Readmission and Imaging Outcomes in Pediatric Complicated Appendicitis: A Matched Case-Control Study
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INTRODUCTION: Currently, the treatment guidelines for perforated appendicitis generally include primary appendectomy or non-operative management followed by an interval appendectomy 6 to 12 weeks post discharge (first-line antibiotics). First-line antibiotics along with abscess drainage and deferred appendectomy is selected with the intent to minimize complications of surgical management. However, investigation of specific, clinically-relevant outcomes identified that primary appendectomy reduced time away from normal activities and was associated with higher family satisfaction, fewer CT scans, and fewer visits to the emergency department. The benefits of each continue to be debated. The aim of this study was to compare clinically-relevant outcomes such as length of stay, imaging rate and readmission between patients selected for first-line antibiotics and first-line appendectomy using a matched case-control approach. METHODS: The electronic medical record system at Children's Medical Center was queried for all patients diagnosed with perforated appendicitis who underwent an appendectomy. A total of 3,491 were identified over 4 years. Among 905 patients with perforated appendicitis, 105 underwent first-line antibiotic therapy. The patients were grouped by intervention, first-line antibiotics vs. first-line appendectomy. No standardized protocol currently exists for management of delayed appendectomy at our institution. The 291 patients were matched with a ratio of 1:2 and based on age, gender, and presence of a fecalith on imaging. Data points including length of stay (LOS), total number of imaging scans, and number of visits to the ED and readmission to the hospital were collected. The values are reported as mean and standard deviation. RESULTS: The first-line antibiotic group had significantly longer primary hospitalization (LOS) in addition to a longer total LOS (158.40 ± 129.10 vs. 108.19 ± 97.91, p < 0.0001; 199.72 ± 142.65 vs. 118.80 ± 93.217, p < 0.0001). These were readmitted more often (0.21 ± 0.48 vs. 0.08 ± 0.311, p = 0.0026) though ED visits were statistically similar to primary appendectomy (0.17 ± 0.40 vs. 0.10 ± 0.35, p = 0.1024). Re-hospitalization LOS was not longer (p = 0.2000). The first-line antibiotic group also underwent more imaging scans during their initial hospital visit as well as after the primary diagnostic scan (1.02 ± 0.46 vs. 0.54 ± 0.57, p < 0.0001; 0.26 ± 0.52 vs. 0.06 ± 0.28, p < 0.0001). CONCLUSIONS: In this study, we found that delayed appendectomy is associated with longer hospital stays, increased hospital admissions, and more imaging scans. Readmissions are also higher. These outcomes may be related to selection bias as well as lack of a standardized approach outlining when to scan patients and in access to outpatient surgical care.