Cost analysis of antibiotic therapy versus appendectomy for treatment of uncomplicated acute appendicitis: 5-year results of the APPAC randomized clinical trial.

Jussi Haijanen,Juha Grönroos,Pia Nordström,Hannu Paajanen,Tuomo Rantanen,Tero Rautio,Paulina Salminen,Suvi Sippola,Markku Aarnio,Saija Hurme,Risto Tuominen,Martina Crivellari

doi:10.1371/journal.pone.0220202

Abstract

BackgroundThe efficacy and safety of antibiotic treatment for uncomplicated acute appendicitis has been established at long-term follow-up with the majority of recurrences shown to occur within the first year. Overall costs of antibiotics are significantly lower compared with appendectomy at short-term follow-up, but long-term durability of these cost savings is unclear. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years.Methods and findingsThis multicentre, non-inferiority randomized clinical trial randomly assigned 530 adult patients with CT-confirmed uncomplicated acute appendicitis to appendectomy or antibiotic treatment at six Finnish hospitals. All major costs during the 5-year follow-up were recorded, whether generated by the initial visit and subsequent treatment or possible recurrent appendicitis. Between November 2009 and June 2012, 273 patients were randomized to appendectomy and 257 to antibiotics. The overall costs of appendectomy were 1.4 times higher (p<0.001) (€5716; 95% CI: €5510 to €5925) compared with antibiotic therapy (€4171; 95% CI: €3879 to €4463) resulting in cost savings of €1545 per patient (95% CI: €1193 to €1899; p<0.001) in the antibiotic group. At 5 years, the majority (61%, n = 156) of antibiotic group patients did not undergo appendectomy.ConclusionsAt 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy. As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up.

Highlights

Out of the more than 200 million annual surgical procedures performed globally, appendectomy is one of the most common incurring significant health care costs.[1,2,3] Appendectomy has been the standard treatment for all appendicitis cases for over a century, even though both current epidemiological and clinical data suggest that there may be two different forms of acute appendicitis
At 5-year follow-up antibiotic treatment resulted in significantly lower overall costs compared with appendectomy
As the majority of appendicitis recurrences occur within the first year after the initial antibiotic treatment, these results suggest that treating uncomplicated acute appendicitis with antibiotics instead of appendectomy results in lower overall costs even at longer-term follow-up

Summary

Introduction

Out of the more than 200 million annual surgical procedures performed globally, appendectomy is one of the most common incurring significant health care costs.[1,2,3] Appendectomy has been the standard treatment for all appendicitis cases for over a century, even though both current epidemiological and clinical data suggest that there may be two different forms of acute appendicitis. Increasing short-term evidence from randomized trials[6, 8,9,10] and prospective cohort studies [11, 12] shows that antibiotic therapy for uncomplicated acute appendicitis is a safe and viable treatment alternative. The study objective was to compare the long-term overall costs of antibiotic therapy versus appendectomy in the treatment of uncomplicated acute appendicitis in the APPAC (APPendicitis ACuta) trial at 5 years

Methods

Results

Conclusion