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Original Investigation
Pacific Coast Surgical Association
November 2018

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis

Author Affiliations
  • 1Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Center for Applied Pediatric Quality Analytics, Boston Children’s Hospital, Boston, Massachusetts
  • 3Children’s Hospital Association, Lenexa, Kansas
  • 4Division of Pediatric Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 5Division of Pediatric Surgery, Primary Children’s Hospital, Salt Lake City, Utah
  • 6Division of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, Ohio
JAMA Surg. 2018;153(11):1021-1027. doi:10.1001/jamasurg.2018.2085
Key Points

Question  Are intraoperative findings associated with the risk of postoperative complications and use of health care resources in children with complicated appendicitis?

Findings  In this multicenter cohort study of 1333 children undergoing appendectomy, intraoperative findings were found to markedly influence postoperative outcomes. Compared with patients with 1 intraoperative finding, multiple findings were associated with higher rates of complications (16.4% vs 10.6%), more revisits (22.9% vs 8.9%), longer length of stay (8.9 vs 4.0 days), and higher hospital cost ($32 282 vs $13 296).

Meaning  Adjustment for disease severity may be necessary to ensure fair reimbursement and comparative performance reporting among hospitals, particularly at hospitals treating underserved populations, where more severe presentation is common.


Importance  The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals.

Objective  To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis.

Design  This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children’s hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014.

Main Outcomes and Measures  Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals.

Results  A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001).

Conclusions and Relevance  More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

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