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Davidson GH, Flum DR, Talan DA, Kessler LG, Lavallee DC, Bizzell BJ, Farjah F, Stewart SD, Krishnadasan A, Carney EE, Wolff EM, Comstock BA, Monsell SE, Heagerty PJ, Ehlers AP, DeUgarte DA, Kaji AH, Evans HL, Yu JT, Mandell KA, Doten IC, Clive KS, McGrane KM, Tudor BC, Foster CS, Saltzman DJ, Thirlby RC, Lange EO, Sabbatini AK, Moran GJ. Comparison of Outcomes of antibiotic Drugs and Appendectomy (CODA) trial: a protocol for the pragmatic randomised study of appendicitis treatment. BMJ Open 2017; 7:e016117. [PMID: 29146633 PMCID: PMC5695382 DOI: 10.1136/bmjopen-2017-016117] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Several European studies suggest that some patients with appendicitis can be treated safely with antibiotics. A portion of patients eventually undergo appendectomy within a year, with 10%-15% failing to respond in the initial period and a similar additional proportion with suspected recurrent episodes requiring appendectomy. Nearly all patients with appendicitis in the USA are still treated with surgery. A rigorous comparative effectiveness trial in the USA that is sufficiently large and pragmatic to incorporate usual variations in care and measures the patient experience is needed to determine whether antibiotics are as good as appendectomy. OBJECTIVES The Comparing Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial for acute appendicitis aims to determine whether the antibiotic treatment strategy is non-inferior to appendectomy. METHODS/ANALYSIS CODA is a randomised, pragmatic non-inferiority trial that aims to recruit 1552 English-speaking and Spanish-speaking adults with imaging-confirmed appendicitis. Participants are randomised to appendectomy or 10 days of antibiotics (including an option for complete outpatient therapy). A total of 500 patients who decline randomisation but consent to follow-up will be included in a parallel observational cohort. The primary analytic outcome is quality of life (measured by the EuroQol five dimension index) at 4 weeks. Clinical adverse events, rate of eventual appendectomy, decisional regret, return to work/school, work productivity and healthcare utilisation will be compared. Planned exploratory analyses will identify subpopulations that may have a differential risk of eventual appendectomy in the antibiotic treatment arm. ETHICS AND DISSEMINATION This trial was approved by the University of Washington's Human Subjects Division. Results from this trial will be presented in international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02800785.
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Affiliation(s)
- Giana H Davidson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David R Flum
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - David A Talan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Larry G Kessler
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | | | - Bonnie J Bizzell
- The Comparative Effectiveness Research Translation Network, CODA Chair, Patient Advisory Group, Seattle, Washington, USA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Skye D Stewart
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Anusha Krishnadasan
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Erin E Carney
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Erika M Wolff
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sarah E Monsell
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Annie P Ehlers
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, Califorina, USA
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Heather L Evans
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Julianna T Yu
- Department of Emergency, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Katherine A Mandell
- Department of Surgery, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Ian C Doten
- Department of Emergency Medicine, Swedish Medical Center-First Hill, Seattle, Washington, USA
| | - Kevin S Clive
- Department of Surgery, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Karen M McGrane
- Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Washington, USA
| | - Brandon C Tudor
- Department of Emergency Medicine, Providence Regional Medical Center, Everett, Washington, USA
| | - Careen S Foster
- Department of Trauma and Acute Care Surgery, Providence Regional Medical Center, Everett, WA, USA
| | - Darin J Saltzman
- Department of Surgery, Olive-View UCLA Medical Center, Sylmar, California, USA
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Erin O Lange
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Amber K Sabbatini
- Department of Emergency Medicine, Harborview Medical Center, Seattle, Washington, USA
| | - Gregory J Moran
- Department of Emergency Medicine, Olive-View UCLA Medical Center, Sylmar, California, USA
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