Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis | Emergency Medicine | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
McCutcheon  BA, Chang  DC, Marcus  LP,  et al.  Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis.  J Am Coll Surg. 2014;218(5):905-913.PubMedGoogle ScholarCrossref
Minneci  PC, Mahida  JB, Lodwick  DL,  et al.  Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis.  JAMA Surg. 2016;151(5):408-415.PubMedGoogle ScholarCrossref
Ehlers  AP, Talan  DA, Moran  GJ, Flum  DR, Davidson  GH.  Evidence for an antibiotics-first strategy for uncomplicated appendicitis in adults: a systematic review and gap analysis.  J Am Coll Surg. 2016;222(3):309-314.PubMedGoogle ScholarCrossref
Varadhan  KK, Neal  KR, Lobo  DN.  Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials.  BMJ. 2012;344:e2156.PubMedGoogle ScholarCrossref
Georgiou  R, Eaton  S, Stanton  MP, Pierro  A, Hall  NJ.  Efficacy and safety of nonoperative treatment for acute appendicitis: a meta-analysis.  Pediatrics. 2017;139(3):e20163003.PubMedGoogle ScholarCrossref
Ehlers  AP, Davidson  GH, Bizzell  BJ,  et al.  Engaging stakeholders in surgical research: the design of a pragmatic clinical trial to study management of acute appendicitis.  JAMA Surg. 2016;151(6):580-582.PubMedGoogle ScholarCrossref
Findlay  JM, Kafsi  JE, Hammer  C, Gilmour  J, Gillies  RS, Maynard  ND.  Nonoperative management of appendicitis in adults: a systematic review and meta-analysis of randomized controlled trials.  J Am Coll Surg. 2016;223(6):814-824.e2.PubMedGoogle ScholarCrossref
Mazur  DJ.  What should patients be told prior to a medical procedure? ethical and legal perspectives on medical informed consent.  Am J Med. 1986;81(6):1051-1054.PubMedGoogle ScholarCrossref
Brazell  NE.  The significance and applications of informed consent.  AORN J. 1997;65(2):377-380, 382, 385-386.PubMedGoogle ScholarCrossref
Grady  C.  Enduring and emerging challenges of informed consent.  N Engl J Med. 2015;372(9):855-862.PubMedGoogle ScholarCrossref
Robertson  L.  Contemporary interpretation of informed consent: autonomy and paternalism.  Br J Hosp Med (Lond). 2016;77(6):358-361.PubMedGoogle ScholarCrossref
Weber  EU, Blais  A-R, Betz  NE.  A domain-specific risk-attitude scale: measuring risk perceptions and risk behaviors.  J Behav Decis Making. 2002;15(4):263-290. doi:10.1002/bdm.414Google ScholarCrossref
Rosenbaum  L.  The paternalism preference—choosing unshared decision making.  N Engl J Med. 2015;373(7):589-592.PubMedGoogle ScholarCrossref
Basson  MD, Gomez  R, Fishman  L, Panzini  L.  Informed consent for screening sigmoidoscopy in a Veterans Administration population.  Dis Colon Rectum. 2004;47(11):1939-1946.PubMedGoogle ScholarCrossref
Losanoff  JE, Litwinczuk  KM, Ranella  MJ, Basson  MD.  Elective inguinal hernia repair: a unified informed consent, or who wants to know what?  Am Surg. 2009;75(4):296-300.PubMedGoogle Scholar
Johnson  JD, Roberts  CS, Cox  CE, Reintgen  DS, Levine  JS, Parsons  M.  Breast cancer patients’ personality style, age, and treatment decision making.  J Surg Oncol. 1996;63(3):183-186.PubMedGoogle ScholarCrossref
Halkoaho  A, Pietilä  AM, Ebbesen  M, Karki  S, Kangasniemi  M.  Cultural aspects related to informed consent in health research: a systematic review.  Nurs Ethics. 2016;23(6):698-712.PubMedGoogle ScholarCrossref
Hermann  H, Trachsel  M, Elger  BS, Biller-Andorno  N.  Emotion and value in the evaluation of medical decision-making capacity: a narrative review of arguments.  Front Psychol. 2016;7:765.PubMedGoogle ScholarCrossref
Bruera  E, Willey  JS, Palmer  JL, Rosales  M.  Treatment decisions for breast carcinoma: patient preferences and physician perceptions.  Cancer. 2002;94(7):2076-2080.PubMedGoogle ScholarCrossref
Bronner  K, Mesters  I, Weiss-Meilik  A,  et al.  Determinants of adherence to screening by colonoscopy in individuals with a family history of colorectal cancer.  Patient Educ Couns. 2013;93(2):272-281.PubMedGoogle ScholarCrossref
Felsen  CB, Piasecki  A, Ferrante  JM, Ohman-Strickland  PA, Crabtree  BF.  Colorectal cancer screening among primary care patients: does risk affect screening behavior?  J Community Health. 2011;36(4):605-611.PubMedGoogle ScholarCrossref
Schug-Pass  C, Geers  P, Hügel  O, Lippert  H, Köckerling  F.  Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis.  Int J Colorectal Dis. 2010;25(6):751-759.PubMedGoogle ScholarCrossref
Sawyer  RG, Claridge  JA, Nathens  AB,  et al.  Trial of short-course antimicrobial therapy for intraabdominal infection.  N Engl J Med. 2015;372(21):1996-2005.PubMedGoogle ScholarCrossref
Scarpa  CR, Buchs  NC, Poncet  A,  et al.  Short-term intravenous antibiotic treatment in uncomplicated diverticulitis does not increase the risk of recurrence compared to long-term treatment.  Ann Coloproctol. 2015;31(2):52-56.PubMedGoogle ScholarCrossref
Kwoh  CK, Vina  ER, Cloonan  YK, Hannon  MJ, Boudreau  RM, Ibrahim  SA.  Determinants of patient preferences for total knee replacement: African-Americans and whites.  Arthritis Res Ther. 2015;17:348.PubMedGoogle ScholarCrossref
Arega  A, Birkmeyer  NJ, Lurie  JD,  et al.  Racial variation in treatment preferences and willingness to randomize in the Spine Patient Outcomes Research Trial (SPORT).  Spine (Phila Pa 1976). 2006;31(19):2263-2269.PubMedGoogle ScholarCrossref
Original Investigation
Association of VA Surgeons
May 2018

Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis

Author Affiliations
  • 1Department of Surgery, University of North Dakota School of Medicine and Health Sciences, Grand Forks
  • 2Department of Psychiatry and Behavioral Science, University of North Dakota School of Medicine and Health Sciences, Grand Forks
  • 3Neuropsychiatric Research Institute, Fargo, North Dakota
JAMA Surg. 2018;153(5):471-478. doi:10.1001/jamasurg.2017.5310
Key Points

Question  Which treatment will patients with uncomplicated acute appendicitis choose when presented with both surgical and nonsurgical options, and what might make nonsurgical antibiotic therapy a more appealing option?

Findings  In a survey of 1728 participants, most respondents chose laparoscopic appendectomy over open appendectomy and antibiotics alone as a treatment option for acute appendicitis, while a sensitivity analysis involving 220 individuals demonstrated that antibiotics alone was more appealing when short-term failure or long-term recurrence rates were decreased.

Meaning  Patients should be presented with all viable treatment options, including antibiotics alone, while future research on antibiotic treatment for appendicitis should focus on improving failure rates.


Importance  Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective.

Objectives  To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing.

Design, Setting, and Participants  This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017.

Main Outcomes and Measures  Treatment preferences.

Results  Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as “gender fluid” within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P < .001), identified as other than non-Hispanic white (24 [14.9%]; P < .001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P = .02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment—rather than reductions in the duration of hospitalization or antibiotic treatment—were more likely to increase the desirability of choosing antibiotics.

Conclusions and Relevance  Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.