Historical changes in the postoperative treatment of appendicitis in children: impact on medical outcome.
OBJECTIVE
The introduction of managed care in the 1980s caused increased pressure to reduce costs for hospitalized patients. The authors hypothesized that these market forces have resulted in a decreased hospital stay and utilization of sophisticated diagnostic testing in children treated for appendicitis. If true, the impact of this paradigm shift on patient outcome is unknown.


METHODS
Hospital records for 913 pediatric patients treated for appendicitis from 1974 to 1998 were reviewed retrospectively. Patients were stratified into those with perforated appendicitis (PA) and nonperforated appendicitis (NPA). Demographics, perioperative hospital course, diagnostic testing, complications, and long-term outcomes were analyzed after stratification into time intervals.


RESULTS
Over time, children with NPA were treated with shorter antibiotic courses (P<.05) and were placed on a regular diet earlier (P<.05). These changes in treatment resulted in an earlier discharge (P<.05). The amount of time to become afebrile with a normal white blood cell count (WBC) did not change over time. Children with PA exhibited similar results with shorter antibiotic courses (P<.05), earlier dietary intake (P<.05) and earlier hospital discharge (P<.05) over time. In all children with appendicitis there was no significant difference in the rate of wound infections, abscesses requiring drains, readmission, or reoperations overtime. The utilization of abdominal radiographs (83%) and ultrasonography (USN; 40%) was high and remained unchanged over time. Utilization of computed tomography (CT scan) was low (4.3%) in the early decades and was not used as a preoperative test from 1991 to 1994. Given the high diagnostic accuracy of a pediatric surgeon for this disease, Bayesian analysis indicates that USN utilization rates should be 15%.


CONCLUSIONS
The market pressures of managed care have resulted in a new treatment paradigm with an earlier discharge of all children with appendicitis. There has been no concomitant increase in the complication rate in either group as a result of this paradigm shift. Bayesian analysis indicates that USN and abdominal radiographs are overutilized in our institution.
Lelli
J L
JL
Department of Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor 48109-0245, USA.
Drongowski
R A
RA
Raviz
S
S
Wilke
L
L
Heidelberger
K P
KP
Hirschl
R B
RB
D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001064:Appendicitis / Q000000981:diagnostic imaging / Q000601:surgery*; D001499:Bayes Theorem; D002648:Child; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000601:surgery*; D008297:Male; D008824:Michigan; D011182:Postoperative Care / Q000639:trends*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014463:Ultrasonography
D000900:Anti-Bacterial Agents