Cost-effectiveness and superior clinical outcomes of appendectomy are evidenced within 6 months of the index admission for uncomplicated appendicitis compared to nonoperative management.

Abstract

Nonoperative management with antibiotics is an alternative to appendectomy for patients with uncomplicated appendicitis. Nonoperative management may reduce initial costs and recovery time, but concerns about recurrence and delayed surgery raise questions about its long-term value. We compared clinical outcomes and determined the cost-effectiveness of appendectomy and nonoperative management using a national data set. We selected patients with uncomplicated appendicitis from the Nationwide Readmissions Database (2016-2021). Patients were stratified by appendectomy or nonoperative management at index admission. Outcomes included 6-month readmissions, in-hospital mortality, discharge disposition, and length of stay. Costs included index admission, readmissions, and total expenditures. Cost-effectiveness was assessed as the incremental cost-effectiveness ratio, defined as incremental cost per readmission avoided. Probabilistic sensitivity analysis and cost-effectiveness acceptability curves tested robustness. Among 83,533 patients, 68,908 (82.5%) had appendectomy and 14,625 (17.5%) nonoperative management. Readmissions were higher in nonoperative management (6.3% vs 0.1%). Nonoperative management patients had longer index stays (median 4 vs 2 days), less routine discharge (85.2% vs 95.0%), and greater need for postdischarge care. In-hospital mortality was rare but higher with nonoperative management (0.2% vs 0.1%). Total 6-month costs were modestly lower with nonoperative management ($11,558 vs $12,648), but appendectomy nearly eliminated readmissions. The incremental cost-effectiveness ratio was $17,615 per readmission avoided, with robust sensitivity analyses. Appendectomy provided definitive cure with near-zero readmissions and an acceptable incremental cost. Nonoperative management offered initial savings, but higher recurrence limited its value. Appendectomy was clinically superior and cost-effective within 6 months, whereas nonoperative management may be reasonable only in select patients or settings.