Background: Nonoperative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared with appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of nonoperative vs operative management for pediatric uncomplicated acute appendicitis.

Methods: A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional nonrandomized controlled trial investigating NOM vs surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System. Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and 1-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year. Primary outcome measures included total and incremental mean costs, QALY, disability-adjusted life year, and incremental cost-effectiveness ratios.

Results: Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791 per patient and yielded an average of 0.884 QALYs, whereas NOM cost an average of $8,044 per patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating uses.

Conclusions: NOM is cost-effective compared with laparoscopic appendectomy for pediatric uncomplicated appendicitis for 1 year.