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Age-related disparities and trends in national healthcare spending for management of appendicitis in the United States: A retrospective cost-analysis

Published:January 13, 2023DOI:https://doi.org/10.1016/j.surg.2022.12.003

      Abstract

      Background

      Changes in clinical care for appendicitis have impacted healthcare use associated with treatment. We evaluated national trends and assessed factors associated with healthcare costs for appendicitis in the United States.

      Design

      The Disease Expenditure Project, the Global Burden of Disease study, and the National Inpatient Sample were used to estimate total national expenditures, per-capita costs for incident cases, and factors associated with inpatient costs for appendicitis management, respectively. The national estimates of appendicitis costs were obtained from 1996 to 2016. Appendicitis incidence was estimated to calculate per-capita costs. After application of survey weights for the stratified sample design, 191,180 weighted discharges for appendicitis from the 2016 National Inpatient Sample study were evaluated. The Disease Expenditure Project and the Global Burden of Disease study were used to estimate total and per-capita spending. Temporal trends were evaluated using joinpoint regression, expressed as annual percent change. Multivariable linear regression was used to evaluate patient factors associated with total hospital charges.

      Results

      In 2016, total spending on appendicitis was $9.3 billion (95% confidence interval: $8.0–$10.8], a 2-fold increase from $4.7 billion ($4.0–$5.3) in 1996. Per-capita spending decreased significantly after 2011 (annual percent change –3.7% [–4.4% to –2.9%]). Patients ≥65 years accounted for 64.1% (61.1%–67.3%) of total spending for appendicitis. The hospital charges for older patients were significantly higher among those undergoing appendectomy.

      Conclusion

      Overall healthcare spending for appendicitis has doubled from 1996 to 2016, but per capita spending has decreased since 2011, driven by improved efficiency of inpatient care. Nearly two-thirds of spending is on patients ≥65 years, with significantly higher costs associated with surgical management in this population.
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      References

        • Ferris M.
        • Quan S.
        • Kaplan B.S.
        • et al.
        The global incidence of appendicitis: a systematic review of population-based studies.
        Ann Surg. 2017; 266: 237-241
        • Fingar K.R.
        • Stocks C.
        • Weiss A.J.
        • Steiner C.A.
        Most frequent operating room procedures performed in U.S. hospitals, 2003–2012. HCUP Statistical Brief #186.
        Agency for Healthcare Research Quality, Rockville (MD)2006
        • Salminen P.
        • Paajanen H.
        • Rautio T.
        • et al.
        Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.
        JAMA. 2015; 313: 2340-2348
        • Flum D.R.
        • Davidson G.H.
        • et al.
        • CODA Collaborative
        A randomized trial comparing antibiotics with appendectomy for appendicitis.
        N Engl J Med. 2020; 383: 1907-1919
        • Addiss D.G.
        • Shaffer N.
        • Fowler B.S.
        • et al.
        The epidemiology of appendicitis and appendectomy in the United States.
        Am J Epidemiol. 1990; 132: 910-925
        • Weinandt M.
        • Godiris-Petit G.
        • Menegaux F.
        • et al.
        Appendicitis is a severe disease in older patients: a twenty-year audit.
        JSLS. 2020; 24e2020.00046
        • Yuan J.
        • Chen Q.
        • Hong W.
        • et al.
        Comparison of clinical features and outcomes of appendectomy in older vs. non-older: a systematic review and meta-analysis.
        Front Surg. 2022; 9818347
        • Franz M.G.
        • Norman J.
        • Fabri P.J.
        Increased morbidity of appendicitis with advancing age.
        Am Surg. 1995; 61: 40-44
        • Bhullar J.S.
        • Chaudhary S.
        • Cozacov Y.
        • et al.
        Acute appendicitis in the older: diagnosis and management still a challenge.
        Am Surg. 2014; 80: E295-E297
        • Cohen-Arazi O.
        • Dabour K.
        • Bala M.
        • et al.
        Management, treatment and outcomes of acute appendicitis in an older population: a single-center experience.
        Eur J Trauma Emerg Surg. 2017; 43: 723-727
        • Segev L.
        • Keidar A.
        • Schrier I.
        • et al.
        Acute appendicitis in the older in the twenty-first century.
        J Gastrointest Surg. 2015; 19: 730-735
        • Schenning K.J.
        • Deiner S.G.
        Postoperative delirium in the geriatric patient.
        Anesthesiol Clin. 2015; 33: 505-516
        • Blomqvist P.G.
        • Andersson R.E.
        • Granath F.
        • et al.
        Mortality after appendectomy in Sweden, 1987-1996.
        Ann Surg. 2001; 233: 455-460
        • Pallin D.J.
        • Espinola J.A.
        • Camargo Jr., C.A.
        US population aging and demand for inpatient services.
        J Hosp Med. 2014; 9: 193-196
        • Dieleman J.L.
        • Baral R.
        • Birger M.
        • et al.
        US Spending on Personal Health Care and Public Health, 1996-2013.
        JAMA. 2016; 316: 2627-2646
        • GBD 2019 Diseases and Injuries Collaborators
        Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.
        Lancet. 2020; 396: 1204-1222
        • GBD 2017 Disease and Injury Incidence and Prevalence Collaborators
        Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.
        Lancet. 2018; 392: 1789-1858
        • Jaschinski T.
        • Mosch C.G.
        • Eikermann M.
        • et al.
        Laparoscopic versus open surgery for suspected appendicitis.
        Cochrane Database Syst Rev. 2018; 11CD001546
        • Ball C.G.
        • Kortbeek J.B.
        • Kirkpatrick A.W.
        • et al.
        Laparoscopic appendectomy for complicated appendicitis: an evaluation of postoperative factors.
        Surg Endosc. 2004; 18: 969-973
        • Scott M.J.
        • Baldini G.
        • Fearon K.C.
        • et al.
        Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations.
        Acta Anaesthesiol Scand. 2015; 59: 1212-1231
        • Feldheiser A.
        • Aziz O.
        • Baldini G.
        • et al.
        Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice.
        Acta Anaesthesiol Scand. 2016; 60: 289-334
        • Trejo-Avila M.E.
        • Romero-Loera S.
        • Cardenas-Lailson E.
        • et al.
        Enhanced recovery after surgery protocol allows ambulatory laparoscopic appendectomy in uncomplicated acute appendicitis: a prospective, randomized trial.
        Surg Endosc. 2019; 33: 429-436
        • Nechay T.
        • Sazhin A.
        • Titkova S.
        • et al.
        Evaluation of enhanced recovery after surgery program components implemented in laparoscopic appendectomy: prospective randomized clinical study.
        Sci Rep. 2020; 1010749
        • Skorus U.
        • Rapacz K.
        • Kenig J.
        The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery.
        Acta Chir Belg. 2021; 121: 405-412
        • Ho V.P.
        • Schiltz N.K.
        • Reimer A.P.
        • et al.
        High-risk comorbidity combinations in older patients undergoing emergency general surgery.
        J Am Geriatr Soc. 2019; 67: 503-510
        • Fugazzola P.
        • Ceresoli M.
        • Agnoletti V.
        • et al.
        The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the older (2019 edition).
        World J Emerg Surg. 2020; 15: 19
        • Raats J.W.
        • van Eijsden W.A.
        • Crolla R.M.
        • et al.
        Risk factors and outcomes for postoperative delirium after major surgery in older patients.
        PLoS One. 2015; 10e0136071
        • Moskowitz E.E.
        • Overbey D.M.
        • Jones T.S.
        • et al.
        Post-operative delirium is associated with increased 5-year mortality.
        Am J Surg. 2017; 214: 1036-1038
        • Keller D.S.
        • Lawrence J.K.
        • Nobel T.
        • et al.
        Optimizing cost and short-term outcomes for older patients in laparoscopic colonic surgery.
        Surg Endosc. 2013; 27: 4463-4468
        • Markides G.
        • Subar D.
        • Riyad K.
        Laparoscopic versus open appendectomy in adults with complicated appendicitis: systematic review and meta-analysis.
        World J Surg. 2010; 34: 2026-2040
        • Gray K.D.
        • Burshtein J.G.
        • Obeid L.
        • et al.
        Laparoscopic appendectomy: minimally invasive surgery training improves outcomes in basic laparoscopic procedures.
        World J Surg. 2018; 42: 1706-1713
        • Cataneo J.L.
        • Veilleux E.
        • Lutfi R.
        Impact of fellowship training on surgical outcomes after appendectomies: a retrospective cohort study.
        Surg Endosc. 2021; 35: 4581-4584
        • Fearon K.C.
        • Ljungqvist O.
        • Von Meyenfeldt M.
        • et al.
        Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.
        Clin Nutr. 2005; 24: 466-477
        • Peery A.F.
        • Crockett S.D.
        • Murphy C.C.
        • et al.
        Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.
        Gastroenterology. 2019; 156: 254-272.e11
        • Cash C.L.
        • Frazee R.C.
        • Abernathy S.W.
        • et al.
        A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.
        J Am Coll Surg. 2012; 215 (discussion 105–6): 101-105
        • Yang Z.
        • Sun F.
        • Ai S.
        • et al.
        Meta-analysis of studies comparing conservative treatment with antibiotics and appendectomy for acute appendicitis in the adult.
        BMC Surg. 2019; 19: 110
        • Varadhan K.K.
        • Neal K.R.
        • Lobo D.N.
        Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials.
        BMJ. 2012; 344: e2156
        • Sallinen V.
        • Akl E.A.
        • You J.J.
        • et al.
        Meta-analysis of antibiotics versus appendicectomy for non-perforated acute appendicitis.
        Br J Surg. 2016; 103: 656-667
        • Poprom N.
        • Numthavaj P.
        • Wilasrusmee C.
        • et al.
        The efficacy of antibiotic treatment versus surgical treatment of uncomplicated acute appendicitis: Systematic review and network meta-analysis of randomized controlled trial.
        Am J Surg. 2019; 218: 192-200
        • Huang L.
        • Yin Y.
        • Yang L.
        • et al.
        Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis.
        JAMA Pediatr. 2017; 171: 426-434
        • Park H.C.
        • Kim M.J.
        • Lee B.H.
        Antibiotic therapy for appendicitis in patients aged >/=80 years.
        Am J Med. 2014; 127: 562-564
        • Chehab M.
        • Ditillo M.
        • Khurrum M.
        • et al.
        Managing acute uncomplicated appendicitis in frail geriatric patients: a second hit may be too much.
        J Trauma Acute Care Surg. 2021; 90: 501-506
        • Ponsky T.A.
        • Huang Z.J.
        • Kittle K.
        • et al.
        Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children.
        JAMA. 2004; 292: 1977-1982
        • Barrett M.L.
        • Hines A.L.
        • Andrews R.M.
        Trends in rates of perforated appendix, 2001-2010. HCUP Statistical Briefs.
        Agency for Healthcare Research Quality, Rockville (MD)2006
        • Peacock S.
        • Patel S.
        Cultural Influences on Pain.
        Rev Pain. 2008; 1: 6-9
        • Brooks Carthon J.M.
        • Jarrin O.
        • Sloane D.
        • et al.
        Variations in postoperative complications according to race, ethnicity, and sex in older adults.
        J Am Geriatr Soc. 2013; 61: 1499-1507
        • Duraiswamy S.
        • Ignacio A.
        • Weinberg J.
        • et al.
        Comparative Accuracy of ICD-9 vs ICD-10 Codes for Acute Appendicitis.
        J Am Coll Surg. 2022; 234: 377-383