In Reply We read with interest the concerns raised by Bonadio in response to our study1 examining the relationship between treatment delay and complicated appendicitis. First and foremost, we would disagree with the premise that a lack of knowledge regarding perforation status at presentation undermines the study’s validity. Use of mixed-effects hierarchical regression modeling to control for differences (ie, clustering) in perforation rates within hospitals allows for the assessment of postpresentation treatment delay across hospitals without knowledge of each hospitals’ specific baseline rate. Furthermore, we explored the relationship between treatment delay and adverse outcomes at the level of 23 individual hospitals, collectively representing a broad range of diagnostic practices and time-to-appendectomy profiles. The results were no different with the hospital-level analyses, and no increased risk of complicated disease was found even at hospitals with relatively long treatment delays.
Rangel SJ. Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children—Reply. JAMA Pediatr. 2018;172(1):94–95. doi:10.1001/jamapediatrics.2017.4080
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