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A New View Debates Antibiotics for Appendicitis

A New View Debates Antibiotics for Appendicitis
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Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

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Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

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Here’s what Jane E. Brody, New York Times Personal Health columnist, had to say about surgeons who think appendicitis should be treated with an operation. “This is hardly surprising, because doctors, like many of us, are creatures of habit, and surgeons who don’t operate miss out on a hefty fee.”

The article, “A new view of appendicitis,” began with a story about a woman who went to Europe and on the way developed perforated appendicitis. Somehow this anecdote morphed into a discussion about the treatment of simple appendicitis.

Ms. Brody referred to the Finnish randomized controlled trial published back in June 2015 that found that 27% of patients who were treated with antibiotics eventually required surgery. When this study first came out I pointed out its flaws—only 5.5% of patients underwent laparoscopic appendectomy; the antibiotic in the study was not commonly used in the United States; patients were followed for only one year.

She also cited a review of administrative data from California, which claimed a very low recurrence rate with antibiotics. I had critiqued that paper as well, pointing out that not only is administrative data unreliable for clinical research, the paper covered the years 1997 to 2008 when laparoscopic appendectomy was not yet the standard of care. Also, we do not know how the diagnosis of appendicitis was arrived at for the patients treated with antibiotics. If they didn’t have appendicitis in the first place, then any treatment would have sufficed.

“…a review of administrative data from California claims a very low recurrence rate with antibiotics.”

 

Ms. Brody wrote “People who have had appendectomies, for example, are more likely to experience recurrent infections with the bacterium Clostridium difficile, a debilitating intestinal infection that causes severe, difficult-to-treat diarrhea.” She states this as fact, but it is far from proven. [References available upon request.]

She failed to mention that treating appendicitis patients with antibiotics for the current norm of one week also may lead to the development of Clostridium difficile colitis.

Now, about that “hefty fee.” According to a 2012 survey by the International Federation of Health Plans, the average amount paid to a surgeon for a laparoscopic appendectomy (CPT code 44970) in the US was $1001.00. In 2015, the average Medicare reimbursement to a surgeon for 44970 was $620.34 and for Medicaid it was $399.90.

Before diagnosing appendicitis, a surgeon must interview and examine the patient, review any imaging or lab studies, and as recommended by several authorities, must discuss the recent literature on the antibiotic treatment of appendicitis with the patient and family. The time it takes to do the operation and see the patient postoperatively must also be factored in.

Two-thirds of 94 surgeons polled on Twitter said the perioperative activities mentioned above involve 3 to 4 or more hours.

Is an average reimbursement of less than $200.00 per hour really a “hefty fee”? I think not.

 

Skeptical Scalpel is a retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last six years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 2,500,000 page views, and he has over 15,500 followers on Twitter.

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