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.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

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.

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.

Same-day discharge after laparoscopic appendectomy for non-perforated appendicitis is safe and cost effective.

AIM OF THE STUDY: To compare the outcomes and hospital charges of patients who underwent laparoscopic appendectomy for non-perforated appendicitis and were discharged home either shortly after the operation after being admitted for overnight observation. METHODS: Postoperative (30-day) emergency department (ED) visits, hospital readmissions, and reoperations were compared between patients who were discharged shortly after surgery (same-day discharge [SDD] group) and patients who were discharged after spending one night in the hospital (overnight observation group). STUDY PERIOD: July/2015 to June/2019. Patients with perforated appendicitis and/or who spent > 1 night in the hospital were excluded from the study. RESULTS: We did 1957 laparoscopic appendectomies within the 4-year study period. After excluding all non-eligible cases, 930 patients were included in the overnight observation group, and 511 in the SDD group. Mean age and mean operative time were similar in both groups: 11.5 (SD 3.6)/11.8 (SD 3.5) years, and 35 (SD 13)/33 (SD 12) minutes, respectively. There were 24 (2.6%) ED visits within the overnight observation group. Sixteen patients (1.7%) were discharged from the ED, and 8 (0.9%) required a re-admission. There were 11 (2.1%; P = 0.61) ED visits within the SDD group. Six patients (1.1%; P = 0.41) were discharged from the ED, and 5 (1%; P = 0.82) required a readmission. Six of the 11 ED visits within the SDD group occurred on the 5th postoperative day or later, whereas five (1%) occurred within the first 3 days post appendectomy. These five patients would have likely benefited from an overnight admission and were erroneously discharged on the same day of the appendectomy. There were no reoperations in the overnight observation group, but there were 3 reoperations in the SDD group (0.6%, P = 0.01). The reasons for the reoperations (two bowel obstructions and one bowel perforation) were in no way related to the time of the original discharge. The mean hospital charges per patient in the SDD group and the overnight observation group were significantly different: $32,450 and $35,420, respectively (> 9% margin, P < 0.01). CONCLUSION: Healthy children who undergo laparoscopic appendectomy for non-perforated appendicitis can be discharged home during the same day of the operation after a short period of observation. This approach is safe and does not result in more postoperative ED visits or hospital readmissions. In addition, there is a significant financial benefit when patients are discharged early. LEVEL-OF-EVIDENCE: Level III-retrospective comparative treatment study.

Laparoscopic appendectomy as an index procedure for surgical trainees: clinical outcomes and learning curve.

Surgical training is essential to maintain safety standards in healthcare. The aim of this study is to evaluate learning curves and short-term postoperative outcomes of laparoscopic appendectomy (LA) performed by trainees (TRN) and attendings (ATT). The present study included the medical records of patients with acute appendicitis who underwent a fully LA in our department between January 2013 and December 2018. Cases were divided into trainees (TRN and ATT groups based on the experience of the operating surgeon. The primary outcome measures were 30-day morbidity and mortality. Preoperative patients' clinical characteristics, intraoperative findings, operative times, and postoperative hospitalization were compared. Operative times were used to extrapolate learning curves and evaluate the effects of changes in faculty using CUSUM charts. A propensity score matching analysis was performed to reduce differences between cohorts regarding both preoperative characteristics and intraoperative findings. A total of 1173 patients undergoing LA for acute appendicitis were included, of whom 521 (45%) in the TRN group and 652 (55%) in the ATT group. No significant differences were found between the two groups in terms of complication rates, operative times and length of hospital stay. However, CUSUM chart analysis showed decreased operating times in the TRN group. Operative times improved more quickly for advanced cases. The results of this study indicate that LA can be performed by trainees without detrimental effects on clinical outcomes, procedural safety, and operative times. However, the learning curve is longer than previously acknowledged.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

OBJECTIVE: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA: Reducing surgical costs is paramount to the viability of hospitals. METHODS: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

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.

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.

Surgical Supply Cost Awareness Is Associated With Lower Costs: A Single-Center Experience.

Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.

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.

Pre-Operative Imaging can Reduce Negative Appendectomy Rate in Acute Appendicitis.

INTRODUCTION: Acute appendicitis is a common surgical emergency, with a prevalence of 112 per 100,000 people per year in Europe. Negative appendicectomy is defined as a pathologically normal appendix removed from patient suspected with appendicitis. Negative appendectomy rate (NAR) has been reported to be around 15-25%. We aimed to evaluate our unit's negative appendectomy rate and the effect of pre-operative imaging on NAR. METHOD: A retrospective study including all patients who underwent both open and laparoscopic emergency appendicectomy in a single district general hospital from 2017-2018. Clinical information including cost was calculated based on the 2017/18 national tariff payment system. Patients under 18 years old were excluded from this study. RESULTS: Two hundred thirty-two patients were included in this study, of which 69 (29.74%) had a pre-operative CT scan. The mean length of stay was 2.57 days. The sensitivity, specificity, positive predictive value and negative predictive value for CT were 77.8%, 100%, 87.5% and 100%. The negative appendicectomy rate with and without pre-operative CT scan were 7.25% and 22.09% respectively. Based on the 2017/18 national tariff payment system, a CT abdomen and pelvis with contrast and emergency appendicectomy with CC score of 0 cost 92 and 2370 pounds respectively. The total cost of patients who underwent appendicectomy without imaging was £ 322,320. If all patients undergo pre-operative CT, with a reduction of 15% in negative appendicectomy rate, the overall total cost would significantly lower to £ 36,212. CONCLUSION: Our study demonstrated that the negative appendicectomy rate could be improved by preoperative imaging. The study also showed that implementation of preoperative imaging for suspected appendicitis cases could save costs, allowing better allocation of resources.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.

Prognostic Factors Associated with Clinical and Economic Outcomes of Appendectomies in Children: A Multilevel Analysis in a National Retrospective Cohort Study.

BACKGROUND: Acute appendicitis is the most common acute surgical abdominal pathology in children, and it has a large impact on morbidity and the costs incurred by health care systems. In low- and median-income countries, national information on the clinical and economic outcomes associated with this surgery does not exist. This study aimed to identify and describe the clinical and economic outcomes for children undergoing appendectomy in Colombia's contributory system and to determine the prognostic factors associated with these outcomes. METHODS: A retrospective cohort study was conducted using administrative data from patients under 18 years of age who underwent an appendectomy between July 1, 2013, and September 30, 2015, in Colombia's contributory health system. Thirty-day mortality rates, intensive care unit (ICU) admission rates, length of stay (LOS), readmission rates and median costs were estimated for the entire country by geographic region and insurer. The prognostic factors associated with these outcomes were identified using generalized multilevel mixed models. RESULTS: A total of 21,674 children were included. The 30-day postoperative mortality rate was 0.06% [95% CI 0.02-0.9], the ICU admission rate was 8.00% [95% CI 7.63-8.36], the mean LOS was 2.48 days (SD 5.24), the readmission rate was 1.5% [95% CI 1.33-1.66] and the median cost for Colombia was 394 USD [p25-p75: 256-555]. The prognostic factors that were associated with the 30-day ICU admission rate, LOS and readmission rate were the insurer, geographic region, age, occurrence of an appendectomy with peritoneal drainage, and certain comorbidities, such as cancer and neurological, respiratory and gastrointestinal illnesses. The prognostic factors associated with costs were those previously mentioned as well as the occurrence of a laparoscopic appendectomy. CONCLUSIONS: In Colombia's contributory health system, large differences in clinical outcomes and the costs incurred by the system exist, and these differences are associated with the geographic region, the insurer, and some of the clinical characteristics of the children undergoing appendectomy.

Disease burden of appendectomy for appendicitis: a population-based cohort study.

BACKGROUND: Few large-scale epidemiologic studies evaluate the clinical and economic burden of appendicitis. These data may impact future research and treatment strategies. In this study, the objective was to determine the burden of appendectomy for appendicitis in terms of incidence rates, length of hospital stay (LOS) and hospital costs on a national level. In addition, outcomes were compared for subgroups based on surgical treatment, age and hospital setting. METHODS: Observational retrospective population-based cohort study using the national Dutch healthcare reimbursement registry, which covers hospital registration and reimbursement for 17 million inhabitants. Patients with a diagnosis of appendicitis who underwent appendectomy between 2006 and 2016 were included. Primary outcomes were incidence rates, LOS and hospital costs. RESULTS: A total of 135,025 patients were included. Some 53% of patients was male, and 64% was treated in a general hospital. The overall incidence rate of appendectomy was 81 per 100,000 inhabitants and showed a significant decreasing trend across time and age. Mean ± SD LOS per patient was 3.66 ± 3.5 days. LOS showed a significant increase with age and was significantly longer for open versus minimally invasive appendectomy. Mean ± SD hospital costs per patient were €3700 ± 1284. Costs were initially lower for open compared to minimally invasive appendectomy, but were similar from 2012 onward. Compared to non-university hospitals, patients treated in university hospitals had a significantly longer LOS and higher costs. CONCLUSIONS: Appendectomy for appendicitis represents a substantial clinical and economic burden in the Netherlands. A preference for minimally invasive technique seems justified.