Giving Aria’s Family a Choice
It wasn't the pizza and the Christmas cookies she had eaten, but 9-year-old Aria had thought so when she began feeling sharp pain her abdomen. That evening, the pain became so severe that she couldn't walk.
Her parents carried her to the car and took her to the hospital.
An ultrasound revealed she had appendicitis. Because Aria's appendix swelled but had not burst, doctors at Nationwide Children's offered an alternative to removing her appendix in surgery: she could participate in an ongoing study using antibiotics to treat mild appendicitis for patients who have experienced abdominal pain 48 hours or less. After receiving the antibiotics, if Aria's appendix remained infected, her family could then have her appendix removed through surgery.
“I felt like it was a risk-free option for us,” says Aria's mother, Aubrey. “I thought: Let's try this and of course if it doesn’t work, we'll be right here to do what we need to do.”
With surgery, Aria would have to be hospitalized one to two days, then restricted from strenuous exercise for about a month. She would have to undergo anesthesia, and as with any surgery, there is the risk of complications.
A couple of other considerations influenced the family's choice to try antibiotics: In four days, Aria was to perform the lead role in a play, and weeks later, the family planned to travel to Disney World.
Aria received intravenous antibiotics in the hospital one day. When she returned home, she began taking an oral antibiotic daily for nine more days. Within a couple of days after of leaving the hospital, she danced and sang on stage for her school's Christmas play, and the family flew to Disney World later that month.
That was four years ago. Today, Aria has not had a recurrence of appendicitis and she still has her appendix.
Shared Decision Making and a New Paradigm for Appendicitis Care
At Nationwide Children's, we believe that parents, patients and physicians should make treatment decisions together whenever possible. We also believe in challenging the status quo and looking for better solutions.
A landmark study led by Peter C. Minneci, MD, and Katherine J. Deans, MD, principal investigators in the Center for Innovation in Pediatric Practice and co-directors of the Center for Surgical Outcomes Research, highlights our commitment to both.
First, Drs. Minneci and Deans developed a study to challenge the conventional practice of always treating appendicitis with antibiotics followed by surgery.
“We noticed that after being on antibiotics overnight, many children with acute appendicitis were feeling better by the time they could be taken in to surgery,” explains Dr. Minneci. “Parents began to question whether or not these kids really needed surgery, so we decided to find the answer.”
The answer they found is compelling. In the study, of the families who chose to be treated with antibiotics alone, three out of four patients managed nonoperatively did not have appendicitis again and have not undergone surgery one year after discharge.
Second, the study involved an unprecedented level of shared decision making.
For shared decision making, both the clinician and family must be comfortable with the level of certainty, and the process varies with each family, explains Dr. Minneci. In Aria's case, the family saw the benefits to treating her appendicitis with antibiotics, and they were confident in knowing that surgery was still an option if needed later on.
Drs. Minneci and Deans are now expanding this research. They have an ongoing study investigating shared decision making in pediatric appendicitis that is supported by a $1.6 million Patient-Centered Outcomes Research Institute (PCORI) award. In addition, they are beginning a multi-center study upon receiving a new $2.9 million award from PCORI. The expanded study will measure the amount of time missed from everyday activities, quality of life after treatment, satisfaction with care, burden on the caregiver and the success of nonoperative management at one year.
As for Aria's family, they are happy to have had a choice in her care.
“I think it's an amazing advance,” says Aubrey. “She didn’t have to go under anesthesia. They didn’t have to cut her. We just didn’t have to worry about that.”