Abstract
Background
The World Society for Emergency Surgery determined that for appendicitis managed with appendectomy, there is a paucity of evidence evaluating costs with respect to disease severity. The American Association for the Surgery of Trauma (AAST) disease severity grading system is valid and generalizable for appendicitis. We aimed to evaluate hospitalization costs incurred by patients with increasing disease severity as defined by the AAST. We hypothesized that increasing disease severity would be associated with greater cost.
Methods
Single-institution review of adults (≥ 18 years old) undergoing appendectomy for acute appendicitis during 2010–2016. Demographics, comorbidities, operative details, hospital stay, complications, and institutional cost data were collected. AAST grades were assigned by two independent reviewers based on operative findings. Total cost was ascertained from billing data and normalized to median grade I cost. Non-parametric linear regression was utilized to assess the association of several covariates and cost.
Results
Evaluated patients (n = 1187) had a median [interquartile range] age of 37 [26–55] and 45% (n = 542) were female. There were 747 (63%) patients with Grade I disease, 219 (19%) with Grade II, 126 (11%) with Grade III, 50 (4%) with Grade IV, and 45 (4%) with Grade V. The median normalized cost of hospitalization was 1 [0.9–1.2]. Increasing AAST grade was associated with increasing cost (ρ = 0.39; p < 0.0001). Length of stay exhibited the strongest association with cost (ρ = 0.5; p < 0.0001), followed by AAST grade (ρ = 0.39), Clavien–Dindo Index (ρ = 0.37; p < 0.0001), age-adjusted Charlson score (ρ = 0.31; p < 0.0001), and surgical wound classification (ρ = 0.3; p < 0.0001).
Conclusions
Increasing anatomic severity, as defined by AAST grade, is associated with increasing cost of hospitalization and clinical outcomes. The AAST grade compares favorably to other predictors of cost. Future analyses evaluating appendicitis reimbursement stand to benefit from utilization of the AAST grade.
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Availability of data and material
The datasets generated and/or analyzed during the current study are not publicly available in accordance with institutional policy on the reporting of billing data. Data are however available from the authors upon reasonable request and with the permission of Mayo Clinic.
Abbreviations
- AAST:
-
American Association for the Surgery of Trauma
- EGS:
-
Emergency general surgery
- IQR:
-
Interquartile range
- SD:
-
Standard deviation
- US:
-
United States
- WSES:
-
World Society for Emergency Surgery
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EJF designed the study, collected data, performed the analyses, and wrote the manuscript. MCH participated in the design of the study, collection and analysis of the data, and was a major contributor to the writing of the manuscript. JMA contributed to the design of the study and the writing of the manuscript. MDZ oversaw the design of the study, data collection, and writing of the manuscript. All authors read and approved the final manuscript.
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Eric J. Finnesgard, Matthew C. Hernandez, Johnathon M. Aho, and Martin D. Zielinski declare that they have no competing interests and financial ties to disclose.
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Institutional review board approval was obtained and the requirement for individual consent was waived prior to the start of the investigation.
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Finnesgard, E.J., Hernandez, M.C., Aho, J.M. et al. The American Association for the Surgery of Trauma Emergency General Surgery Anatomic Severity Scoring System as a predictor of cost in appendicitis. Surg Endosc 32, 4798–4804 (2018). https://doi.org/10.1007/s00464-018-6230-0
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DOI: https://doi.org/10.1007/s00464-018-6230-0