Needless appendix surgery cited
Surgeons needlessly remove the appendixes of thousands of children who don't have appendicitis -- a problem most acute at hospitals that perform the operation infrequently -- according to a new study that raises difficult questions about improving pediatric care.
Overall, at least 8.4 percent of appendectomies -- one of the most common pediatric surgical procedures -- are performed on children who turn out to have a normal appendix, researchers at Children's Hospital in Boston found. That's largely because appendicitis can be difficult to diagnose, since the sharp abdominal pain and nausea of an intestinal virus, gynecological problems in girls, and other conditions produce similar symptoms, and no test for the disease is 100 percent accurate.
The risk of misdiagnosis is much lower -- 4.8 percent -- at hospitals that do many pediatric appendectomies, perhaps because doctors are more skilled at interpreting children's symptoms and more likely to confirm the diagnosis with a CT scan or ultrasound. But appendectomies are so common that the Children's Hospital researchers say it would be impractical to perform most appendectomies in a few major medical centers, a practice common with complex surgeries like coronary bypass operations.
"An appendectomy is not something you should have to go to a big-city medical center for," said Dr. Steven Fishman, a pediatric surgeon at Children's who led the appendectomy research. "Even if we could do that, we would be inundated" at hospitals like Children's, which already does 372 pediatric appendectomies a year, the most in New England.
Surgeons long have accepted a high error rate in their decisions to remove the appendix, a small tube-shaped organ with no clear function, because failing to remove an appendix that later ruptures is considered far more dangerous than removing a healthy one.
Surgeons normally tell a patient that there is a chance he or she doesn't have appendicitis before the procedure, which can involve either a single inch-long incision, or, if done laparoscopically, three smaller cuts. Only when the organ is extracted can the surgeon determine whether the appendix is a "red worm" (infected) or a "white worm" (no appendicitis). Fishman recalls that when he went to medical school in the mid-1980s, he was taught that a surgeon should expect "white worms" 15 percent of the time.
But recent research has questioned that tolerance of error, showing that unnecessary appendectomies are both risky and expensive. A University of Washington study found that, among adults, unnecessary appendectomies typically resulted in a six-day hospital stay, while one patient in 40 develops serious complications and 1.5 percent of the patients die.
Dr. David R. Flum, an assistant professor of surgery at the University of Washington in Seattle who led the 2002 study, estimates that Americans paid $741.5 million for unnecessary appendectomies on adults in 1997, the year on which his study focused.
The Children's Hospital study, which appears in today's edition of the journal Pediatrics, is part of a growing body of research that suggests patients get better results from doctors who have more experience with a given procedure. But, where most of the research has focused on adults undergoing technically demanding surgeries, the Children's researchers looked at a common surgery performed at thousands of small community hospitals.
The Children's researchers found that the highest-volume hospitals were strikingly better at avoiding unnecessary appendectomies, based on 1997 hospital data from 22 states. The 90 percent of hospitals that perform fewer than one appendectomy a week on children were 50 percent more likely to wrongly diagnose appendicitis than the handful of hospitals that do at least three appendectomies weekly.
Most at risk for misdiagnosis were children under 10, who may have difficulty explaining their symptoms, and adolescent girls. Girls age 15 to 18 were 2.3 times more likely than boys of the same age to have an unnecessary appendectomy, the researchers found, perhaps because gynecological problems such as ectopic pregnancy can produce symptoms that mimic appendicitis.
Malpractice attorneys say the study's findings are consistent with their own experience: They get lots of complaints from people who've had their appendix removed unnecessarily. But few lawsuits are ever filed, because "at the end of the day, these cases are so expensive and complex and time-consuming to bring that [lawsuits are] limited to catastrophic cases," said Andrew C. Meyer Jr., a malpractice lawyer in Boston.
But officials at the Leapfrog Group, an error-reduction organization founded by major corporations, said the high rate of needless appendectomies is a symptom of a catastrophe of sorts: the enormous waste built into the health care system. "There are clear ramifications for our inefficient use of health care resources that should concern us all when we have so many uninsured people" and other unmet medical needs, said Suzanne Delbanco, Leapfrog's executive director.
Until now, efforts to reduce the appendectomy error rate have had mixed results. For example, high-tech CT scans and ultrasound allow surgeons to get a better look at the appendix to see if it is inflamed -- technologies that have helped some surgeons reduce the error rate to less than 4 percent. But Washington's Flum points out that some hospitals have a CT scan error rate closer to 15 percent, which is no better than a doctor's abdominal exam.
With pediatric care, the issues may be less about technology than about understanding children, said Douglas Smink, lead author of the Children's study who is now a surgery resident at Brigham and Women's Hospital.
"Our thought is we should study the high-volume centers and see what it is that they do better, so other hospitals can learn from their experience," said Smink.
Scott Allen can be reached at allen@globe.com. 
