Patient-Provider Decision-Making Is Crucial for Patients with Appendicitis

The April article in the ACS Bulletin “Are Antibiotics the Answer to Treating Appendicitis?” demonstrates how much the treatment of appendicitis is in evolution. For the past 120 years, appendectomy has been the preferred treatment for appendicitis. It is a “one-and-done” approach to appendicitis that often can be completed with an overnight hospitalization or outpatient procedure.

However, an appendectomy may not be right for everyone. Like all surgical procedures, there are risks, discomfort, and time required for recovery. For many, the out-of-pocket costs for emergency surgery can have devastating financial consequences. Over the past 15 years, multiple randomized studies comparing antibiotics alone to appendectomy have demonstrated that a nonoperative approach is an effective alternative to appendectomy, albeit resulting in 25%–30% of patients having an appendectomy by 90 days, and as many as 50% having surgery in 3 to 5 years.¹

These two treatment options confer a unique set of risks (e.g., primary treatment failure and recurrence versus surgical complications, disability, and cost) and benefits (e.g., more rapid return to work with antibiotics versus decreased chance of readmission with initial appendectomy) for patients to consider (see Table).

Surgeons are growing increasingly aware of the evidence from these clinical trials, and as described in the article, often have strong beliefs about which treatment is better and when they should or should not offer antibiotics as an option. Furthermore, surgeons and emergency medicine teams face increasing pressures for time while on call and few tools exist to support effective communication for patients and their families. Patients often have limited knowledge of these treatment options and may prioritize specific risks and benefits differently than surgeons.

For example, a surgeon may not want to offer antibiotics to a patient with an appendicolith because they consider the 40% chance of needing an appendectomy too great. A patient with an appendicolith may view this as a 60% chance of avoiding a surgical procedure, and given their circumstances (e.g., limited insurance, childcare or work responsibilities), antibiotics might be a completely reasonable choice.

After years of conducting the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial—the largest randomized control trial (RCT) of antibiotics for appendicitis and the first large-scale US trial—and now helping to implement its findings, we think all patients should be offered information about these two options and given support as they choose the treatment that is right for them. We recognize that health systems also need to make available structures and supportive tools for clinical teams, patients, and their families to use when having these conversations in the emergency room.

Informing patients about their treatment options for appendicitis has unique challenges. There is a lot of evidence to summarize, several competing outcomes to describe, a time-sensitive emergency room setting, and varied clinical experiences and biases about using antibiotics instead of surgery. Lastly, there is no billing code to enable the direct compensation of the time required for surgeons to explain these options.

In situations like this, decision support tools (DSTs) are helpful, because they provide information to patients in formats that are readily accessible and at an reasonable level of literacy and numeracy, often using video-based materials. DSTs also prompt the patient to elicit preferences about outcomes. Taken together, these benefits reduce the burden on surgeons to explain the options and lead to a more informed conversation between the surgeon and patient.

Concurrent to the CODA trial, our group developed a DST for appendicitis treatment (www.appyornot.org). The AppyOrNot Appendicitis Decision Support Tool has three main components (see Figures 1–3)

• A video describing appendicitis and treatment options with race and language-concordant narrators
• An outcome prioritization section
• A treatment suggestion based on prioritized outcomes

The appyornot.org DST has been used by more than 10,000 patients worldwide and is part of a Patient-Centered Outcomes Research Institute-funded tool called the Treatment Individualized Appendicitis Decision Making (TRIAD) implementation program², now deployed at 17 hospitals.

TRIAD includes access to the DST, education for all clinicians and allied health professionals involved in appendicitis care, and electronic health record-based prompts and protocols to support antibiotics use. A recent presentation at the American Surgical Association described early results of the DST and its use by more than 8,000 people in 66 countries and all 50 US states.³ Use of the DST improved knowledge and reduced the proportion of patients who were undecided about what treatment was right for them.

Once offered information about both treatment options, most patients (approximately 80%–85%) still wanted surgery, but for some, antibiotics was the favored approach. The DST can help clarify options and help people find a treatment that is right for them. For example, after using the DST, among the subset surveyed both before and after its use, the percentage of individuals who were uncertain about undergoing surgery decreased, while the proportion favoring antibiotic treatment increased from 14% to 21%.

The broader use of a DST can impact another area of concern regarding the use of antibiotics for appendicitis. As antibiotics move from the research arena to broader use in the community, there also have been concerns about whether they would be used equitably and how long their effectiveness would last.⁴

In 2023, we surveyed 357 ACS Fellows and found most had serious concerns about the way antibiotics might be used in the community at large. These concerns were related to effectiveness, equity, and appropriateness of use. Specifically, 35% thought that their colleagues might be using antibiotics, not necessarily to avoid appendectomy, but to convert emergency into elective procedures, even in those who responded favorably to antibiotics. Approximately 20% were concerned that other surgeons would selectively offer antibiotics based on non-evidence-based characteristics (e.g., insurance status, social support, rurality), and 28% were concerned surgeons were using antibiotics among those excluded from prior RCTs such as those who are immunocompromised or pregnant.

The broader use of the DST, especially if used as part of the TRIAD implementation program, can address all these issues head-on. TRIAD is aimed at helping surgeons share the evidence of antibiotics for appendicitis in an unbiased and patient-centered fashion. It addresses inequity by providing information in languages and with narrators that are selected by the patient and tackles the issues of appropriateness by educating clinicians and patients about eligibility criteria for antibiotics.

Lastly, this tool deals with the role of appendectomy after a successful response to antibiotics with both clinician training and patient education. Working in coordination with the ACS and its Emergency General Surgery Verification Program, ongoing improvement with input from patients and surgeons with a plan for expansion of this tool is planned. We encourage surgeons and systems to join the TRIAD implementation program, either by providing their patients with access to the DST or by taking part in the nationwide implementation program rolling out over the next year.

When it comes to treatments for appendicitis, it’s time for the question to shift from “Which treatment is better?” to “Which treatment is better for my patient, given their unique circumstances, preferences, and priorities?” This transformation demands a change in the way we inform patients and solicit their perspectives. The wider use of the DST and programs like TRIAD can help with that.

When our community creates DSTs like appyornot.org, we demonstrate a willingness to challenge convention and “walk the talk” on patient-centered care. We believe this also is a model for how ACS Fellows should help close the gap between evidence generation and practice change.

Dr. Flum was the PI of the CODA Trial and Dr. Davidson was the CO-PI of the CODA Trial and led the Clinical Coordinating Center. Drs. Davidson and Flum are co-PIs of TRIAD.

Disclaimer

The thoughts and opinions expressed in this viewpoint article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. David Flum is vice-chair for research in the Department of Surgery at the University of Washington School of Medicine in Seattle. He also is a professor of surgery and an adjunct professor of health services and pharmacy.

Dr. Giana Davidson is section head of emergency general surgery and assistant dean for professional development in the Office of Faculty Affairs at the University of Washington School of Medicine in Seattle. She also is a professor in the Department of Surgery and adjunct professor in the Department of Health Systems and Population Health.

References

1. CODA Collaborative, Flum DR, Davidson GH, Monsell SE, et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383(20):1907-1919.
2. Patient-Centered Outcomes Research Institute. Promoting informed decision making when choosing between antibiotics or surgery for appendicitis: TRIAD (Treatment Individualized Appendicitis Decision-making) Implementation Program. Project Summary. 2022. Available at: https://www.pcori.org/research-results/2022/promoting-informed-decision-making-when-choosing-between-antibiotics-or-surgery-appendicitis-triad-treatment-individualized-appendicitis-decision-making-implementation-program. Accessed April 15, 2024.
3. TRIAD Collaborative, Rosen JE, Monsell SE, DePaoli SC, et al. The use and impact of a decision support tool for appendicitis treatment. Ann Surg. 2024. In press.
4. Jacobs D. Antibiotics for appendicitis—proceed with caution. N Engl J Med. 2020;383(20):1985-1986.