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for the Midwest Pediatric Surgery Consortium IMPORTANCE Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery.OBJECTIVE To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. DESIGN, SETTING, AND PARTICIPANTS Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. INTERVENTIONS Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (Յ12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). MAIN OUTCOMES AND MEASURESThe 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, Ն70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. RESULTS Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, −4.3 days (99% CI, −6.17 to −2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference.CONCLUSION AND RELEVANCE Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not stat...

IMPORTANCE Appendicitis may be missed during initial emergency department (ED) presentation.OBJECTIVE To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis. DESIGN, SETTING, AND PARTICIPANTSIn this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged Ն18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis. MAIN OUTCOMES AND MEASURESPotentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis. RESULTSOf 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, ...