Interhospital variation in the non-operative management of uncomplicated appendicitis in adults

Baran Khoraminejad; Sara Sakowitz, MS, MPH; Giselle Porter, BS; Nikhil Chervu, MD; Konmal Ali; Saad Mallick, MD; Syed Shahyan Bakhtiyar, MD, MBE; Peyman Benharash, MD

Surgery Open Science (Aug 2024)

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults

Baran Khoraminejad,
Sara Sakowitz, MS, MPH,
Giselle Porter, BS,
Nikhil Chervu, MD,
Konmal Ali,
Saad Mallick, MD,
Syed Shahyan Bakhtiyar, MD, MBE,
Peyman Benharash, MD

Affiliations

Baran Khoraminejad: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America; Boston University, Boston, MA, United States of America
Sara Sakowitz, MS, MPH: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
Giselle Porter, BS: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
Nikhil Chervu, MD: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America; Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
Konmal Ali: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
Saad Mallick, MD: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America
Syed Shahyan Bakhtiyar, MD, MBE: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America; Department of Surgery, University of Colorado, Aurora, CO, United States of America
Peyman Benharash, MD: CORELAB, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America; Department of Surgery, University of California, Los Angeles, Los Angeles, CA, United States of America; Corresponding author at: 10833 Le Conte Avenue, UCLA Center for Health Sciences, Room 62-249, Los Angeles, CA 90095, United States of America.

Journal volume & issue: Vol. 20
pp. 32 – 37

Abstract

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Background: Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis. Methods: The 2016–2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH). Results: Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission. Conclusions: We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Published in Surgery Open Science

ISSN: 2589-8450 (Online)
Publisher: Elsevier
Country of publisher: United States
LCC subjects: Medicine: Surgery
Website: https://www.journals.elsevier.com/surgery-open-science/

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