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Antibiotics for Appendicitis? I’m Still Not Convinced

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery. The first paper was a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients. Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and two had tubo-ovarian abscesses The abstract says “After 2 years, the overall recurrence rate was 13.8% (22/159).” This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery. If you look at this paper more carefully, you will find the following figures from Table 3: ♦ US done 116 (73%) ♦ US positive88 (76%) ♦ CT scan done 27 (17%) ♦ CT scan positive 21 (78%) ♦ Clinical diagnosis only of acute appendicitis 16 (10%) The authors do not explain why patients with negative ultrasounds and CT scans were included in the cohort of nonoperatively treated patients with appendicitis. If they were going to disregard the results of the imaging studies, they shouldn’t have done them in the first place. If you add the 16 patients with clinical diagnoses only, the 28 with negative ultrasounds and the six with negative CT scans, a total of 50 (31%) of the patients may not have even had appendicitis. These patients would have gotten better no...

Comparing Appendectomy Methods

Researchers in Tennessee have found that early appendectomy for children with perforated appendicitis appears to be associated with significantly lower hospital charges and costs when compared with interval appendectomy. Average total hospital costs were $17,450 and $22,518 for patients treated with early and interval appendectomy, respectively, according to the findings. Costs were significantly increased with unplanned readmissions and adverse events, but these occurred more frequently among patients randomized to interval appendectomy. Abstract: Journal of the American College of Surgeons, April...

Wide Disparity in Hospital Charges for Appendicitis. Why?

If you wonder why hospitals are under fire for outrageous and often baffling accounting practices, look no further than a brief paper published last month in Archives of Internal Medicine. Hospital charges for straightforward appendectomies done for acute appendicitis in California in 2009 were examined with the following inclusion criteria: Patients between the ages of 18 and 59 Hospital stays fewer than 4 days Discharged home For the more than 19,000 records reviewed, the median hospital charge was $33,611 with a low of $1,529 and a high of $182,955. Not included in the article but mentioned in news stories about the paper were more details about the care of the two patients at the extremes of charges. From the Huffington Post: “The costliest bill, totaling $182,955, involved a woman who also had cancer. She was treated at a hospital in California’s Silicon Valley. Her bill didn’t show any cancer-related treatment. The smallest bill, $1,529, involved a patient who had her appendix removed in rural Northern California. Otherwise, the cases were similar: Both patients were hospitalized for one day, had minimally invasive surgery, and had similar numbers of procedures and tests on their bills.” A California Healthline story about this clarifies the issue. It said: “Dave Glyer, CFO for Community Memorial Health System, said that the study ‘assumed that hospital charges matter when they don’t,’ making it ‘completely off base.’ He said that insured patients pay rates negotiated by health insurers and that certain uninsured patients are aided by assistance programs.” It’s all clear to me now. Hospital charges don’t matter. What if you have no insurance and are not...
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