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Investigators from Boston Children’s Hospital, Boston, MA, conducted a retrospective study to assess trends in use of non-operative management (NOM) for children with uncomplicated appendicitis, estimate the rate of subsequent appendectomy, and compare outcomes in patients managed with NOM and those undergoing immediate surgery. For the study, they reviewed data from the Pediatric Health Information System (PHIS) database that includes demographic, diagnostic, procedure, laboratory, radiology, and pharmacy information on encounters by patients at children’s hospitals in the US. For the current study, data on children <19 years old seen at 47 PHIS hospital emergency departments with a primary diagnosis of appendicitis (based on ICD-9 and ICD-10 codes) between 2011 and 2020 were abstracted. The management of these study patients was categorized as operative management if there was a procedure code for appendectomy during the index visit or NOM if there was no code for surgical intervention and the child received parenteral antibiotics. Temporal trends in the use of NOM during the study period were assessed with logistic regression. Other study outcomes included failure rate of NOM, defined as subsequent appendectomy and/or a diagnosis of perforated appendix, rate of perforation at the time of appendectomy, and health care utilization, including ED visits, hospitalizations for gastrointestinal problems, abdominal ultrasound, and CT, during the 12 months following the index visit. Cumulative NOM failure rates at 1, 2, and 5 years were assessed using Kaplan-Meier curves. Rates of perforation among all patients presenting with appendicitis, and in children managed with NOM at the index visit who subsequently required surgery, were compared using chi-square tests. Chi-square tests also were used to compare rates of health care use among patients in the 2 treatment groups.
Data were analyzed on 117,705 children with an index visit for appendicitis. Of these, 44,161 (37.5%) presented with a perforated appendix. The mean age of the remaining 73,544 patients was 11.4 years, 63,150 (85.9%) of whom underwent appendectomy at the index visit and 10,394 (14.1%) of whom had NOM. There was a statistically significant increase in use of NOM during the study period, with rates of NOM rising from 2.7% during the first quarter of 2011 to 32.9% during the first quarter of 2020. Among children initially treated with NOM, 2,084 (20.1%) had treatment failure during the study period. The median time to treatment failure in these patients was 2 days (interquartile range, 1-5 days). Cumulative failure rates at 1, 2, and 5 years were 18.6% (95% confidence interval [CI], 17.9, 19.4), 19.2% (95% CI, 18.4, 20.0), and 23.3% (95% CI, 22.1, 24.6), respectively. Rates of perforated appendicitis were significantly higher for patients with NOM treatment failure than in the general study population (45.7% vs 37.5%; P <0.001), and rates of ED visits, hospitalization, abdominal ultrasound, and CT in the NOM group all were significantly higher in the...
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