Weighting the risks and benefits of nonoperative and operative care for older patients with appendicitis resulted in a mixed bag of fewer complications, but a higher mortality rate and higher hospital costs.¹

A team, led by Jennie Meier, MD, MPH, Department of Surgery, University of Texas Southwestern, compared the outcomes following nonoperative and operative management of appendicitis in older adults and assessed whether they differ from the results of younger patients.

The Need

There remains a need, despite high rates in older individuals, for randomized clinical trials comparing nonoperative and operative management of appendicitis. It is also unclear whether clinical trial data can be used to guide treatment in this patient population.

“We hypothesized that, compared to appendectomy, nonoperative management of acute appendicitis would be associated with similar morbidity and mortality but increased hospitalization length and costs for older adults and that nonoperative management in older adults would have a different risk-benefit profile than for younger adults,” the authors wrote. “This study has implications for whether existing data are sufficient to inform decision-making in older adults with acute uncomplicated appendicitis.”

The Study

In the retrospective cohort study, the investigators used data on US hospital admissions from the Agency for Healthcare Research and Quality’s National Inpatient Sample between 2005-2017. They identified 723,889 adult patients with acute uncomplicated appendicitis, 474,845 of which had known procedure dates who survived 24 hours postprocedure and did not have inflammatory bowel disease (IBD). Of this group, 43,846 were treated nonoperatively and 430,999 had an appendectomy. The median age was 39 years.

The investigators sought primary outcomes of the incidence of posttreatment complications and secondary outcomes of mortality, length of stay, and inpatient costs. The team estimated differences using inverse probability weighting of the propensity score with sensitivity analysis to quantify effects of unmeasured confounding.

Comparing the 2 Groups

Nonoperative management was associated with a 3.72% decrease in the risk of complications (95% confidence interval [CI], 2.99-4.46) and a 1.82% increase in mortality (95% CI, 1.49-2.15) in patients who were aged 65 years and older. Nonoperative management was also linked to increased length of hospitalization and costs.

The results also showed that outcomes in patients younger than 65 years were significantly different than what was found in older adults, with only minor differences between nonoperative and operative management with respect to morbidity and mortality. There were smaller differences found in length of hospitalization and costs between younger and older patients.

Finally, morbidity and mortality results were somewhat sensitive to bias from unmeasured confounding.

“Nonoperative management was associated with reduced complications in older but not younger patients; however, operative management was associated with reduced mortality, hospital length of stay, and overall costs across all age groups,” the authors wrote. “The different outcomes of nonoperative vs operative management of appendicitis in older and younger adults highlights the need for a randomized clinical trial to determine the best approach for managing appendicitis in older patients.”

References:

Meier J, Stevens A, Bhat A, Berger M, Balentine C. Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US. JAMA Surg. Published online April 05, 2023. doi:10.1001/jamasurg.2023.0284