivity analysis with 1000 draws resulted in average ICER of $172,992 in nonoperative management with ILA and $462,843 in Nonoperative management without ILA. The threshold analysis demonstrated that regardless of willingness-to-pay, nonoperative management without ILA would not be most cost-effective strategy. CONCLUSIONS: Nonoperative management with ILA and Nonoperative management without ILA were not cost-effective strategies compared with operative management to treat complicated appendicitis. Based on our findings, operative management remains the standard of care and nonoperative management would be reconsidered as a treatment option in complicated appendicitis from economic perspective.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis.

BACKGROUND: Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS: In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS: Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS: This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time.

BACKGROUND: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. METHODS: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. RESULTS: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). CONCLUSIONS: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

The Unintended Consequences of Nonoperative Management of Acute Appendicitis.

BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.

A systematic review on the cost evaluation of two different laparoscopic surgical techniques among 996 appendectomies from a single center.

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

Operative Delay in Adults with Appendicitis: Time is Money.

BACKGROUND: Evidence suggests that operative delay of up to 24 h is not associated with adverse outcomes among patients undergoing emergent appendectomy. However, the fiscal implication of operative delay is not well described in adults. We sought to examine the effect of delayed appendectomy on clinical outcomes and hospital cost. METHODS: We conducted a retrospective cohort study of patients undergoing nonelective laparoscopic appendectomy from 2014 to 2018 at both a tertiary care center and an affiliated short-stay hospital. Using a unique data set constructed from merged electronic health record and patient-level hospital financial data, patients with delayed surgery, defined as >12 h from emergency department (ED) arrival to operation, were compared with patients who underwent surgery within 12 h. Patient-specific variables were analyzed for their association with resource utilization, and subsequent multivariable linear regression was performed for total hospital cost. RESULTS: 1372 patients underwent laparoscopic appendectomy during the study period. 938 patients (68.3%) underwent surgery within 12 h of ED arrival, and 434 patients (31.6%) underwent delayed surgery. Delayed cases had longer length of stay (44.6 ± 42.5 versus 34.5 ± 36.5 h, P < 0.01) and increased total hospital cost ($9326 ± 4691 versus $8440 ± 3404, P < 0.01). The cost difference persisted on multivariable analysis (P < 0.01). There were no significant differences between delayed cases and nondelayed cases for operative time, intraoperative findings, including rate of perforation, or postoperative complications. CONCLUSIONS: Although safe, delayed appendectomy is associated with an increased length of stay and increased total hospital costs compared with appendectomy within 12 h of reaching the ED.

A tiered approach to optimize pediatric laparoscopic appendectomy outcomes.

BACKGROUND/PURPOSE: Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. METHODS: Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. RESULTS: A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. CONCLUSIONS: SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Treatment of appendicitis: Do Medicaid and non-Medicaid-enrolled patients receive the same care?

BACKGROUND: Studies using national data sets have suggested that insurance type drives a disparity in the care of emergency surgery patients. Large databases lack the granularity that smaller, single-institution series may provide. The goal of this study is to identify factors that may account for differences in care between Medicaid and non-Medicaid enrollees with appendicitis in central Massachusetts. METHODS: All adult patients with acute appendicitis in an academic medical center between 2010 and 2018 were included. Sociodemographic and clinical characteristics were compared according to Medicaid enrollment status. Analyses were performed to assess differences in the frequency of operative treatment, time to surgery, length of stay, and rates of readmission. RESULTS: The sample included 1,257 patients, 10.7% of whom (n = 135) were enrolled in Medicaid. The proportions of patients presenting with perforated appendicitis (28.9% vs 31.2%, P = .857) and undergoing laparoscopic appendectomy (96.3% vs 90.7%, P = .081) were similar between the 2 groups, as were length of stay (20 hours 30 minutes versus 22 hours 38 minutes, P = .109) and readmission rates (17.8% vs 14.5%, P = .683). Medicaid enrollees did experience somewhat greater time to surgery (6 hours 47 minutes versus 4 hours 49 minutes, P < .001). CONCLUSION: Despite anticipated differences in population, the treatment of appendicitis was similar between Medicaid and non-Medicaid enrollees. Medicaid enrollees experienced greater time to surgery; however, further studies are needed to explain this disparity in care.