Similar Outcomes at a Lower Cost: An Argument for Open Appendectomy in Simple Appendicitis

Acute appendicitis is the most common abdominal emergency resulting in over 250,000 appendectomies annually in the United States.1 Open appendectomy (OA) is still frequently performed, but laparoscopic appendectomy (LA) is gaining in popularity.2, 3 Multi- ple studies, including randomized controlled trials, meta-analyses, systematic reviews, and retrospective studies, have analyzed the differences in outcomes be- tween the two approaches. A 2010 Cochrane Review favored laparoscopy with reduced risk of wound in- fection, reduced mean pain scores, shorter length of stay (LOS), and shorter time for return to normal activity; however, an increased risk of intra-abdominal abscess was noted with LA.4 Based on these results, the authors of the Cochrane Review recommended the use of lap- aroscopy and LA in all patients with suspected simple appendicitis if surgical expertise and equipment are available and affordable and in the absence of contra- indications to laparoscopy.4 Affordability has emerged as a vital healthcare topic and demands attention now more than ever. A recent large database study by Sporn et al.3 described a substantially higher cost for LA and calculated a potential $93 million in savings had ap- pendectomies been performed exclusively open during a1-yeartimeperiod.

Given the current state of the healthcare economy and need for improved cost containment efforts, the purpose of this study was to examine the differences in clinical outcomes between OA and LA performed at a university-affiliated tertiary referral center and to scrutinize the results within a financial context.

A retrospective chart review was conducted for all nonpregnant adult patients who underwent an appen- dectomy between January 1, 2007, and December 31, 2008, at Fletcher Allen Health Center. Patient demo- graphics, clinical course, imaging findings, information from intraoperative and postoperative notes, pathology diagnosis, and total charges billed were recorded. Complex appendicitis was defined by perforation or abscess. The majority of our surgeons perform either all OA or all LA, and therefore, pseudorandomization was presumed based on the surgeon on call. All patients received preoperative antibiotics. The primary outcomes were: operative time, pain scores, wound infection, intra- abdominal abscess, time until first nonliquid meal, postoperative LOS, and total charges billed. Normally distributed continuous variables were tested for sig- nificance with two-sample t tests, skewed continuous variables were tested with the Kruskal-Wallis test, and categorical variables were tested with Pearson's x2 test. Stata/MP (Version 12.1) was used for all statistical testing. A P value of # 0.05 was defined as significant.

Three hundred sixty-four patients were identified for analysis and 40 were excluded (10 incidental appen- dectomies, 10 chronic appendicitis, seven interval appendectomies, seven pregnant females, five patients without charts, and one ileal conduit) resulting in the inclusion of 324 patients. The majority of the cases were OA versus LA (73.1 vs 26.9%). Sixteen surgeons per- formed the 324 procedures with a median of 24 pro- cedures per surgeon. Of the 324 patients, 250 (77.2%) had simple appendicitis and 74 (22.8%) had complex appendicitis.

In the subset analysis for simple appendicitis (SIMPLE) (n 4 250), 70.8 per cent were OA and 29.2 per cent were LA. There were no demographic or pre- operative clinical differences between the two groups with the exception that the LA group had a higher body mass index (28.0 vs 26.0 kg/m2, P <0.022)(Table1). TheoperativetimeforLAwassignificantlylonger(56 vs 47 minutes, P < 0.001) and the total charges billed for LA were significantly greater ($16,727 vs $12,840, P < 0.001) (Table 2). The differences between pain scores, wound infection, intra-abdominal abscess, time to first nonliquid meal, and postoperative LOS were not sta- tistically significant.

In the subset analysis for complex appendicitis (COMPLEX) (n 4 74), 81.1 per cent were OA and 18.9percentwereLA.TheLAgroupwasolder(54.9 vs 44.5 years, P < 0.044), had a greater percentage of females (71.4 vs 36.7%, P 4 0.018) and a larger body mass index (31.3 vs 27.2 kg/m2, P < 0.033). The op- erative time was again statistically longer for the LA group (84 vs 52 minutes, P < 0.001) (Table 2). The differences among pain scores, intra-abdominal abscess, time to first nonliquid meal, postoperative LOS, and total charges billed were not statistically significant. The wound infection rate approached significance (P 4 0.055) with no infections in LA versus 21.7 per cent in OA (Table 2).

Over the years, laparoscopic appendectomy has become the more favorable procedure to treat acute appendicitis with respect to increased use throughout the country and outcomes including wound infection, pain scores, LOS, and time for return to normal acti- vity.2-4 However, an increased risk of intra-abdominal abscess with LA has been noted and the financial implications of a potential $93 million saved over 1 year for preferentially performing OA over LA cannot be ignored.3, 4 At our institution, the majority of appen- dectomies are still performed open at 73.1 per cent. The LA and OA groups differed significantly with respect to a greater body mass index for LA in the SIMPLE group and a greater percentage of females and a higher body mass index for LA in the COMPLEX group. Although we believe our study was randomized effectively based on the pronounced propensity for individual surgeons on call to perform exclusively OA or LA, the presence of demographic differences suggests a slight surgeon preference for the laparoscopic approach with female and overweight patients, likely reflective of prior studies that have suggested some benefit of LA in these groups.4 Operative times were significantly longer for LA in both groups and likely account for some of the increased charges seen with LA. The remaining clinical outcomes were statistically insignificant and also clin- ically insignificant with differences of half to 1 point for pain scores and 4 hours for LOS for the SIMPLE group. Despite the insignificant longer LOS for OA, the total charges were still greater for LA.

There is a clear cost difference between OA and LA as seen by the significant differences in total charges billed in this study. Although charges billed are just that and not equivalent to the actual cost of the pro- cedure and hospital stay, the charge serves as the best surrogate that can be obtained reliably for each patient in the retrospective setting. In the SIMPLE group, charges incurredforLAwere$3887.58morethanforOA.Based on our results, there were no significant beneficial outcomes for undergoing LA for simple appendicitis, and the cost was substantially greater. Multiplying the difference in cost by the number of simple LAs per- formed (73) results in a potential $283,793.34 that could have been saved over the 2-year study period at our institution. The retrospective design of this study pro- hibited measuring time until return to normal activity or work and global costs such as societal productivity. Al- though we do not disagree the global costs are an es- sential piece to a complete cost-benefit analysis, they are often difficult to quantify and analyze and, ultimately, mean nothing to the healthcare industry's bottom line.

LA is generally supported as an acceptable approach for simple appendicitis with the appropriate equipment and surgical expertise and when affordable.4 In our study, we showed no benefit of LA over OA in simple appendicitis and, in fact, demonstrated a substantial increase in the total charge. The importance of hospital charge versus global cost can be argued, but in the current era when the need for cost containment is crit- ical, the direct cost of LA cannot be ignored. Although abandoning LA altogether is unlikely, and may even seem outrageous to the young surgeon who saw only a handful of open appendectomies during training, we, as physicians, must participate in the dialogue on healthcare reform and actively seek out the most cost- effective ways to practice medicine appropriately for the welfare of both our patients and our society.

REFERENCES

1. Owings MF, Kozak LJ. Ambulatory and inpatient procedures in the United States. Vital Health Stat 1998;139:1-119.

2. Ingraham AM, Cohen ME, Bilimoria KY, et al. Comparison of outcomes after laparoscopic versus open appendectomy for acute appendicitis at 222 ACS NSQIP hospitals. Surg 2010;148:625-35.

3. Sporn E, Petroski GF, Mancini GJ, et al. Laparoscopic ap- pendectomy-is it worth the cost? Trend analysis in the US from 2000 to 2005. J Am Coll Surg 2009;208:179-85.

4. Sauerland S, Jaschinski T, Neugebauer EAM. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010;10:CD001546.

Presented at the New England Surgical Society, September 23- 25, 2011, Bretton Woods, New Hampshire.

Address correspondence and reprint requests to Erin M. Garvey, M.D., The Mayo Clinic Arizona, Department of Surgery, 5779 E. Mayo Boulevard, General Surgery Surg SP 3-519, Phoenix, AZ 85054. E-mail: [email protected].

Erin M. Garvey, M.D.

James C. Hebert, M.D.

Turner Osler, M.D.

Department of Surgery

University of Vermont College of Medicine

Burlington, Vermont