Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort

OBJECTIVE

To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.

SUMMARY BACKGROUND DATA

The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.

METHODS

We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.

RESULTS

The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.

CONCLUSIONS

Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02800785.

Analysis of Outcomes Associated With Outpatient Management of Nonoperatively Treated Patients With Appendicitis

IMPORTANCE

In the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which found antibiotics to be noninferior, approximately half of participants randomized to receive antibiotics had outpatient management with hospital discharge within 24 hours. If outpatient management is safe, it could increase convenience and decrease health care use and costs.

OBJECTIVE

To assess the use and safety of outpatient management of acute appendicitis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study, which is a secondary analysis of the CODA trial, included 776 adults with imaging-confirmed appendicitis who received antibiotics at 25 US hospitals from May 1, 2016, to February 28, 2020.

EXPOSURES

Participants randomized to antibiotics (intravenous then oral) could be discharged from the emergency department based on clinician judgment and prespecified criteria (hemodynamically stable, afebrile, oral intake tolerated, pain controlled, and follow-up confirmed). Outpatient management and hospitalization were defined as discharge within or after 24 hours, respectively.

MAIN OUTCOMES AND MEASURES

Outcomes compared among patients receiving outpatient vs inpatient care included serious adverse events (SAEs), appendectomies, health care encounters, satisfaction, missed workdays at 7 days, and EuroQol 5-dimension (EQ-5D) score at 30 days. In addition, appendectomy incidence among outpatients and inpatients, unadjusted and adjusted for illness severity, was compared.

RESULTS

Among 776 antibiotic-randomized participants, 42 (5.4%) underwent appendectomy within 24 hours and 8 (1.0%) did not receive their first antibiotic dose within 24 hours, leaving 726 (93.6%) comprising the study population (median age, 36 years; range, 18-86 years; 462 [63.6%] male; 437 [60.2%] White). Of these participants, 335 (46.1%; site range, 0-89.2%) were discharged within 24 hours, and 391 (53.9%) were discharged after 24 hours. Over 7 days, SAEs occurred in 0.9 (95% CI, 0.2-2.6) per 100 outpatients and 1.3 (95% CI, 0.4-2.9) per 100 inpatients; in the appendicolith subgroup, SAEs occurred in 2.3 (95% CI, 0.3-8.2) per 100 outpatients vs 2.8 (95% CI, 0.6-7.9) per 100 inpatients. During this period, appendectomy occurred in 9.9% (95% CI, 6.9%-13.7%) of outpatients and 14.1% (95% CI, 10.8%-18.0%) of inpatients; adjusted analysis demonstrated a similar difference in incidence (-4.0 percentage points; 95% CI, -8.7 to 0.6). At 30 days, appendectomies occurred in 12.6% (95% CI, 9.1%-16.7%) of outpatients and 19.0% (95% CI, 15.1%-23.4%) of inpatients. Outpatients missed fewer workdays (2.6 days; 95% CI, 2.3-2.9 days) than did inpatients (3.8 days; 95% CI, 3.4-4.3 days) and had similar frequency of return health care visits and high satisfaction and EQ-5D scores.

CONCLUSIONS AND RELEVANCE

These findings support that outpatient antibiotic management is safe for selected adults with acute appendicitis, with no greater risk of complications or appendectomy than hospital care, and should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02800785.

Outcomes of Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has become a critical component of caring for patients with end-stage lung disease. This study examined outcomes of patients who received ECMO as a BTT.

METHODS

Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients who received ECMO as BTT at Columbia University Medical Center from April 2009 through July 2018.

RESULTS

A total of 121 adult patients were placed on ECMO as BTT, and 70 patients (59%) were successfully bridged to lung transplantation. Simplified Acute Physiology Score II, unplanned endotracheal intubation, renal replacement therapy, and cerebrovascular accident were identified as independent predictors of unsuccessful BTT. Ambulation was the only independent predictor of successful BTT (odds ratio, 7.579; 95% confidence interval, 2.158 to 26.615; p = 0.002). Among the 64 patients (91%) who survived to hospital discharge, survival was 88% at 1 year and 83% at 3 years. Propensity matching between BTT and non-BTT lung transplant recipients did not show a significant difference in survival (log-rank = 0.53) despite significant differences in the lung allocation score (median, 92.2 [interquartile range, 89.0 to 94.2] vs 49.6 [interquartile range, 40.6 to 72.3], p < 0.01).

CONCLUSIONS

ECMO can be used successfully to bridge patients with end-stage lung disease to lung transplantation. When implemented by an experienced team with adherence to stringent protocols and patient selection, outcomes in BTT patients were comparable to patients who did not receive pretransplant support.