Treatment of perforated appendicitis in children: What is the cost?

Department of Surgery, Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
Journal of Pediatric Surgery (Impact Factor: 1.39). 06/2012; 47(6):1177-84. DOI: 10.1016/j.jpedsurg.2012.03.024
Source: PubMed


We compared direct hospital costs and indirect costs to the family associated with immediate appendectomy or initial nonoperative management for perforated appendicitis in children.
From June 2009 through May 2010, 61 prospectively identified families completed a cost diary, documenting the numbers of missed school days for the child and missed employment days for the adult caregiver(s) over the treatment course. Hospital costs were obtained from hospital financial databases. Mann-Whitney U tests and Fisher exact tests were used to compare outcome measures for each treatment strategy.
Patients treated by initial nonoperative management had a significantly longer median length of stay (9 days vs 7 days, P = .02) and a significantly greater median total hospital cost per patient ($31,349 vs $21,323, P = .01) when compared with those treated by immediate appendectomy. There was no significant difference in median number of missed school days (9 days vs 10 days, P = .23) or missed employment days for adult caregiver(s) (5 days vs 7 days, P = .18) between treatment strategies.
Patients with perforated appendicitis treated by initial nonoperative management had a greater length of stay and a significantly greater total hospital cost but were not burdened by significantly greater indirect costs compared with those treated by immediate appendectomy.

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    • "periappendiceal abscess formation caused by perforated appendicitis [20] [21] [22] [23]. Thus, detection of perforation may change management. "
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    ABSTRACT: This study aimed to determine whether routine urinalysis may serve as a tool in discriminating between acute appendicitis and perforated appendicitis in children. We prospectively collected 357 patients with clinically suspected acute appendicitis. Urinalysis was performed in patients with clinically suspected acute appendicitis before surgical intervention. Routine urinalysis is composed of 2 examinations: chemical tests for abnormal chemical constituents and microscopic tests for abnormal insoluble constituents. Receiver operating characteristic curves for urine white blood cell (WBC) counts and urine red blood cell (RBC) counts in distinguishing between patients with simple appendicitis and patients with perforated appendicitis were also analyzed. Urine ketone bodies, leukocyte esterase, specific gravity, pH, WBC, and RBC counts were all significant parameters among patients with normal appendices, simple appendicitis, and perforated appendicitis (all P < .05). Based on multivariate logistic regression analysis, positive urine ketone bodies and nitrate were significant parameters in predicting perforated appendicitis (P = .002 and P = .008, respectively). According to the results of receiver operating characteristic curves, the appropriate cutoff values were 2.0/high-power field for urine RBC counts and 4.0/high-power field for urine WBC counts in predicting perforated appendicitis in children. Routine urinalysis may serve to aid in discriminating between simple and perforated appendicitis. Clinically, we believe that these urine parameters may aid primary emergency physicians with decision making in patients with clinically suspected appendicitis.
    Full-text · Article · Sep 2013 · The American journal of emergency medicine
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    ABSTRACT: The purpose of this study was to examine the impact on the family of immediate appendectomy compared with initial nonoperative management for perforated appendicitis in children. Sixty-six prospectively identified families of children with perforated appendicitis completed a daily activity journal and the Impact on Family Scale at presentation and at completion of therapy. There were no significant differences in postoperative surgical site infections or number of missed school or employment days between the immediate appendectomy group (n = 40) and the initial nonoperative management group (n = 26). Impact on Family Scale total scores decreased over time for both groups, but this improvement over time was significant only in the initial nonoperative management group (P < .01). Immediate appendectomy or initial nonoperative management can effectively manage perforated appendicitis in children with no statistically significant differences in the number of missed school or employment days. Greater improvements in family impact are associated with initial nonoperative management as measured by the Impact on Family Scale at completion of therapy.
    No preview · Article · Oct 2012 · Journal of Pediatric Surgery
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    ABSTRACT: Background: In 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis. Materials and methods: We reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008-2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation. Results: We identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67-0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53-0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19-1.35, P < 0.001). Conclusions: The absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.
    No preview · Article · May 2013 · Journal of Surgical Research
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