Nonoperative management for appendicitis linked to fewer complications in older adults
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Key takeaways:
- Nonoperative management was associated with reduced complications only in adults older than 65 years.
- Reduced mortality, length of hospital stay and cost was consistent with appendectomy across all age groups.
Nonoperative management of acute uncomplicated appendicitis was associated with fewer complications in patients older than 65 years, while appendectomy was linked to reduced mortality, length of hospital stay and cost, regardless of age.
“Appendicitis has traditionally been treated with appendectomy, but there is growing evidence to support nonoperative management with antibiotics for uncomplicated appendicitis,” Jennie Meier, MD, MPH, of the department of surgery at the University of Texas Southwestern, and colleagues wrote in JAMA Surgery. “However, randomized clinical trials of nonoperative vs. operative management have primarily included patients younger than 65 years with limited comorbidities, while adults 65 years and older were underrepresented or excluded.
“As a result, it is unclear if existing data can generalize to older adults and guide therapeutic decisions.”
In a retrospective study of data from the Agency for Healthcare Research and Quality’s National Inpatient Sample from 2004 to 2017, Meier and colleagues assessed outcomes of 474,845 patients (median age, 39 years; 51.3% women) with uncomplicated appendicitis. Patients underwent either nonoperative management (n = 43,846; median age, 49 years) or appendectomy (n = 430,999; median age, 38 years). Nearly 13% of the total sample was aged 65 years and older, of whom 18.4% were treated nonoperatively compared with 7.9% of younger patients. Studied outcomes included the incidence of post-treatment complications, mortality, length of hospital stay and inpatient costs.
Results showed nonoperative management correlated with a 3.72% decrease in morbidity (95% CI, 2.99-4.46) and a 1.82% increase in mortality (95% CI, 1.49-2.15) among those aged 65 years and older. Older patients who received nonoperative treatment also had increased length of hospital stay by 3.22 days (95% CI, 3.03-3.41) and higher hospital costs ($5,270.84; 95% CI, 4,644.95-5,896,73) than those who underwent surgery.
Among those younger than 65 years, nonoperative management correlated with a 0.3% increase in postoperative complications (95% CI, 0.02-0.58), a 0.29% increase in mortality (95% CI, 0.23-0.35), a 2.81-day longer length of hospital stay (95% CI, 2.89-2.72) and a $4,334.81 increase in costs (95% CI, 4,052.49-4,617.13).
The odds of developing complications were greater among older adults with operative management compared with younger adults (OR = 1.7; 95% CI, 1.58-1.83 vs. OR = 1.07; 95% CI, 1.02-1.13), as were the odds of mortality (OR = 0.38; 95% CI, 0.33-0.43 vs. OR = 0.16; 95% CI, 0.13-0.19). Older adults also spent approximately 3.09 fewer days in the hospital (95% CI, –3.21 to –2.98) with appendectomy, while younger adults spent 3.17 fewer days in the hospital (95% CI, –3.21 to –3.13).
Researchers noted estimated costs with operative management were also “significantly different” among older vs. younger adults (–$4,924; 95% CI, –5,272.07 to –4,576 vs. –$4,904; 95% CI, –5,017 to –4,792).
“This cohort study found that nonoperative management was associated with reduced complications for older but not younger patients and that mortality, length of stay and reduced hospital costs were associated with operative management,” Meier and colleagues concluded.
“Unsurprisingly, we found that outcomes in younger adults differed from those in older adults,” they continued. “This highlights the need to conduct a comprehensive randomized clinical trial of nonoperative vs. operative management of appendicitis in older adults, so that surgeons have relevant data to use when considering treatment options.”
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