439 - Warfarin Self-Care, Antibiotics in Appendicitis, Comparative Suffering

From the Literature

1) Warfarin Self-Care – Do patients really need to see us in the office?

The technology to enable patient self-testing and/or patient self-management of warfarin’s effect on their INR has been around for a long time. A 2016 Cochrane systematic review established that patient self-testing (PST - testing, reporting the result, and waiting for a change in plan from the healthcare team, also called self-monitoring) and patient self-management (PSM - testing and applying a previously prescribed adjustment algorithm) were both effective at reducing venous thromboembolic events compared with office-based testing, and self-management actually reduced mortality. However, the quality of the studies was considered low overall.

The authors of a recent systematic review and network meta-analysis on this same topic evaluated the evidence for several different strategies against each other, categorizing the studies by three intervention characteristics: 1) PST vs. PSM, 2) intensity (< once a week (low), > once a week (high), and “flexible”), and 3) provider (healthcare provider, patient, or “e-health” (computer algorithm)).

The review was well-done (search, inclusion criteria, critical appraisal of the studies and heterogeneity assessment). The review found 16 trials of 5,895 patients. The overall quality of the trials was low or unclear.

PSM strategies that were high intensity and were managed by the patient themselves or by a computer had the highest time in therapeutic range (TTR, 13 trials were included in this analysis). Lower-quality evidence from 7 trials showed patient self-management to be superior to other strategies for reducing risk of VTE, but a flexible schedule worked better than a high-intensity schedule. Major bleeding was evaluated in 8 trials, and no significant difference in strategies tested was observed (three different PSM strategies and one patient self-testing (PST)). Five trials examined all-cause mortality and found an advantage to PSM with high-intensity testing working best. The authors note that the evidence found conveyed only a low level of certainty overall, but that PSM with more intense testing seemed to be the best strategy.

John’s Comments:

While not conclusive, this evidence gives me hope that we can soon stop dragging our patients into the office multiple times a month for this testing. Insurance coverage of the required monitors will be important for implementation of a PSM strategy, but if all-cause mortality is truly reduced in subsequent trials, then that provides a solid argument for coverage.

References:

·         Dhippayom T, Boonpattharatthiti K, Thammathuros T, Dilokthornsakul P, Sakunrag I, Devine B. Clinical Outcomes of Different Warfarin Self-Care Strategies: A Systematic Review and Network Meta-Analysis. Thromb Haemost. Published online October 25, 2021:a-1677-9608. Link

·         Heneghan CJ, Garcia-Alamino JM, Spencer EA, et al. Self-monitoring and self-management of oral anticoagulation. Cochrane Heart Group, ed. Cochrane Database of Systematic Reviews. 2016;2021(4). Link

From the Literature

2)  Antibiotics Instead of Surgery for Acute Appendicitis?

Although there have been several randomized trials of antibiotics for appendicitis in adults, exclusion of important subgroups (in particular, patients with an appendicolith), small sample sizes, and questions about applicability to the general population have limited the use of this treatment.  However, with the COVID-19 pandemic, health systems and professional societies such as the American College of Surgeons (ACS) have suggested reconsideration of many aspects of care delivery, including the role of antibiotics in the treatment of appendicitis.

The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial was initiated to compare antibiotic therapy with appendectomy in adults with appendicitis, including those with an appendicolith.  The trial design was based on recognition that not all patients prioritize the multiple outcomes related to appendicitis care in the same way.  Data from the trial of 1,552 patients who were randomized equally was published in 2020 and found that antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure.  In the antibiotics group, 29% had undergone appendectomy by 90 days.  

Based on this data, the ACS released updated guidelines in December 2020 indicating; "There is high-quality evidence that most patients with appendicitis can be managed with antibiotics instead of appendectomy (69 percent overall avoid appendectomy by 90 days, 75 percent of those without appendicolith and 59 percent of those with appendicolith).  Based on the surgeon's judgment, patient preferences, and local resources (e.g., hospital staff, bed and PPE supply availability), antibiotics are an acceptable first-line treatment, with appendectomy offered for those with worsening or recurrent symptoms … Antibiotics were associated with a higher risk of complications in those with an appendicolith." 

Follow-up longitudinal data from the CODA Study published in December 2021 for the antibiotics group showed the percentage of patients who underwent subsequent appendectomy was 40% at 1 year and 46% at 2 years; the percentages were 49% at 3 and 4 years, according to limited longer-term follow-up data. 

An additional analysis of the CODA data was published in January 2022.  This analysis found that presence of an appendicolith was associated with a nearly 2-fold increased risk of undergoing appendectomy within 30 days of initiating antibiotics. Clinical characteristics often used to describe severity of appendicitis (eg. fever, leukocytosis, perforation, abscess) were not associated with odds of 30-day appendectomy.  The authors concluded that this information may help guide more individualized decision-making for people with appendicitis.

Mark’s Comments:

I reached out to Dan Tershak, MD, the Chief for the Section of General Surgery at Carilion Clinic, for his interpretation of this trend.  Here are some of his comments:

“The overall consensus of the group is that patients with appendicitis and an appendicolith should still have surgery because of the higher failure rate with non-operative management.  If there's no fecalith and there's minimal inflammation around the appendix, it's not unreasonable to try antibiotics.  I'd say approximately 15% elect antibiotics only.”  

The CODA team has sought to make it easy for patients to consider what its findings and other research on appendicitis mean for them. They created an online decision-making tool (AppyOrNot - Tool ), which has videos in English and Spanish explaining patients' options in simple terms. The website also asks questions about personal preferences, priorities, and resources to help them choose the best option for them. 

References:

·         AppyOrNot Appendicitis decision support tool (AppyOrNot - Tool )

·         CODA Collaborative.  Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis.  JAMA Surgery. Published online January 12, 2022.  Link

·         CODA Collaborative. Antibiotics versus Appendectomy for Acute Appendicitis—Longer Term Outcomes. Research letter. N Engl J Med. Posted online October 25, 2021. Link

·         American College of Surgeons. COVID-19 Guidelines for Triage of Emergency General Surgery Patients.  Posted online December 8, 2020.  Link

·         CODA Collaborative. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis (CODA). N Engl J Med. 12 Nov 2020;383(20):1907-1919. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Comparative Suffering: Are You a Self-Suffer Stuffer? 

“Saying someone shouldn’t feel sad because someone else may have it worse is like saying someone can't be happy because someone else may have it better.”                                                                                                                                     Unknown 
 

If you’re like many who work in healthcare, even in the midst of our many recent challenges, you’ve likely found yourself at times thinking, “Who am I to complain when there are so many who have it so much worse?”  There may even be a voice or voices from your past joining in that chorus.  The psychological literature has coined this common mindset as “comparative suffering.” 

Comparative suffering is when one feels the need to contrast one person’s suffering with the suffering of others.  Those of us in healthcare have generally been socialized to believe that our struggles and/or suffering are not legitimate or can wait because it is our job to care for the many others in distress.  We often even take it one step further and find ourselves participating in a process termed “competitive suffering,” in which we assign all suffering, both ours and that of others, a “legitimacy score” along some sort of self-created legitimacy scale.  And those of us in healthcare usually judge our own by much more stringent criteria – a phenomenon commonly known as minimizing ….       

Recently I found myself doing this very thing when I experienced some “twinges” similar to those of a serious and quite painful back injury I had a year ago for which I was unable to walk without assistance for a period of time.  While the symptoms in this case were fortunately transient (and likely unrelated), I found myself “joking” with a colleague “it’s just a little PTSD” (legitimacy scale) when the fact is there isn’t a day that goes by when I don’t think about that injury, usually when lifting something, and in the process, experience a “twinge” of both gratitude for my healing and fear of recurrence.  

Some might conclude that comparative suffering is a healthy pattern of thinking.  Afterall, isn’t “counting your blessings” encouraged throughout the well-being literature (and by me)?  And no one wants to be labeled a “whiner.”  But being grateful is not the same as pretending that you don’t have struggles, and one can express their struggles in constructive ways, such as sharing them with a trusted friend.  In fact, denying or suppressing your suffering rather than addressing it can actually cause greater suffering because the distress doesn’t magically go away, and we then also feel ALONE with it.  The consequence is a diminished ability to be compassionate, both with others and oneself.    

Remember, we can live our most authentic life by both keeping our struggles in perspective AND allowing ourselves and others to feel and express them in healthy ways.  Afterall, no one goes through life without them, so why not practice validating what you feel.   Perhaps you can even take it one step further, letting your PeerRxMed partner serve as your “becoming more human” practice partner as you officially announce your retirement from competitive suffering.  I’d welcome the opportunity to attend your “retirement party” … and would love for you to come to mine!

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org