When deciding between two or more treatment options, gaining a better understanding of how patients and caregivers value the specific risks and benefits of each choice can facilitate shared decision making. According to published research, nonoperative management using antibiotics alone has been shown to be safe for pediatric patients who have uncomplicated appendicitis and wish to avoid surgery. However, data are lacking on how patients and caregivers value the different risks and benefits of these options when making treatment decisions.
In a recent study, Peter C. Minneci, MD, MHSc, and colleagues tested a tablet-based patient activation tool that was designed to improve decision making in pediatric patients and caregivers choosing between surgery and nonoperative management for uncomplicated appendicitis. “In this study, we found that pediatric patients and families could effectively participate in an informed shared decision-making process in the acute care setting,” Dr. Minneci says.
Valuing Surgery Vs Nonoperative Management
To build on this research, Dr. Minneci and colleagues conducted a follow-up study, published in JAMA Pediatrics, that assessed how patient–caregiver dyads valued the risks and benefits of surgery and nonoperative management when deciding on uncomplicated appendicitis treatment. Patients aged 7-17 were evaluated by a physician who introduced both treatment options and answered initial questions. Patient–caregiver dyads were then randomized to receive a scripted standardized surgical consultation with or without the patient activation tool.
“For the intervention, all dyads using the patient activation tool received the same information about the expected course for each treatment, as well as the associated risks and benefits,” explains Dr. Minneci. The dyads subsequently rated the importance of eight treatment-associated risks and benefits of surgery versus nonoperative management. Specifically, the dyads were asked about aversion to risks of surgical and nonoperative management and about preferences associated with missing school or activities and work. More than two-thirds of participants chose surgery over nonoperative management.
In the group that chose surgery, the highest priorities were avoiding recurrence of appendicitis, risks of bleeding and infection, and adverse effects from antibiotics. In the nonoperative management group, the highest priorities were the same but included the addition of avoiding an operation for appendicitis (Figure). Overall, the lowest priorities among children were missing less school, returning to activities, and not having to take antibiotics at home. Caregivers noted that taking less time off from work to care for a child was a low priority.
“The two most important factors in this treatment decision were the same for those selecting surgery and for those choosing nonoperative management,” says Dr. Minneci. “This shows that patients and caregivers weigh factors differently when they are making a treatment decision, even when they are presented with the same information. As clinicians, we should not direct patients to a specific treatment course. Instead, we should have honest discussions with patients and caregivers on the risks and benefits of surgery and nonoperative management and then let them decide on their treatment.”
Ultimately, Dr. Minneci says the study reveals the relative importance of treatment-associated risks and benefits and key differences between patients and caregivers choosing surgery over nonoperative management. “Our results support the need for shared decision making with patients and their caregivers when deciding on treatment for uncomplicated appendicitis,” he says. “While clinicians may have strong opinions on optimal management for their patients, we should not let these biases play a role in patient and caregiver treatment decisions.”
Of note, Dr. Minneci says other ongoing research projects are aiming to identify patients with uncomplicated appendicitis who are more likely to be successfully treated with nonoperative management. “This data would further help inform patient and caregiver treatment decisions,” he says. “We also need to conduct studies that assess how we implement treatment choices in practice. By improving nonoperative management protocols, we may be able to reduce length of stay in the hospital and, thus, decrease risks associated with hospitalization.”
Apfeld JC, Cooper JN, Minneci PC, Deans KJ. Pediatric patient and caregiver values in treatment decision-making for uncomplicated appendicitis. JAMA Pediatr. 2021;175(1):94-96. Available at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2769070.
Minneci PC, Cooper JN, Leonhart K, et al. Effects of a patient activation tool on decision making between surgery and nonoperative management for pediatric appendicitis: a randomized clinical trial. JAMA Netw Open. 2019;2(6):e195009.
Minneci PC, Mahida JB, Lodwick DL, et al. Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis. JAMA Surg. 2016;151(5):408-415.
Brahmamdam P, Carveth SL, Smyth M, Gendelman BS, Maisels MJ. Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis. J Pediatr Surg. 2019;54(9):1800-1803.