Influence of Intraoperative Findings on Outcomes and Resource Utilization in Children with Appendicitis: Implications for an Evidence-based and Public Health Relevant Definition for Complicated Disease
*Danielle B Cameron1, *Patrice Melvin1, *Dionne A Graham1, *Stephanie K Serres1, *Seema Anandalwar1, *Charity C Glass1, *Brian D. Kenney2, *Jacqueline M. Saito3, *Douglas C. Barnhart4, *Matthew Hall5, Shawn J. Rangel1
1Boston Children's Hospital, Boston, MA;2Nationwide Children's Hospital, Columbus, OH;3Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO;4Primary Children's Hospital, University of Utah, Salt Lake City, UT;5Children's Hospital Association, Lenexa, KS
Objective: To characterize the influence of intraoperative findings on adverse events and resource utilization as a means to establish an evidence-based and public-health relevant definition for complicated appendicitis.
Design: Retrospective cohort study using intraoperative findings and outcome data from the ACS NSQIP-Pediatric Appendectomy Pilot Database and cost data from the Pediatric Health Information System database. Logistic regression was used to examine the influence of four candidate intraoperative findings (visible hole [VH] in the appendix, diffuse fibrinopurulent exudate [DFE] extending outside the RLQ/pelvis, abscess, and free-floating fecalith) on outcomes after controlling for eachother and patient and hospital-level characteristics. Uncomplicated appendicitis (absence of all four findings) was used as a reference for each analysis.
Setting: 13 free-standing children’s hospitals
Patients: Patients ages 3 to 18 years who underwent appendectomy from 1/1/2013-12/31/2014 (n=2,768).
Main Outcome: Outcomes included cumulative hospital cost and length of stay (from index and revisit encounters), and 30-day postoperative rates of SSI and hospital revisits.
Results: Candidate findings were reported in 785 (28.4%) cases, with multiple findings reported in 41.8%. The most common findings included DFE alone (26.2%), followed by VH alone (16.9%), DFE+VH (16.8%), and abscess alone (10.1%). Each finding was independently associated with higher cost and worse outcomes compared to patients with uncomplicated appendicitis (table).
Conclusion: All four intraoperative findings were associated with worse outcomes and higher cost compared to uncomplicated appendicitis. Each finding should be considered an independent criterion for differentiating complicated from uncomplicated appendicitis for the purpose of comparative performance reporting and reimbursement considerations.
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