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Invited Critique
March 1, 2007

Risk Factors for the Development of Abdominal Abscess Following Operation for Perforated Appendicitis in Children—Invited Critique

Arch Surg. 2007;142(3):241. doi:10.1001/archsurg.142.3.241

At first glance, the conclusions of this report would imply that there are few “definites” when it comes to the management of perforated appendicitis in children. Henry et al have bravely chosen to wade into waters that have long been muddied by clinical perceptions. Most surgeons view their own treatment algorithm of appendicitis as a core competency, one resistant to challenge or change. Noble, perhaps, but potentially outdated. In this looming “pay for performance” era, payers can and will look past history and dogma to determine how health care resources are allocated for treating common ailments such as appendicitis. This report brings to light misconceptions regarding the treatment of this disease. Many may be surprised to find that their own beliefs were not confirmed, most notably that neither type nor timing of antibiotics, choice of surgery (open vs laparoscopic), nor duration of antibiotic therapy were associated with a change in abscess incidence. Heresy, indeed. But, instead of using a “Joan of Arc” response and burning the conclusions, the 21st century surgeon has in his or her armamentarium an even greater matchstick: the electronic medical record. With its inherent database capabilities, the electronic medical record can be used to make true “apples-to-apples” comparisons of like risk groups and analyze the impact of treatment changes on outcome. The result of such an analysis gives today's surgeons the weapons to compete in the pay for performance arena. Studies, like this one, that identify and define the appropriate “benchmarks” for care will play an increasingly prominent role in the future of surgery. The battle for improved clinical care is one that can and should be fought from every stage, from the tertiary academic medical center to the local specialty surgery practice. Better clinical outcomes should be the goal for all.