PEDIATRICS Vol. 115 No. 4 April 2005, pp. 920-925 (doi:10.1542/peds.2004-1363)
Effects of Race, Insurance Status, and Hospital Volume on Perforated Appendicitis in Children
,
,||,¶
* Department of Surgery
Harvard Pediatric Health Services Research Fellowship
¶ Division of General Pediatrics, Children's Hospital Boston, Boston, Massachusetts
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
|| Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume.
Methods. We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis.
Results. Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10–1.39) and Hispanic (OR: 1.19; 95% CI: 1.10–1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22–1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis.
Conclusions. Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.
Key Words: appendicitis • perforation • race • outcome
Abbreviations: KID, Kids' Inpatient Database • LOS, length of stay • OR, odds ratio • CI, confidence interval
Appendicitis is one of the most common surgical diseases of childhood, affecting 70000 American children annually.1 In one third of children with appendicitis, the appendix perforates before surgery,2 resulting in increased morbidity and longer hospital stays.3 A number of factors have been associated with an increased likelihood of perforated appendicitis, including young age,2,4 delay in seeking medical attention,5,6 and delay in treatment once the patient reaches medical care.7,8 In addition, both children2,9 and adults10 with Medicaid insurance have been shown to have higher rates of appendiceal perforation.
Minority race has been implicated as a risk factor for disparities in treatment and outcome for a number of conditions, including myocardial infarction,11 childhood asthma,12 and renal transplantation.13,14 Causes of these disparities include inadequate access resulting in delayed presentation to medical care,15,16 differential physician practices based on patient race,17,18 and patient preference of various treatment options.19 Any or all of these factors could influence perforation in appendicitis. The relationship between race and perforated appendicitis, however, remains largely uninvestigated. In the pediatric population, neither study of the association of Medicaid insurance and perforation adjusted for race.2,9 Although a recent study of perforated appendicitis in children did focus on race, its analysis was limited to only 2 US states.20 It is critical to discern whether perforated appendicitis is associated with insurance status, minority race, or both, as interventions to improve care for at-risk populations would be markedly different.
In addition to patient characteristics such as race and insurance status, hospital volume may be associated with perforation. Studies suggest that high-volume hospitals have improved patient outcomes for a number of surgical procedures.21,22 We recently reported that high hospital volume of pediatric appendectomies is associated with lower rates of misdiagnosis of appendicitis in children.23 Whether high hospital volume of cases of appendicitis is associated with lower rates of appendiceal perforation is unknown.
In this study, we used a national data set to test the hypothesis that in children with acute appendicitis, perforation is more common in patients of minority race, while controlling for insurance status. In addition, we sought to determine whether high hospital volume of appendicitis cases is associated with lower rates of perforation.
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METHODS |
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Using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID),24 we performed a retrospective analysis of perforated appendicitis in children. The KID is a nationally representative database of pediatric inpatient admissions for children aged 0 to 18 to 2521 community hospitals in 22 states in 1997. The KID contains a random sample of 80% of all nonbirth discharges from each hospital in the database. For each patient, up to 15 diagnosis and 15 procedure International Classification of Diseases, 9th Revision codes are available. In addition, the KID contains both patient demographics and hospital characteristics.
We included in our analysis all patients in the KID with a principal discharge diagnosis code of acute appendicitis (International Classification of Diseases, 9th Revision codes 540.0, 540.1, and 540.9).25 Perforation, the primary outcome in this analysis, was defined by a diagnosis code for acute appendicitis with generalized peritonitis (540.0) or acute appendicitis with peritoneal abscess (540.1), as previously described.2,10 All other patients with appendicitis were considered to be nonperforated. Two patients with missing gender were excluded from the analysis, as were 298 patients who were transferred to the treating hospital from another hospital. Patients who received a diagnosis of appendicitis at one hospital and subsequently transferred to another hospital were included in the analysis and were considered to have been treated at the initial hospital. To help confirm that the definitions of perforated and nonperforated appendicitis represented different groups of patients, we calculated length of stay (LOS) and total charges and compared children with perforated and nonperforated appendicitis using Student’s t test.
Race was categorized as black, Hispanic, Asian, other (including Native American), unreported, and white. White patients served as the reference group in multivariate models. Our analysis also included patient age, gender, insurance status, and median income by patient ZIP code. Variables were categorized as shown in Table 1.
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Hospital characteristics included teaching status, urban or rural location, and hospital volume, defined as the number of cases of pediatric appendicitis treated in 1997. Because the KID provides an 80% sample of each hospital's discharges, we estimated the annual volume of cases by multiplying the KID total by 1.25. Before beginning the analysis, we stratified hospitals into 5 volume groups: lowest (<1 case per month), low (at least 1 case per month but <1 per week), medium (1–2 cases per week), high (2–3 cases per week), and highest (3 or more cases per week), in accordance with a previous study.23 Highest volume hospitals formed the reference group. Although designation as a children's hospital is available in the KID, we did not include this variable in our analysis because of its high correlation with hospital volume.
We used logistic regression to calculate the univariate and multivariate odds of perforation, using generalized estimating equations to control for clustering within hospitals.26,27 All independent variables were included in the final multivariate analysis. We also considered interaction terms, which allow the magnitude of effect of 1 predictor on an outcome to vary with respect to a second predictor. For example, age might be an independent predictor in boys but not in girls. We tested interaction between age and gender, as well as race and volume and race and insurance. Only interaction terms that were significant at the .05 level were included in the final model.
For independent variables with unreported data, a separate category for missing values was included in the analysis. In our primary analysis, patients were not excluded because of unreported race, insurance, or income data. Because race data were unavailable for 21% of patients, we repeated our final multivariate model while excluding patients with unreported race. All statistical analyses were performed using SAS Version 8.2 (Cary, NC). The institutional review boards of Children's Hospital Boston and Harvard Pilgrim Health Care approved the protocol.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Our sample included 33184 patients with acute appendicitis, 10777 (32.5%) of which were perforated (Table 1). The mean age was 11.9 years; 60.7% of patients were male. Fifty-one percent of patients were classified as white, 5% as black, 18% as Hispanic, and 2% as Asian; race was not reported for 21%. Nearly one quarter (23%) had Medicaid insurance.
LOS and total charges differed between children with perforated and nonperforated appendicitis. The mean LOS of patients with perforated appendicitis was >3 days longer than the mean LOS of patients with nonperforated appendicitis (5.8 and 2.2 days; P < .001). In addition, mean total hospital charges in the perforated group were twice the charges in the nonperforated group ($14122 and $6846; P < .001).
In the univariate analysis, perforation differed significantly by insurance status (Table 1). Perforated appendicitis was more common in patients who were insured by Medicaid (39.9%) and uninsured patients (34.6%) compared with privately insured patients (29.7%). In addition, patients of minority race had a higher incidence of perforation. Compared with white patients (29.7%), black patients (36.8%) were more likely to have perforated appendicitis, as were Hispanic patients (39.5%), Asian patients (34.6%), and patients of other minority races (35.4%).
Annual hospital volume of cases of acute appendicitis ranged from 1 to 238. In the univariate analysis, patients who were treated at lowest (30.3%), low (31.0%), and medium (34.1%) volume hospitals were less likely to have perforated appendicitis than those who were treated at highest volume hospitals (42.3%; P < .001). Patients who were treated at teaching hospitals had an increased likelihood of perforation (34.9% vs 31.1%; P < .001).
The multivariate model showed a significant relationship between insurance status and perforated appendicitis (Table 2). Patients who were insured by Medicaid (odds ratio [OR]: 1.30; 95% confidence interval [CI]: 1.22–1.39) and uninsured patients (OR: 1.23; 95% CI: 1.12–1.35) had a increased likelihood of perforation compared with privately insured patients. The relationship between minority race and perforation persisted in the multivariate analysis, even while controlling for insurance status. Compared with white patients, black patients had increased odds of perforation (OR: 1.24; 95% CI: 1.10–1.39), as did Hispanic patients (OR: 1.19; 95% CI: 1.10–1.29). Perforation in patients with unreported race did not differ significantly from white patients. The race–volume and race–insurance interaction terms were not statistically significant.
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Age and gender were associated with perforation, and their interaction term was significant. Compared with boys aged 15 to 18, boys in all younger age groups had increased odds of perforation, with perforation most likely in boys aged 0 to 4 (OR: 4.16; 95% CI: 3.57–4.84). Except for girls aged 15 to 18, girls showed a similar relationship: younger girls had an increased likelihood of perforation, with perforation being most common in the youngest girls (OR: 5.75; 95% CI: 4.81–6.88).
Although in the univariate analysis, hospital volume of cases of appendicitis was associated with perforation, this relationship was not present in the multivariate model (P > .05 for each volume level compared with highest volume). In addition, teaching and urban hospitals were not associated with increased odds of perforation. Repeating the multivariate analysis limited to the subset of patients with reported race yielded nearly identical results (Table 2).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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In this analysis of a national pediatric discharge database, we observed that the likelihood of perforated appendicitis differed by patient race. In children with acute appendicitis, perforation was more common in both black and Hispanic children compared with white children. This relationship persisted while controlling for other factors that previously have been shown to be associated with perforation, including age2,4 and insurance status.2,9,10 Our findings confirm numerous reports of differences by patient race in treatment and outcome for other conditions and procedures.11–15 Hospital volume of cases of appendicitis, a frequent correlate of higher quality care,21–23 was not associated with the likelihood of perforation.
To our knowledge, ours is the first study to use nationally representative data to focus on the relationship between race and perforation in acute appendicitis in children. Two studies that showed that children with Medicaid insurance were more likely than privately insured children to have perforated appendicitis were performed in regional populations and did not control for race.2,9 Another study of the effect of insurance on perforated appendicitis, performed in a nationally representative adult population, did suggest an increased risk for perforation in black patients.10 Race was not the focus of that study, however, and the study sample excluded children who were younger than 18 years. A recently published study did show that patients of minority race in New York and California were more likely to experience appendiceal perforation.20 Our study confirms those results in a large, nationally representative study population.
Insurance status has been implicated as a risk factor for perforated appendicitis in children2,9 and adults.10 In children with acute appendicitis in Washington state, both Medicaid-insured (30% increase) and uninsured patients (10% increase) were more likely to have appendiceal perforation than patients with commercial insurance.2 Similar results were found in adults, with Medicaid-insured and uninsured patients having 46% and 49% increased likelihood of perforated appendicitis, respectively.10 Our findings of the relationship between insurance status and perforation are consistent with and similar in magnitude to these studies.
This study also provides valuable information about the relative roles of patient and hospital factors in perforated appendicitis. Many studies conclude that high-volume hospitals21,22 and teaching hospitals28 provide the highest quality care. A recent study showed that for pediatric appendectomy, misdiagnosis of appendicitis was less common at highest volume hospitals.23 In our unadjusted analysis, perforation was unexpectedly more common at highest volume hospitals. This effect did not persist in our multivariate model after controlling for race, insurance status, and age, suggesting that these demographic factors are more important than hospital volume in determining perforation. Unlike outcomes for other conditions, the quality of care delivered once a child with acute appendicitis presents to a hospital seems to have little effect on the likelihood of perforation.
Traditionally, a hospital or surgeon's misdiagnosis and perforation rates were considered to be inversely related.29 Surgical dictum taught that to reduce misdiagnosis, a surgeon needed to delay operating until the diagnosis was certain, at which time more patients progress to perforation; to reduce perforation, a surgeon needed to operate quickly, risking that more patients would receive an incorrect diagnosis of appendicitis. Our findings, in combination with a recent study of misdiagnosis of appendicitis in children using data from the KID,23 bring this commonly held belief into question. These studies suggest that perforation and misdiagnosis are not inversely related. Increased use of high-volume hospitals might reduce the misdiagnosis of appendicitis but not affect rates of appendiceal perforation.
Racial disparities in medical care have long been described. A recent Institute of Medicine report described these disparities as both "extensive" and "unacceptable" and encouraged additional research to describe the scope of the problem.30 Possible causes for differences in treatment based on race include delayed presentation as a result of inadequate access,15,16 differential physician practices,17,18 and patient preference for alternative treatments.19 Although insurance status could explain some of these differences, racial disparities often persist while controlling for insurance status.11,15,16 Many studies show that patients of minority race are less likely to receive timely intervention for their conditions,11,13–17 yet timely intervention is imperative in appendicitis; without treatment, acute appendicitis typically progresses to perforation within 48 hours after the onset of symptoms.7 The administrative nature of our data does not allow identification of the causes of the observed outcome differences. Perhaps black and Hispanic patients with acute appendicitis present to medical attention later in their disease course, at which time perforation is more likely. Such late presentation could be attributable to inadequate access to medical care or differences in perceived seriousness of symptoms. Discrimination once a patient presents for medical care could also explain the observed differences. For example, primary care and emergency department providers may not refer patients of minority race to a surgeon as expeditiously, or surgeons may improperly delay operation once the patient has been evaluated. Finally, biological differences among races must also be considered. We know of no data to suggest, however, that black and Hispanic patients develop appendicitis that is more prone to perforation.
Use of this administrative data set allowed analysis of a large number of patients from 22 states but introduced limitations as well. Race can be difficult to define and categorize and may have been reported by the patient, the provider, or a hospital employee. Nonetheless, our findings are consistent with numerous reports of racial disparities in treatment and outcome. In addition, heterogeneity exists within race categories. Because of social, economic, and cultural factors, perforation may be more common in certain subgroups of black and Hispanic patients20 and may have contributed to our findings. We were unable to determine these variations with the data available, however. That race was not recorded for almost one quarter of the patients in our sample did not seem to affect our results; unreported race was not a significant predictor of perforation, and exclusion of patients with missing race did not change our results appreciably. Our previous study of appendicitis using the KID showed that nearly all patients with unreported race were treated at hospitals that did not report race for any of their patients; the characteristics of these hospitals were similar to the other hospitals in the database.23 We therefore believe that including children with unreported race did not introduce significant bias into our analysis. Moreover, we relied on diagnosis codes for appendicitis and perforation without confirmation by pathology reports, which are not included in the KID. Although miscoding of perforated appendicitis may have occurred, we have no reason to believe that miscoding varied by patient race, insurance status, or hospital volume. Finally, our data set contains information only on inpatient admissions and does not provide insight into the cause of treatment delay, be it patient or provider related. Studies using a range of data sources, including medical records and patient reports of care processes, will be necessary to clarify the causes of the disparities seen here.
In this analysis of a national pediatric discharge database, black and Hispanic children with acute appendicitis were more likely than white children to develop perforated appendicitis, while controlling for multiple factors including insurance status. Hospital volume of cases of appendicitis did not have a significant effect on the likelihood of perforation. These results echo the extensive literature showing differences among races in treatment and outcome and further confirm the need for intervention. Efforts to reduce perforated appendicitis in children should focus on patients from at-risk populations, particularly those of minority race or who are insured by Medicaid. Only with broad-based education and interventions aimed at patients, families, and primary and acute care providers will such inequalities be corrected.
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ACKNOWLEDGMENTS |
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Dr Smink was supported by grant T32HS00063 from the Agency for Healthcare Research and Quality.
An abstract of this study was presented at the annual meetings of the Pediatric Academic Societies in Seattle, WA, May 2003; and the American College of Surgeons, Chicago, IL, October 2003.
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FOOTNOTES |
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Accepted Aug 30, 2004.
Reprint requests to (D.S.S.) Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02215. E-mail: dsmink{at}partners.org
No conflict of interest declared.
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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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