Project Summary

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project is putting a program in place to promote informed decision making when choosing between antibiotics or surgery to treat appendicitis.

Appendicitis occurs when the appendix, a small part of the intestine, gets inflamed. In the United States, most doctors treat appendicitis with surgery to remove the appendix. But studies show that for many patients, antibiotics are safe and work to treat appendicitis.

What is the goal of this implementation project?

A PCORI-funded research study compared treatment with antibiotics for 10 days versus surgery among patients with appendicitis. The study found that antibiotics worked just as well as surgery when measuring patients’ general health 30 days after treatment. Many patients avoided surgery for years after treatment. But patients who took antibiotics also had more hospital stays and emergency room, or ER, visits.

Based on results from this study and others, the American College of Surgeons updated its national guidelines to include antibiotics as an initial treatment for appendicitis. They also recommend that patients be involved in making informed decisions about their treatment.

This project is putting a program in place at hospitals to promote and support informed decision making between patients and their doctors about the use of antibiotics and surgery for appendicitis.

What will this project do?

The project team is working with 15 hospitals across the United States to put the program in place. The project is addressing barriers to discussing treatment options for appendicitis in the ER. For example, patients may not know that antibiotics are an option. Doctors may not be aware of the need for ongoing symptom management for patients on antibiotics. Also, most hospitals don’t have protocols or tools in place to guide informed decision making when choosing between antibiotics and surgery.

The program has three parts. In the first part, patients receive a decision aid. Decision aids help people choose between two or more treatment options based on what is most important to them. The decision aid is a video ( that can be viewed on a phone, tablet, or a computer; paper versions are also available.

In the second part, doctors, nurses, radiology staff, and other hospital support team members receive training. Topics include who may be eligible for antibiotics and the benefits and harms of each treatment.

In the third part, the program offers sites standard approaches to support treatment decisions, such as adding order sets or prompts to the hospital electronic health record, or EHR, system and patient instructions.

The project team is:

  • Working with sites to adapt the program to each site’s needs and workflows.
  • Training a team of clinicians and staff at each site to help put the program in place. The teams will then train local staff.
  • Developing online trainings for clinicians on how to use the decision aid with patients, work with patients to make decisions, and provide follow-up care.

Through the project, 500 clinicians and staff will receive training to support patients in making informed treatment decisions. The sites have committed to protecting time for clinicians and staff to complete this training.

What is the expected impact of this project?

The project will demonstrate what’s required to put the program in place. At least 2,500 patients are expected to receive the program. The project evaluation will confirm that the program is working as intended to help patients decide between antibiotics and surgery for appendicitis.

In partnership with the American College of Surgeons, the project is laying the foundation for future uptake of the program. In the future, more than 700 hospitals could use the program.

More about this implementation project:

Stakeholders Involved in This Project

  • American College of Surgeons
  • Surgical Infection Society
  • American College of Emergency Physicians
  • Association of Academic Chairs of Emergency Medicine
  • Patient advisors

Implementation Strategies

  • Promote shared decision making
  • Incorporate clinical decision supports into sites’ EHR systems, such as order sets and prompts
  • Adapt the shared decision making approach, including plans for decision aid integration, to work with sites’ existing resources and workflows
  • Create and support implementation teams at sites
  • Provide sites with tools to support implementation, such as training manuals and communication scripts
  • Provide educational materials to patients as part of a video-based decision aid
  • Develop and use online education modules for clinicians and allied health professionals
  • Train local implementation teams in how to use the decision aid with patients, work with patients to make decisions, and provide follow-up care
  • Use train-the-trainer strategies to train additional staff
  • Use a phased implementation approach
  • Offer continuing education credits
  • Partner with a national stakeholder organization to develop plans for further program scale-up

Evaluation Outcomes

To document implementation:

  • Proportion of patients admitted to the emergency department with acute appendicitis who receive the patient decision support tool
  • Clinician self-efficacy related to offering antibiotics and knowledge and attitudes about antibiotic treatment for appendicitis
  • Adherence to follow-up care protocols

To assess healthcare and health outcomes:

  • Rate of appendectomy within 30 days for patients who choose antibiotics
  • Change in appendectomy procedural volume
  • Use of antibiotics
  • Patient-reported decisional conflict and regret
  • General health status
  • Change in patient time spent in the emergency department
  • Time spent in health care
  • Days away from work and activities
  • Patient knowledge
  • Satisfaction

Project Information

David Flum, MD, MPH
Giana Davidson, MD, MPH
University of Washington
The TRIAD (Treatment Individualized Appendicitis Decision Making) Implementation Program

Key Dates

July 2022
September 2025

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Comparing Surgery versus Antibiotics to Treat Appendicitis -- The CODA Study


Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: January 20, 2023