Inform patients about surgical, nonoperative options for appendicitis: researchers

Last Updated: 2018-01-17

By Marilynn Larkin

NEW YORK (Reuters Health) - Most patients would prefer surgery to antibiotics to treat acute uncomplicated appendicitis, but because some would choose nonsurgical management, clinicians should present all viable treatment options, researchers say.

Although many studies have compared surgical with nonsurgical treatment for acute uncomplicated appendicitis, none have taken a patient-centered perspective, according to Dr. Marc Basson of the University of North Dakota School of Medicine and Health Sciences, in Grand Forks, and colleagues.

"I personally would choose or recommend surgical management for myself, or if I were asked by a family member, because surgical treatment for appendicitis is generally rapid and relatively safe," Dr. Basson said in an email to Reuters Health.

"That being said, it's clear that some patients are likely to choose antibiotic therapy over surgery with our current state of the art (technique)," he added.

To investigate, the team conducted both an online survey and an in-person sensitivity analysis survey.

For the web survey, 1,728 respondents (95% ages 20 to 69; 71% women; 91% non-Hispanic white) in a convenience sample were asked to imagine that they or their child had acute uncomplicated appendicitis. Then they were given information about laparoscopic and open appendectomy and antibiotic treatment alone and were asked which treatment they might choose.

For themselves, 86% of respondents chose laparoscopic appendectomy, 5% chose open appendectomy, and 9% chose antibiotics alone, according to the January 10 online report in JAMA Surgery.

Respondents were somewhat more likely to choose antibiotics for themselves if they had more than a college education, self-identified as other than non-Hispanic white, or did not know anyone who had previously been hospitalized. They were less likely to choose antibiotics for themselves if they were surgeons.

For their child, 79% chose laparoscopic appendectomy; 6%, open appendectomy; and 15% antibiotics alone. Respondents were more likely to choose antibiotics for their child if they had more than a college education, knew nobody with appendicitis, or were not surgeons.

The sensitivity analysis included 220 participants (92% ages 18 to 69; 55% women; 93% non-Hispanic white). According to the authors, "their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment - rather than reductions in the duration of hospitalization or antibiotic treatment - were more likely to increase the desirability of choosing antibiotics."

Dr. Basson said, "The issue is whether the surgeon will actually find out the patient's perspective. For the average patient who doesn't know about an antibiotic-alone option, that depends on whether the surgeon discussed it with him."

"The real issue," he continued, "is whether the surgeon sees antibiotic-alone treatment as essentially futile and/or substandard, so not worth discussing, or as a viable option to be presented with pros and cons, (whether or not) the surgeon would recommend it."

"A variety of studies now show that antibiotics are a real option and describe the positive outcomes (likelihood of avoiding surgery) as well as the negative outcomes (failure, recurrence, prolonged treatment, etc.) from choosing it."

"I hope our study will convince surgeons that the choice of antibiotics alone, with the likely outcomes as described, is at least something that some patients might rationally choose and is therefore worth describing to the patient in the informed consent discussion," he concluded.

Dr. Patricia Ayoung-Chee, assistant professor of surgery at NYU Langone Health in New York City, told Reuters Health, "The results of the sensitivity analysis are very interesting - individuals have different risk-tolerance profiles; understanding that patients would be willing to tolerate a small amount of risk of recurrence to avoid the inherent risks of surgery is very helpful in understanding where future research efforts should be directed."

"This also highlights the importance of trying to individualize risk," she said by email. "If we were able to tailor information regarding risk of recurrence based on patient profile - including imaging and laboratory findings as well as duration of symptoms - we would further empower patients to make the best decisions for themselves."

"As the authors correctly stated," she added, "we have started empowering patients to become active participants in their medical decision making. Being able to present patients with the relevant information so they can make a decision that is right for them as individuals is important."

"The key to patient-centered medicine is to ensure that we present the data to patients in a way that they understand and in a way that they can use," Dr. Ayoung-Chee said. "Shared decision-making models should be employed for discussions regarding treatment options so that patients are truly making an informed decision."

It's also important, she said, that "we, as surgeons, fully explain why one treatment option is not appropriate over the other."

SOURCE: http://bit.ly/2FEykuF

JAMA Surg 2018.