Belief in antibiotics for appendicitis linked to fewer surgeries


Patients who were more confident that antibiotics could treat appendicitis seemed less likely to undergo surgery for this condition than those who expressed more reservations about this approach, according to further analysis of data from a landmark trial on this issue.

David R. Flum, MD, MPH, of the University of Washington, and his colleagues looked at data from the comparison of antibiotic drug outcomes and Appendectomy (CODA) to see how patients’ beliefs about treatment options may have affected their outcomes.

In 2020, first results from the CODA trial by Flum and colleagues showed that antibiotic therapy was not inferior to appendectomy, as assessed by a standard measure of health status. In the antibiotic group, almost 3 in 10 participants – 29% – had had an appendectomy at 90 days, meaning the majority had at least temporarily avoided this surgery.

In an article published in JAMA Surgery, Flum and colleagues reported on their analysis of a survey of CODA participants’ views on antibiotics and their outcomes. Of the 776 study participants assigned to antibiotic treatment in CODA, 425 patients who were unaware of their treatment assignment at the time of the baseline survey were included in this analysis.

After 48 hours, the cumulative incidence of appendectomies in the group with the greatest belief in antibiotics was 5%, while it was 9% among those with an intermediate belief in this approach and 16% among those who were most uncertain about the value of antibiotics.

These trends continued after 30 days.

The cumulative incidence of appendectomy then in the group with the greatest belief in antibiotics was 14%, while it was 19% in those with an intermediate belief in this approach and 26% in those who were the more uncertain.

Before completing the survey, study participants received a standardized set of materials, including a brochure or video, that explained the results and risks seen in previous studies of treating appendicitis with antibiotics or an appendectomy.

Study participants then indicated in the survey how effective they thought antibiotics might be in treating appendicitis. They chose a number on a scale of 0 to 10, with 0 being a failure, 5 being in doubt, and 10 being a completely successful appendicitis treatment. Flum and his colleagues categorized the participants into belief groups as follows: failed/uncertain (0-5), intermediate (6-9), or completely successful (10).

“The study is about how well the patient thinks the antibiotics are going to work for them and how much does that affect whether or not the antibiotics can work without causing an appendectomy,” Flum said. . Medscape Medical News. “And it turns out it’s quite significant.”

But in a guest comment on the study, John C. Alverdy, MD, of the University of Chicago, cautioned against claims of a strong link between belief in antibiotics and outcomes. Alverdy calls this secondary analysis of the CODA study, which focused on belief, “well done,” but disputes it as a basis for drawing conclusions.

Alverdy notes that Flum and colleagues recognized that “a purely descriptive study such as this cannot clarify whether an observed association implies causation.” Instead, “the hard work necessary to support the mechanistic plausibility of this claim, as they acknowledge, remains to be produced,” writes Alverdy.

“Unless we insist on complementary measures at the biological level and strong mechanistic evidence to support our clinical observations, it seems that we are no better than the homeopathic claims that state ‘if you think you are getting better, then you’re better,” writes Alverdy. .

“Armed with good information”

Other researchers saw Flum’s new paper as further evidence of the need for shared decision-making.

Harlan Krumholz, MD, SM, Director of Center for Research and Outcome Evaluation (CORE) at Yale New Haven Hospital, called the new CODA analysis “a fascinating study that shows that what people think about a treatment’s effectiveness can affect the success of that treatment.”

This work reinforces the need to listen to patient preferences and recognize that their beliefs can influence their outcomes, wrote Krumholz, who is also Harold H. Hines, Jr, professor of medicine at Yale School of Medicine, in an e -email to Medscape.

“The results strengthen the case for shared decision-making because in situations where there is no best approach, the best strategy may be the one you believe in,” Krumholz wrote. “There is a lot more to learn, but these findings are intriguing and will certainly prompt more research into potential mechanisms.”

Erica Spatz, MD, MHS, director of the preventative cardiovascular health program at Yale School of Medicine, told Medscape that the study results reflect what physicians see in practice. Like Krumholtz, Spatz has studied ways doctors can help patients better understand the risks and benefits of treatments.

“As physicians, we know from experience: Patients who are very clear that they do not want a particular therapy or surgery, and yet are convinced to follow the treatment, are usually those who suffer a devastating outcome,” Spatz wrote to Medscape. . “Conversely, patients who believe in a given treatment tend to do well.

“Armed with the right information, patients can choose what’s best for them,” she added. “This study supports the imperative of involving patients in shared decision-making; this may not only lead to a better experience and less decisional regret, but may also improve outcomes.”

The CODA trial resulted in the creation of a website,, which offers videos in multiple languages ​​that explain in simple terms the benefits and potential drawbacks of options for appendicitis. The development of was supported by the National Institute of Diabetes, Digestive and Kidney Diseases and the Patient-Centered Outcomes Research Institute (PCORI).

PCORI is an organization created by the Affordable Care Act of 2010 to fund research aimed at improving the practice of medicine, including studies assessing the merits of different options available to patients. He also funded the CODA study and is now supporting the Individualized Decision Making for the Treatment of Appendicitis (TRIAD) program, which aims to further spread the message about antibiotics as an alternative to surgery.

The CODA study has already marked medicine. National guidelines for appendicitis care by the American College of Surgeons now say “antibiotics are an accepted first-line treatment,” PCORI said. But there are still obstacles to their use, such as the lack of information for patients and doctors on the use of antibiotics to treat appendicitis. TRIAD aims to solve these problems through continuous training. It is planned to take place in 15 hospitals, with the aim of involving more than 2,500 patients.

Flum told Medscape that among the challenges of treating people with appendicitis are longstanding misconceptions about the disease. There are still lingering effects from the old “ticking time bomb” portrayal of appendicitis. Over the years, many popular medical television series have portrayed the disease as a crisis.

Thus, physicians may need to help their patients understand the evidence from studies of antibiotics as an effective treatment.

“If we did that, we would have fewer people ending up with an appendectomy after starting antibiotics,” Flum said. “That’s the take home message.”

The study was supported by grants from the Patient-Centered Outcomes Research Institute, the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, the Agency for Healthcare Research and Quality, and the University of Washington. The authors reported financial relationships with various companies and organizations, which are listed in the original article.

JAMA Surg. Published online October 5, 2022. Full Text

Kerry Dooley Young is a freelance journalist based in Miami Beach. Previously, she covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the US Food and Drug Administration for Bloomberg. Follow her on Twitter @kdooleyyoung.

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