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Louw J, McCaul M, English R, Nyasulu PS, Davies J, Fourie C, Jassat J, Chu KM. Factors Contributing to Delays to Accessing Appendectomy in Low- and Middle-Income Countries: A Scoping Review. World J Surg 2023; 47:3060-3069. [PMID: 37747549 PMCID: PMC10694117 DOI: 10.1007/s00268-023-07183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Appendicitis is one of the most common emergency surgical conditions worldwide. Delays in accessing appendectomy can lead to complications. Evidence on these delays in low- and middle-income countries (LMICs) is lacking. The aim of this review was to identify and synthesise the available evidence on delays to accessing appendectomy in LMICs. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews framework. The delays and their interconnectivity in LMICs were synthesised and interpreted using the Three Delays framework. We reviewed Africa Wide EBSCOhost, PubMed-Medline, Scopus, Web of Science, African Journals Online (AJOL), and Bioline databases. RESULTS Our search identified 21 893 studies, of which 78 were included in the final analysis. All of the studies were quantitative. Fifty per cent of the studies included all three types of delays. Delays in seeking care were influenced by a lack of awareness of appendicitis symptoms, and the use of self and alternative medication, which could be linked to delays in receiving care, and the barrier refusal of medical treatment due to fear. Financial concerns were a barrier observed throughout the care pathway. CONCLUSION This review highlighted the need for additional studies on delays to accessing appendectomy in additional LMICs. Our review demonstrates that in LMICs, persons seeking appendectomy present late to health-care facilities due to several patient-related factors. After reaching a health-care facility, accessing appendectomy can further be delayed owing to a lack of adequate hospital resources.
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Affiliation(s)
- Johnelize Louw
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - M McCaul
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - R English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - P S Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Davies
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Fourie
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - J Jassat
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - K M Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Surgery, University of Botswana, Plot 4775 Notwane Rd, Gaborone, Botswana
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Handler C, Weiner N, Meir E, Abu-Hatoum O, Kopelman D, Kaplan U. Is acute appendicitis more severe in foreign workers of northern Israel? A retrospective cohort study. Eur J Trauma Emerg Surg 2023; 49:2235-2240. [PMID: 35524779 DOI: 10.1007/s00068-022-01980-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/16/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute appendicitis (AA) is one of the most common surgical emergencies worldwide. It's classified into simple or complicated disease. Due to the high prevalence of the disease, AA has been studied as a marker to assess the quality of care afforded to minority groups. The purpose of this study was to compare AA outcomes in foreign workers (FW) to the general population in northern Israel. METHODS This is a retrospective cohort study. We identified all patients aged 18-50 who were admitted to our institution between January 1st, 2013 and October 31st, 2018, with the diagnosis of acute appendicitis. The study group included all FW and the control group included citizens of Israel. Study patients were matched based on age, sex, and co-morbidities. We compared time to presentation, admission parameters and disease outcomes. Our study outcomes were disease severity and length of hospital stay. RESULTS We identified 20 FW and 97 matched local patients. FW presented with significantly higher heart rate, temperature, and white blood cell count (WBC). Duration of symptoms was comparable between the two groups. The rates of complicated disease were significantly higher among FW (45 vs 17.5%, p < 0.0001). Length of hospitalization was significantly longer in the FW group (4.8 vs. 3.9 days, p = 0.01). The odds ratio of FWs for having a complicated disease was OR = 3.85 [95% CI: 1.38, 10.72], p = 0.01. Multivariate analysis identified FW and duration of symptoms as significantly contributing to a complicated disease outcome. CONCLUSIONS Although duration of symptoms was comparable to the local population, FW in northern Israel are at increased risk for a complicated disease which resulted in longer hospital stay. Further studies may enlighten the reason for this disparity.
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Affiliation(s)
- Chovav Handler
- Department of General Surgery, Ziv Medical Center, Rambam St, 13100, Zefat, Israel
| | - Noam Weiner
- Department of General Surgery B., Emek Medical Center, Yitshak Rabin Boulevard 21, 1834111, Afula, Israel
| | - Eyal Meir
- Department of General Surgery B., Emek Medical Center, Yitshak Rabin Boulevard 21, 1834111, Afula, Israel
| | - Ossama Abu-Hatoum
- Department of General Surgery B., Emek Medical Center, Yitshak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron st. 1, Bat Galim, 3525433, Haifa, Israel
| | - Doron Kopelman
- Department of General Surgery B., Emek Medical Center, Yitshak Rabin Boulevard 21, 1834111, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron st. 1, Bat Galim, 3525433, Haifa, Israel
| | - Uri Kaplan
- Department of General Surgery B., Emek Medical Center, Yitshak Rabin Boulevard 21, 1834111, Afula, Israel.
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Efron st. 1, Bat Galim, 3525433, Haifa, Israel.
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Huynh R, Tree K, Builth-Snoad L, Smith M, Fisher D. Impact of socioeconomic status and road distance to hospital on perforated appendicitis rates at a large rural referral centre. ANZ J Surg 2023; 93:1571-1576. [PMID: 36869020 DOI: 10.1111/ans.18334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Socioeconomic status and distance from hospital have been shown to be associated with poor surgical outcomes related to acute appendicitis. Indigenous populations experience greater socioeconomic disadvantages and poorer healthcare access than their non-Indigenous counterparts. This study aims to determine whether socioeconomic status and road distance from hospital are predictors of perforated appendicitis. It will also compare surgical outcomes of appendicitis between Indigenous and non-Indigenous populations. METHODS We performed a 5-year retrospective study of all patients who underwent appendicectomy for acute appendicitis at a large rural referral centre. Patients were identified using the hospital database for theatre events coded as appendicectomy. Regression modelling was used to determine if socioeconomic status and road distance from hospital were associated with perforated appendicitis. The outcomes of appendicitis between Indigenous and non-Indigenous populations were compared. RESULTS Seven hundred and twenty-two patients were included in this study. The rate of perforated appendicitis was not significantly impacted by socioeconomic status (OR 0.993, 95% CI 0.98-1.006, P = 0.316) or road distance from hospital (OR = 0.911, 95% CI 0.999-1.001, P = 0.911). Indigenous patients did not have a significantly higher rate of perforation compared to non-Indigenous patients (P = 0.849) despite having overall lower socioeconomic status (P = 0.005) and longer road distance from hospital (P = 0.025). CONCLUSION Lower socioeconomic status and longer road distance from hospital were not associated with an increased risk of perforated appendicitis. Indigenous populations have poorer socioeconomic status and longer road distance to hospital but did not have higher rates of perforated appendicitis.
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Affiliation(s)
- Roy Huynh
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
- Faculty of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Lily Builth-Snoad
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
| | - Matthew Smith
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Dean Fisher
- Department of Surgery, Dubbo Base Hospital, Dubbo, New South Wales, Australia
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Quevedo-Fernandez E, Gonzalez-Urquijo M, Hinojosa-Gonzalez DE, Morales-Flores LF, Morales-Morales CA, Zambrano-Lara M, Guajardo-Nieto D, Rodarte-Shade M. Analysis of deferral times in patients diagnosed with acute appendicitis. Asian J Surg 2023; 46:1187-1192. [PMID: 36041893 DOI: 10.1016/j.asjsur.2022.08.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation. MATERIALS AND METHODS We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h. RESULTS A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001). CONCLUSION Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis.
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Affiliation(s)
- Enrique Quevedo-Fernandez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mauricio Gonzalez-Urquijo
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - David E Hinojosa-Gonzalez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Luis Fernando Morales-Flores
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Carlos Antonio Morales-Morales
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Zambrano-Lara
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Diego Guajardo-Nieto
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Rodarte-Shade
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
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Postdischarge Racial and Ethnic Disparities in Pediatric Appendicitis: A Mediation Analysis. J Surg Res 2023; 282:174-182. [PMID: 36308900 DOI: 10.1016/j.jss.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge. MATERIALS AND METHODS We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes. RESULTS A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively. CONCLUSIONS Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.
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Duraiswamy S, Sanchez SE, Flum DR, Paasche-Orlow MK, Kenzik KM, Tseng JF, Drake FT. Caveat emptor: The accuracy of claims data in appendicitis research. Surgery 2022; 172:1050-1056. [PMID: 35985898 DOI: 10.1016/j.surg.2022.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report. METHODS Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system. RESULTS In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change. CONCLUSION International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes.
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Affiliation(s)
- Swetha Duraiswamy
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA.
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA
| | - Kelly M Kenzik
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - Frederick Thurston Drake
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA. https://twitter.com/F_ThurstonDrake
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Zewdu D, Wondwosen M, Tantu T, Tilahun T, Teshome T, Hamu A. Predictors and management outcomes of perforated appendicitis in sub-Saharan African countries: A retrospective cohort study. Ann Med Surg (Lond) 2022; 80:104194. [PMID: 36045808 PMCID: PMC9422206 DOI: 10.1016/j.amsu.2022.104194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/10/2022] [Accepted: 07/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background Previous studies have found an association between various predictors and perforated appendicitis. However, there is limited evidence of studies determining the severity of acute appendicitis (AA) in resource-limited settings. Thus, this study aimed to identify predictors and outcomes of perforated appendicitis (PA) in sub-Saharan countries. Methods This is a retrospective cohort study of 298 adult patients who underwent surgical intervention for acute appendicitis. Demographic characteristics, clinical parameters, intraoperative findings, length of hospital stay, and postoperative complications were collected. We computed multivariate logistic regression to identify predictors of PA. P-value <0.05 was considered statistically significant. Results Of 298 patients, PA was 142(47.65%). The identified risk factors for PA are referred patients (AOR = 3.932; 95% CI (2.201–7.027), fever >38 °C (AOR = 4.569; 95% CI (2.249–9.282), and duration of symptoms >2 days (AOR = 2.704; 95% CI (1.400–5.222). Perforation was associated with an increased rate of postoperative complications (45.07vs. 6.41%; P < 0.001) and a longer length of hospital stay (3 vs. 5 days; P < 0.001). Conclusions The incidences of PA in our study are consistent with other reports in developing countries. Referred patients, longer duration of symptoms >2 days, and presence of fever >38 °C were the best predictors of PA. The overall total postoperative complications and the length of hospital stays were higher in PA. Based on our findings, we recommend that the identified predictors should be considered during the preoperative diagnosis and subsequent management. The rate of Perforated Appendix is relatively high in sub-Saharan countries. Duration of symptoms, fever and referred patients were the predictors of PA. PA increased the risk of postoperative morbidity and length of hospital stays.
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Yeob KE, Kim SY, Park JE, Park JH. Complicated Appendicitis Among Adults With and Without Disabilities: A Cross-Sectional Nationwide Study in South Korea. Front Public Health 2022; 10:813608. [PMID: 35444990 PMCID: PMC9013817 DOI: 10.3389/fpubh.2022.813608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAppendicitis is usually diagnosed based on a reliable set of signs and symptoms, and can be effectively treated with surgery, with low morbidity and mortality rates. However, appendicitis is often overlooked in vulnerable populations, including people with disabilities. This study compared 10-year trends of complicated appendicitis between South Koreans with a disability, according to disability severity and type, and those without disabilitiesMethodsTo identify cases of appendicitis, we used the DRG codes in the National Health Information Database of South Korea. Patients with appendicitis were classified in terms of severity based on the DRG codes. Age-standardized incidence rates were calculated for each year during 2008–2017 according to the presence, type, and severity of the disability. Factors associated with complicated appendicitis were examined by multivariate logistic regression using the most recent data (i.e., 2016–2017).ResultsThe incidence of complicated appendicitis was higher in people with disabilities, especially those with severe disabilities (26.9 vs. 11.6%). This difference was particularly marked when considering those with a severe disability (aOR = 1.868, 95% CI:1.511–2.309), internal organ problems (aOR = 10.000, 95% CI:5.365–18.638) or a mental disability (aOR = 2.779, 95% CI:1.563–4.939).ConclusionsThe incidence of complicated appendicitis was higher in people with disability than in those without disability in all years. There was a substantial difference in the incidence of complicated appendicitis between the severe disability and non-disabled groups. Among the various disability types, the incidence of complicated appendicitis was highest for major internal organ problems, followed by intellectual or psychological disabilities. Our findings may be explained by barriers to healthcare access among people with disabilities, particularly those with a severe disability, internal organ problem, or mental disability.
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Affiliation(s)
- Kyoung Eun Yeob
- Institute of Health and Science Convergence, Chungbuk National University, Cheongju, South Korea
| | - So Young Kim
- Institute of Health and Science Convergence, Chungbuk National University, Cheongju, South Korea
- Department of Public Health and Preventive Medicine, Chungbuk National University Hospital, Cheongju, South Korea
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jong Eun Park
- Institute of Health and Science Convergence, Chungbuk National University, Cheongju, South Korea
| | - Jong Hyock Park
- Institute of Health and Science Convergence, Chungbuk National University, Cheongju, South Korea
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
- *Correspondence: Jong Hyock Park
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Alyhari Q, Ahmed F, Nasreldin M, Nikbakht HA, Alamin A, Al-Wageeh S, Ghabisha S, Al-Shami E, Mohammed F. Prehospital Delay and Its Associated Factors in Sudanese Patients Presenting With Acute Appendicitis at a Teaching Hospital. Cureus 2022; 14:e23036. [PMID: 35425682 PMCID: PMC9005156 DOI: 10.7759/cureus.23036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background Delayed prehospital presentation of acute appendicitis may increase the risk of perforation and other complications. This study investigated the prevalence of prehospital delay in the presentation of acute appendicitis, clinical features, and outcomes in Sudanese patients. Method A retrospective study conducted from January 2017 to December 2020 in a teaching hospital affiliated with Gezira University enrolled 191 patients with prehospital delay presentation of acute appendicitis (at least 48 hours from symptom onset). Patient characteristics, causative factors, primary treatment, and complication rate were gathered and analyzed. Result The mean age of the patients was 36.55 ± 16.3 years (range: 15-78 years), with 122 (64%) males and 69 (36%) females. Most cases of prehospital delay were misdiagnosed firstly as other diseases (n = 124, 65%). The physicians made misdiagnosis of acute appendicitis in 65 (53%) patients. Age less than 30 years, male gender, living in rural areas, and lower educational level are associated with a high incidence of prehospital delay presentation of acute appendicitis (p < 0.05). Most cases have appendicular mass (46%, p < 0.001). Wound infection was the most common postoperative complication (7.85%, p < 0.001). Conclusion The high incidence rate of prehospital delay presentation of acute appendicitis is associated with patients' age ofless than 30 years, male gender, living in a rural area, and lower educational level. With the high rate of misdiagnosed acute appendicitis, it is essential to increase the knowledge about the signs and symptoms of appendicitis among our physicians and health practitioners.
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Duraiswamy S, Ignacio A, Weinberg J, Sanchez SE, Flum DR, Paasche-Orlow MK, Kenzik KM, Tseng JF, Drake FT. Comparative Accuracy of ICD-9 vs ICD-10 Codes for Acute Appendicitis. J Am Coll Surg 2022; 234:377-383. [PMID: 35213502 DOI: 10.1097/xcs.0000000000000058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND ICD codes are used to identify patients with appendicitis and to classify disease severity for reimbursement and research purposes. We sought to compare the accuracy of ICD-9 vs ICD-10 codes in classifying appendicitis as uncomplicated vs complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report. STUDY DESIGN This is a retrospective review of operative reports and discharge ICD-9/10 codes for patients 18 years or older who underwent noninterval, nonincidental appendectomy from January 2012 to December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for ICD-9/10 codes to classify appendicitis as complicated when compared with surgeon description. Chi-square testing was used to compare agreement between ICD-9/10 codes and surgeon description. RESULTS A total of 1,585 patients underwent appendectomy. ICD-9 codes had higher sensitivity than ICD-10 codes for complicated appendicitis (sensitivity 0.84 and 0.54, respectively) and a similar positive predictive value (0.77 and 0.76, respectively). Overall, 91% of ICD-9 codes agreed with surgical description of disease, but 84.4% of ICD-10 codes agreed with surgical description (p < 0.01). Among cases classified as complicated by the surgeon, 84% (79/94) had an accurate ICD-9 code for complicated disease, but only 53.8% (57/106) of cases had an accurate ICD-10 code (p < 0.01). CONCLUSIONS Compared with ICD-9 codes, ICD-10 codes were less accurate in characterizing severity of appendicitis. The ICD-10 coding schema does not provide an accurate representation of disease severity. Until this system is improved, significant caution is needed for people who rely on these data for billing, quality improvement, and research purposes.
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Affiliation(s)
- Swetha Duraiswamy
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - Amanda Ignacio
- the Department of Biostatistics, Boston University School of Public Health, Boston, MA (Ignacio, Weinberg)
| | - Janice Weinberg
- the Department of Biostatistics, Boston University School of Public Health, Boston, MA (Ignacio, Weinberg)
| | - Sabrina E Sanchez
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - David R Flum
- the Department of Surgery, University of Washington Medical Center, Seattle, WA (Flum)
| | - Michael K Paasche-Orlow
- the Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA (Paasche-Orlow)
| | - Kelly M Kenzik
- the Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL (Kenzik)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
| | - Frederick Thurston Drake
- From the Department of Surgery, Boston Medical Center and Boston University School of Medicine, Boston, MA (Duraiswamy, Sanchez, Tseng, Thurston Drake)
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Willer BL, Mpody C, Thakkar RK, Tobias JD, Nafiu OO. Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children. J Surg Res 2021; 269:178-188. [PMID: 34571261 DOI: 10.1016/j.jss.2021.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/15/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma. MATERIALS AND METHODS We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity. RESULTS We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers. CONCLUSIONS Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio.
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Rajan K Thakkar
- Department of General Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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12
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Withers N, Hepburn L, Palmer J, Evans F, Mosher J, Dasril J, Liyanage C, Eglinton T, Sakowska MM. Multicentre study of appendicitis management comparing a large South Island metropolitan hospital, to its referring regional and rural centres. ANZ J Surg 2021; 91:2054-2059. [PMID: 34405500 DOI: 10.1111/ans.17125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Globally, patients presenting with acute surgical disease in rural areas have poorer outcomes when compared to urban areas; little data are available regarding outcomes for New Zealand (NZ) rural patients. This study aimed to compare the surgical management of appendicitis in a large metropolitan centre with its regional referral centres. METHODS In this retrospective cohort study, patient data were collated from the studied centres between November 2014 and October 2019. In addition to patient demographics, patterns of referral and presentation, the primary outcome was time to the theatre; secondary outcomes were perforation rates, length of stay and complications. Data are presented as medians (interquartile range). RESULTS A total of 3533 patients underwent appendicectomy over the period studied. For those presenting directly to the metropolitan centre, the median wait-time to the theatre was 16 h (9.2-23.2); if patients were transferred, they waited for 20.8 h (13.6-27). Patients presenting to regional centres waited for 7.6 h (4.5-15.4, P < 0.001). Perforation rates for transferred patients were 31% which was greater than for those presenting to the metropolitan (20%) or regional centres (17%, P = 0.014). Complications were also highest in transferred patients (20%) when compared to the metropolitan (17%) or regional centres (10%, P < 0.001). CONCLUSION Patients who were transferred to Christchurch Hospital from rural centres without surgical services had a longer wait-time than those who presented to Christchurch Hospital directly or were treated in regional centres. This was associated with higher rates of perforated appendicitis.
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Affiliation(s)
- Nicole Withers
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Lucy Hepburn
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jethro Palmer
- Department of Surgery, Timaru Hospital, Timaru, New Zealand
| | - Fergus Evans
- Department of Surgery, Grey Base Hospital, Greymouth, New Zealand
| | - Jamie Mosher
- Department of Surgery, Grey Base Hospital, Greymouth, New Zealand
| | - Juni Dasril
- Department of Surgery, Wairau Hospital and Health Centre, Blenheim, New Zealand
| | - Chris Liyanage
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Tim Eglinton
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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13
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The predictors of perforated appendicitis in the pediatric emergency department: A retrospective observational cohort study. Am J Emerg Med 2021; 49:249-252. [PMID: 34167047 DOI: 10.1016/j.ajem.2021.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Appendiceal perforation has significant effects on perioperative morbidity and postoperative outcome. The present study aimed to identify possible predictive factors associated with perforated appendicitis (PA) in children at admission in the emergency department (ED). METHODS In this retrospective observational cohort study, consecutive medical records of children <18 years old with surgically and histopathologically confirmed acute appendicitis (AA) over three years (2013-2015) were analyzed. Patients were divided into two groups: PA and non-perforated appendicitis (NPA). The differences between the two groups and potential predictors of PA were explored using univariate and multivariate analyses. RESULTS During the study period, 295 patients underwent an appendectomy and had confirmatory AA diagnoses. Ninety-two patients had a PA (31.2%). In the univariate analysis, male gender, vomiting, diarrhea, fever, elevated white blood cell count (WBC) levels, and high C-reactive protein (CRP) were identified as predictors of PA. In the multivariate analysis, male gender (odds ratio [OR]: 3.133; 95% confidence interval [CI]: 1.610-6.096); vomiting (OR: 2.346; 95% CI: 1.141-4.822); diarrhea (OR: 4.549; 95% CI: 1.850-11.181); fever (OR: 3.429; 95% CI: 1.765-6.663); elevated WBC (OR: 2.962; 95% CI: 1.491-5.884) and elevated CRP (OR: 3.061; 95% CI: 1.267-7.396) were variables that predicted the PA in children. CONCLUSION Our data indicate that several clinical and biochemical parameters can reliably distinguish between pediatric PA and NPA at admission in the emergency department.
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14
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Estrella JB, Carmichael H, Myers QWO, Lee S, Velopulos CG. Making it Complicated: Does Disparity in Access to Care Lead to More Perforated Appendicitis? J Surg Res 2021; 266:405-412. [PMID: 34091088 DOI: 10.1016/j.jss.2021.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Delays in obtaining care may lead to perforated appendicitis, increasing risk of morbidity and mortality. We previously explored the role of social determinants in patients undergoing cholecystectomy, finding that emergent presentation is associated with neighborhood Social Vulnerability Index (SVI). We hypothesize that social vulnerability is associated with increased incidence of perforated appendicitis. METHODS We retrospectively identified patients presenting to our urban, academic hospital with acute appendicitis during a 9-month timeframe (11/2019 - 7/2020). Patients were classified as perforated or non-perforated. Patient SVI was determined using geocoding at the census tract level. Because rates of perforation were higher in older patients, we performed a subset analysis of patients ≥ 40 years. RESULTS 190 patients were included. Patients with perforated appendicitis (n = 48, 25%) were older and were more likely to present to a clinic versus the emergency department (P = 0.009). Perforated patients had longer delay before seeking care (56% versus 6% with > 72 hours of symptoms, P < 0.001). However, there were no differences between groups in terms of sex, race/ethnicity, insurance type, language barrier, having a primary care physician, or any of the SVI subscales. Of patients ≥ 40 years, a higher proportion were perforated (28/80, 35%) despite similar rates of delayed care. In this cohort, higher overall SVI as well as the socioeconomic status and household composition/disability subscales were associated with perforation. CONCLUSIONS Contrary to our hypothesis, while perforation was associated with delayed care in this population, we did not find overall that social vulnerability or individual social determinants accounted for this delay.
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Affiliation(s)
| | - Heather Carmichael
- School of Medicine, University of Colorado, Colorado, USA; Department of Surgery, University of Colorado, Colorado, USA
| | | | - Sterling Lee
- School of Medicine, University of Colorado, Colorado, USA
| | - Catherine G Velopulos
- School of Medicine, University of Colorado, Colorado, USA; Department of Surgery, University of Colorado, Colorado, USA.
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15
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Spatial-temporal clusters of pediatric perforated appendicitis in California. J Pediatr Surg 2021; 56:1208-1213. [PMID: 33752913 DOI: 10.1016/j.jpedsurg.2021.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perforated appendicitis is a well-documented child health disparity. Geographic patterns in perforated appendicitis exist in several United States regions, but such patterns have not been described in California. We aimed to analyze spatial-temporal patterns of pediatric perforated appendicitis and identify population characteristics contributing to these cluster patterns. METHODS We geocoded risk-adjusted perforated appendicitis rates per 1000 appendicitis cases in patients 1-17 years from 2005-2015 in California. We performed a space-time cube analysis to identify hot spot trends. We performed logistic regression to estimate rural classification associated with spatial-temporal hot spots and multivariate analysis to assess effects of socioeconomic factors. RESULTS In 2005-2015, 43,888 cases of pediatric perforated appendicitis occurred in California. Median risk-adjusted perforated appendicitis rate was 312 per 1000 appendicitis cases. We identified 11 spatial-temporal hot spots of perforated appendicitis. Rural micropolitan counties had 14 times higher odds of being classified as a hot spot (p<0.05, 95% CI 1-185). Poverty was a significant predictor of high perforated appendicitis median risk-adjusted rate (p<0.004). CONCLUSIONS We identified 11 California hot spots of perforated appendicitis that persisted across a ten-year time span. Incorporating geography alongside our understanding of socioeconomic factors is a critical step in addressing this important child health disparity.
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16
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Factors Affecting Patient Outcomes in Acute Appendicitis in Rural Areas: An Observational Cohort Study. World J Surg 2021; 45:2337-2346. [PMID: 33813629 DOI: 10.1007/s00268-021-06093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The most common surgical emergency both in developed and non-developed countries is acute appendicitis and it has a time-dependent clinical course. In this observational cohort study, we aim to investigate the factors affecting patient outcomes in acute appendicitis at a rural hospital. METHODS This observational cohort study was held between November 2012 and May 2014 at a rural hospital. Patients' pre-operative, perioperative, and post-operative data were collected prospectively. Patients were followed-up for 12-months. RESULTS A total of 151 patients were recorded. Factors significantly associated with complicated cases (abscess/perforation) were referral region as remote towns (OR:7.94, 95%CI [3.46-18.23]; p < 0.001), referral season as winter (OR:2.47, %95CI [1.14-5.36]; p = 0.022), pre-operative hospital delay (OR:6.52, 95%CI [3.49-12.20]; p < 0.001), and duration of referral (OR:1.01, 95%CI [1.00-1.01]; p < 0.001). In the multivariate analysis, only pre-operative hospital delay remained as a significant factor (OR:5.87, 95%CI [2.85 - 12.07]; p < 0.001). Factors affecting length of hospital stay (LoHS) were referral region as remote towns (95%CI, β = 3.10 [2.28-3.93], t = 1.91; p < 0.001), abscess/perforation (95%CI, β = 4.70 [4.04-5.36], t = 14.05; p < 0.001), pre-operative hospital delay (95%CI, β = 1.25 [0.87-1.62], t = 6.58; p < 0.001), and duration of referral (95%CI, β = 0.011 [0.01-0.14], t = 7.34; p < 0.001). In the multivariate analysis, all four factors stayed significant. The rate of complicated appendicitis was significantly high in winter than other seasons for patients referring from remote towns (75% vs 33%, p < 0.001). CONCLUSIONS This observational cohort study is the only study specifically focused on the effect of season and region on abscess/perforation rates, LoHS, and accessibility to hospital in patients with acute appendicitis.
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17
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Diaz A, Schoenbrunner A, Pawlik TM. Trends in the Geospatial Distribution of Inpatient Adult Surgical Services across the United States. Ann Surg 2021; 273:121-127. [PMID: 31090565 DOI: 10.1097/sla.0000000000003366] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to define trends in the geographic distribution of surgical services in the United States to assess possible geographic barriers and disparities in access to surgical care. SUMMARY BACKGROUND DATA Despite the increased need and utilization of surgical procedures, Americans often face challenges in gaining access to health care that may be exacerbated by the closure and consolidation of hospitals. Although access to surgical care has been evaluated relative to the role of insurance, race, and health literacy/education, the relationship of geography and travel distance to access has not been well studied. METHODS The 2005 and 2015 American Hospital Association annual survey was used to identify hospitals with surgical capacity; the data were merged with 2010 Census Bureau data to identify the distribution of the US population relative to hospital location, and geospatial analysis tools were used to examine a service area of real driving time surrounding each hospital. RESULTS Although the number of hospitals that provided surgical services slightly decreased over the time periods examined (2005, n = 3791; 2015, n = 3391; P<0.001), the number of major surgery hospitals increased from 2005 (n = 539) to 2015 (n = 749) (P<0.001). The geographic location of hospitals that provided surgical services changed over time. Specifically, although in 2005 852 hospitals were located in a rural area, that number had decreased to 679 by 2015 (P<0.001). Of particular note, from 2005 to 2015 there was an 82% increase in the number of people who lived further than 60 minutes from any hospital (P<0.001). However, the number of people who lived further than 60 minutes from a major surgery hospital decreased (P<0.001). CONCLUSIONS Although the number of rural hospitals decreased over the last decade, the number of large, academic medical centers has increased; in turn, there has been an almost doubling in the number of people who live outside a 60-minute driving range to a hospital capable of performing surgery.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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18
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Ahmed A, Feroz SH, Dominic JL, Muralidharan A, Thirunavukarasu P. Is Emergency Appendicectomy Better Than Elective Appendicectomy for the Treatment of Appendiceal Phlegmon?: A Review. Cureus 2020; 12:e12045. [PMID: 33447475 PMCID: PMC7802400 DOI: 10.7759/cureus.12045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Appendiceal phlegmon is considered to be sequelae to acute appendicitis which presents as an appendiceal mass composed of the inflamed appendix, the adjacent bowel loops, and the greater omentum. The definitive diagnosis can be obtained by a CT scan of the abdomen. Though conservative management was the most practiced approach, recent studies have shifted the trends towards immediate appendicectomy for the management of appendiceal phlegmon. Thus, the management of appendiceal phlegmon has been debatable. Evidence to support this review was gathered via the PubMed database as this database uses the Medline, PubMed Central, and NLM databases and also offers a quick diverse search with up-to-date citations and numerous open-access free articles focused on Medicine. We did not include other databases like Google Scholar, Embase, and Scopus due to its limited access to free articles, recent articles, and citation information. Search terms used were combinations of "Appendicitis," "Appendiceal phlegmon", "Appendiceal phlegmon (AND) appendicectomy ". The resultant studies were reviewed and cross‐referenced for additional reports. Emergency appendicectomy is defined as appendicectomy carried out during the same, initial admission. An elective or interval appendicectomy is an appendicectomy carried out four to six weeks after the initial episode at a later admission. The interval is bridged by antibiotics and conservative management. Emergency appendicectomy is considered to have a higher rate of complications when compared to conservative management for appendiceal phlegmon. However, interval appendicectomy requires multiple re-admissions, leads to delayed diagnosis of any underlying pathology, and an increased risk of recurrent appendicitis. In our review, we aimed to compare and contrast the effectiveness of the different treatment modalities available for appendiceal phlegmon. Though the meta-analyses showed an increased association of complications with emergency appendicectomy, they included studies conducted before the laparoscopic era. Emergency appendicectomy decreases the financial burden, re-admission rate, and aids in the early diagnosis of any underlying pathology. In the laparoscopic era, we can consider the shifting trends towards emergency appendicectomy for the management of appendiceal phlegmon.
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Affiliation(s)
- Asma Ahmed
- General Surgery, Ramaiah Medical College and Hospital, Bangalore, IND
| | - Shah Huzaifa Feroz
- General Surgery, Jawaharlal Nehru Medical College, Aligarh, IND.,General Surgery, Larkin Community Hospital, Miami, USA
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19
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Golz RA, Flum DR, Sanchez SE, Liu X, Donovan C, Drake FT. Geographic Association Between Incidence of Acute Appendicitis and Socioeconomic Status. JAMA Surg 2020; 155:330-338. [PMID: 32129808 DOI: 10.1001/jamasurg.2019.6030] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Some studies based on proportions of patients with perforated appendicitis (PA) among all patients with acute appendicitis (AA) have found an association between socioeconomic status (SES) and risk of perforation. A potential limitation is their use of proportions, which assumes that incidence of AA is evenly distributed across populations at risk. This assumption may be invalid, and SES may have a more complex association with both AA and PA. Objective To generate population-based incidences of AA and PA and to examine geographic patterns of incidence alongside geographic patterns of SES. Design, Setting, and Participants Retrospective study of data from Washington's Comprehensive Hospital Abstract Reporting System and the 2010 US census. Geographic methods were used to identify patterns of age- and sex-standardized incidence in Washington State between 2008 and 2012. The study included all patients discharged with International Classification of Diseases, Ninth Revision codes for AA or PA. Data were analyzed between November 2016 and December 2018. Exposures Location of primary residence. Main Outcomes and Measures Age- and sex-standardized incidence for AA and PA was generated for each census tract (CT). Global spatial autocorrelation was examined using Moran index (0.0 = completely random incidence; 1.0 = fully dependent on location). Clusters of low-incidence CTs (cold spots) and high-incidence CTs (hot spots) were identified for AA. Census-based SES data were aggregated for hot spots and cold spots and then compared. Results Statewide, over the 5-year study period, there were 35 730 patients with AA (including 9780 cases of PA), of whom 16 574 were women (46.4%). Median age of the cohort was 29 years (IQR, 16-48 years). Statewide incidence of AA and PA was 106 and 29 per 100 000 person-years (PY), respectively. Crude incidence was higher within the male population and peaked at age 10 to 19 years. Age- and sex-standardized incidence of AA demonstrated significant positive spatial autocorrelation (Moran index, 0.30; P < .001), but autocorrelation for PA was only half as strong (0.16; P < .001). Median incidence of AA was 118.1 per 100 000 PY among hot spots vs 86.2 per 100 000 PY among cold spots (P < .001). Socioeconomic status was higher in cold spots vs hot spots: mean proportion of college-educated adults was 56% vs 26% (P < .001), and mean per capita income was $44 691 vs $30 027 (P < .001). Conclusions and Relevance Age- and sex-standardized incidence of appendicitis is not randomly distributed across geographic subunits, and geographic clustering of AA is twice as strong as PA. Socioeconomic advantages, such as higher income and secondary education, are strongly associated with lower incidence of AA. These findings challenge conventional views that AA occurs randomly and has no predisposing characteristics beyond age/sex. Socioeconomic status, and likely other geographically circumscribed factors, are associated with incidence of AA.
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Affiliation(s)
- Reece A Golz
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Geography, San Francisco State University, San Francisco, California
| | - David R Flum
- Department of Surgery, University of Washington School of Medicine, Seattle
| | - Sabrina E Sanchez
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Surgery, University of Washington School of Medicine, Seattle
| | - XiaoHang Liu
- Department of Geography, San Francisco State University, San Francisco, California
| | - Courtney Donovan
- Department of Geography, San Francisco State University, San Francisco, California
| | - F Thurston Drake
- Department of Surgery, Boston University School of Medicine, Boston, Massachusetts.,Department of Surgery, University of Washington School of Medicine, Seattle
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20
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Govind SK, Doumouras AG, Nenshi R, Hong D. Geographic Variation in Appendiceal Perforation Rates in Canada: a Population-Based Cohort Study. J Gastrointest Surg 2020; 24:2620-2627. [PMID: 31792897 DOI: 10.1007/s11605-019-04434-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/19/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We hypothesized that patients living in rural neighborhoods experience delayed access to surgical services manifesting in increased appendiceal perforation rates in cases of appendicitis. METHODS This population-based cohort study included adult patients with acute appendicitis in Canada (excluding Quebec) between April 2008 and March 2015. The main outcome of interest was rate of perforation. Predictors of interest included socioeconomic, geographic, and individual predictors of perforation. Spatial analysis was used to analyze spatial clustering of perforation. RESULTS We identified 143,195 patients throughout the course of the study. The average perforation rate across our study was 35.9% (n = 51,456). Cluster analysis identified 286 (24%) neighborhoods with perforation rates greater than the average. Rural neighborhoods had a 1.89 times higher odds of being in a high perforation cluster (95% CI 1.08-3.08, p = 0.024). Compared to neighborhoods > 75 km from the admitting hospital, closer neighborhoods were less likely to be in a high perforation cluster (0-35 km OR 0.64, 95% CI 0.38-0.98, p = 0.049; 36-75 km OR 0.60, 95% CI 0.37-0.92, p = 0.019). Patients admitted to small community hospitals had a 0.51 times lower odds of perforation than those admitted to academic centers (95% CI 0.47-0.54, p < 0.001) and those who lived in high perforation clusters had a 1.42 times higher odds of perforation (95% CI 1.39-1.46, p < 0.001). CONCLUSION Neighborhoods located far from hospitals have increased appendiceal perforation rates. Also, patients with appendicitis treated at small community hospitals have significantly lower odds of perforation. From a policy point of view, patients with symptoms of appendicitis can be safely treated at the nearest hospital.
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Affiliation(s)
- Shaylan K Govind
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Rahima Nenshi
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. .,Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
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21
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Greear GM, Romano MF, Katz MH, Munarriz R, Rague JT. Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients. Int J Impot Res 2020; 33:184-190. [PMID: 32683416 DOI: 10.1038/s41443-020-0331-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/17/2020] [Accepted: 07/09/2020] [Indexed: 11/09/2022]
Abstract
Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.
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Affiliation(s)
- Garrick M Greear
- Department of Urology, University of California San Diego, 200 West Arbor Drive, MC 7897, San Diego, CA, 92103, USA
| | - Michael F Romano
- Boston University School of Medicine, 72 E. Concord St, Boston, MA, 02118, USA
| | - Mark H Katz
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA
| | - Ricardo Munarriz
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA
| | - James T Rague
- Department of Urology, Boston Medical Center, 725 Albany St., Suite 3B, Boston, MA, 02118, USA.
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22
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Fluke LM, McEvoy CS, Peruski AH, Shibley CA, Adams BT, Stinnette SE, Ricca RL. Evaluation of disparity in care for perforated appendicitis in a universal healthcare system. Pediatr Surg Int 2020; 36:219-225. [PMID: 31654109 DOI: 10.1007/s00383-019-04585-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Racial and socioeconomic disparities have been reported in the management of appendicitis. Perforated appendicitis (PA) is used as an index for barriers to care due to delays in treatment. This study evaluates the effect of racial and socioeconomic differences on the likelihood of PA in a universally insured national healthcare system. METHODS A retrospective review of pediatric patients enrolled in TRICARE who underwent appendectomy during a 5-year period was performed. Logistic regression was used to examine the association between ethnicity, age, gender, parent, or guardian marital status and deployment status of the active duty parent, type of facility, and type of admission with the odds of perforated appendicitis. RESULTS A total of 3124 children met inclusion criteria. One-third of children carried the diagnosis of PA. Increased odds of PA was associated with younger age of patient among children of military personnel with enlisted ranks and senior officer ranks. CONCLUSION In a universal healthcare system, no disparities across race with regard to presentation of appendicitis were identified. Increased odds of perforated appendicitis were observed in younger patients, but this was demonstrated in families of both high and low socioeconomic status. Universal coverage does appear to eliminate some barriers to healthcare.
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Affiliation(s)
- Laura M Fluke
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Christian S McEvoy
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.,Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, 23708, USA
| | - Anne H Peruski
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, 23708, USA
| | - Christina A Shibley
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, 23708, USA
| | - Brian T Adams
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, 23708, USA
| | - Samuel E Stinnette
- Health Analysis Department, Navy and Marine Corps Public Health Center, Portsmouth, VA, 23708, USA
| | - Robert L Ricca
- Department of Pediatric Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA, 23708, USA. .,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
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Health Policy Research in Surgery. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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O'Connell RM, Abd Elwahab S, Mealy K. The impact of hospital grade, hospital-volume, and surgeon-volume on outcomes for adults undergoing appendicectomy. Surgeon 2019; 18:280-286. [PMID: 31806483 DOI: 10.1016/j.surge.2019.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Acute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy. AIM To establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy. METHODS Using the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed. RESULTS During the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year). CONCLUSION Patients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.
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Affiliation(s)
- R M O'Connell
- Department of Surgery, Wexford General Hospital, Ireland.
| | - S Abd Elwahab
- Department of Surgery, Wexford General Hospital, Ireland
| | - K Mealy
- Department of Surgery, Wexford General Hospital, Ireland
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Ko RE, Park SJ, Kim HS. Relationship between the time required for transfer and outcomes in patients with appendicitis: Experience at a tertiary military hospital in South Korea. Medicine (Baltimore) 2019; 98:e17715. [PMID: 31651903 PMCID: PMC6824730 DOI: 10.1097/md.0000000000017715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A few studies have compared patients who were directly admitted with patients who were transferred to a tertiary facility for an appendectomy. However, there have been no reports of an association between the time to transfer and outcome in patients who underwent an appendectomy. As the only tertiary military hospital in South Korea, we occasionally encountered patients who were delayed for transfer due to the military environment. We hypothesize that patients with a longer time to transfer have a worse outcome. This study aimed to evaluate the relationship between the time to transfer and the outcome of patients who underwent an appendectomy.Patients who underwent appendectomy in the tertiary military hospital in South Korea from May 2015 to April 2017 were analyzed retrospectively. The groups were divided by the time for the transfer. Four hours was used as the cut-off point to divide the early and delayed transfer groups. Time from symptom onset to hospitalization, time from diagnosis to surgery, and time from hospitalization to surgery were also analyzed to assess the effect of time for the transfer.A total of 449 patients were analyzed: 293 with direct admission, 110 with early transfer, and 46 with delayed transfer. The time required for transfer was more critical for delaying appendectomy than the time from hospital admission to surgery. There was no difference in outcomes among the groups. When patients were compared according to the perforation, no differences were found in time from hospitalization to surgery, time from diagnosis to surgery, and presence of transfer. Multivariate analysis showed that a greater than 72 hours delay from symptom onset to hospitalization was associated with perforation (odds ratio = 12.61; 95% confidence interval: 3.84-41.40; P < .001).Even if a long transfer time is necessary, an appendectomy can be performed safely if patients were administered antibiotics immediately after diagnosis.
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Affiliation(s)
- Ryoung Eun Ko
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul
| | - Se Jin Park
- Department of Surgery, The Armed Forces Capital hospital, Gyeonggi-do
| | - Ho Seung Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Akhtar-Danesh GG, Doumouras AG, Flageole H, Hong D. Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study. J Pediatr Surg 2019; 54:1804-1808. [PMID: 30482382 DOI: 10.1016/j.jpedsurg.2018.10.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. METHODS Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. RESULTS Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. CONCLUSIONS In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. LEVEL OF EVIDENCE Prognosis study, level II.
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Affiliation(s)
- Gileh-Gol Akhtar-Danesh
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| | - Helene Flageole
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of Pediatric Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Dennis Hong
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
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Geographic Distribution of Adult Inpatient Surgery Capability in the USA. J Gastrointest Surg 2019; 23:1652-1660. [PMID: 30617771 DOI: 10.1007/s11605-018-04078-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/28/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Access to timely, quality, and affordable surgical services is an important component of health care systems. A better understanding of the geographic distribution of surgical services in the USA may help identify disparities in access to surgery. METHODS Using the 2015 American Hospital Association Annual Survey, the 2010 Census Bureau Data, and the American Community Survey 5-year estimates from 2011 to 2016, all hospitals with surgical capabilities were geocoded with 30 straight-line mile service areas around each hospital using geospatial analysis. Major surgical hospitals were defined as meeting three of the four following criteria: bed size ≥ 45, ≥ 8600 operations per year, ≥ 12 operating rooms, and academic medical center. The distribution of the US population based on proximity to a hospital capable of performing adult inpatient surgery and a major surgical hospital was then analyzed and compared. RESULTS Overall, 3409 hospitals were identified that had the capacity to perform adult inpatient surgery of which 1373 were defined as major surgical hospitals. Based on geospatial analysis, 10% of the US population was found to reside outside of a linear 30-mile radius of a surgical hospital. Younger age (OR 0.97, CI 0.96-0.97), female sex (OR 4.6, CI 4.3-5), African-American race (OR = 5.4, CI 4.7-6.2), Hispanic/Latino race (OR 5.5, CI 4.8-6.3), having completed high school or greater (OR = 3.6, CI 3-4.2), being employed (OR 4.8, CI 4.6-4.9), and having any type of health insurance were significantly associated with living in a service area. CONCLUSION A significant proportion of the US population lives greater than 30 straight-line miles from a major surgical hospital. Common demographic and socioeconomic factors highlight disparities in access to surgical care.
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Elliott BM, Witcomb Cahill H, Harmston C. Paediatric appendicitis: increased disease severity and complication rates in rural children. ANZ J Surg 2019; 89:1126-1132. [PMID: 31280500 DOI: 10.1111/ans.15328] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 03/13/2019] [Accepted: 05/22/2019] [Indexed: 02/04/2023]
Affiliation(s)
- Brodie M. Elliott
- Department of General SurgeryWhangārei Hospital Northland New Zealand
| | | | - Christopher Harmston
- Department of General SurgeryWhangārei Hospital Northland New Zealand
- Department of SurgeryThe University of Auckland Auckland New Zealand
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Tom CM, Friedlander S, Sakai-Bizmark R, Shekherdimian S, Jen H, DeUgarte DA, Lee SL. Outcomes and costs of pediatric appendectomies at rural hospitals. J Pediatr Surg 2019; 54:103-107. [PMID: 30389148 DOI: 10.1016/j.jpedsurg.2018.10.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE Despite policy efforts to support rural hospitals, little is known about the quality and safety of pediatric surgical care in geographically remote areas. Our aim was to determine the outcomes and costs of appendectomies at rural hospitals. METHODS The Kids' Inpatient Database (2003-2012) was queried for appendectomies in children <18 years at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), cost) were analyzed with bivariate and multivariable regression analysis. RESULTS Rural hospitals performed 13.6% of appendectomies. On multivariable analysis, rural hospitals were associated with higher negative appendectomy rates (OR 1.49, 95% CI 1.39-1.60, p < 0.001), decreased appendiceal perforation rates (OR 0.86, 95% CI 0.83-0.89, p < 0.001), less laparoscopy use (OR 0.48, 95% CI 0.47-0.50, p < 0.001), higher complication rates (OR 1.29, 95% CI 1.19-1.39, p < 0.001), shorter LOS (IRR 0.90, 95% CI 0.89-0.91, p < 0.001), and slightly increased costs (exponentiated log$ 1.02, 95% CI 1.01-1.02, p < 0.001) CONCLUSIONS: Rural hospitals care for fewer patients with advanced appendicitis but are associated with higher negative appendectomy rates, lower laparoscopy use, and higher complication rates. Additional studies are needed to identify factors that drive this disparity to improve the quality of pediatric surgical care in rural settings. TYPE OF STUDY Treatment/Cost Study (Outcomes). LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cynthia M Tom
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA
| | - Scott Friedlander
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Rie Sakai-Bizmark
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA
| | - Shant Shekherdimian
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Howard Jen
- Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Daniel A DeUgarte
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA 90502, USA; Division of Pediatric Surgery, UCLA, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, USA.
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Tom CM, Howell EC, Won RP, Friedlander S, Sakai-Bizmark R, de Virgilio C, Lee SL. Assessing outcomes and costs of appendectomies performed at rural hospitals. Am J Surg 2018; 217:1102-1106. [PMID: 30389118 DOI: 10.1016/j.amjsurg.2018.10.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 10/18/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals. METHODS The National Inpatient Sample (2001-2012) was queried for appendectomies at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed. RESULTS Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18-1.34,p < 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58-0.72,p < 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97-0.99,p < 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals. CONCLUSIONS Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.
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Affiliation(s)
- Cynthia M Tom
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Erin C Howell
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Roy P Won
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA
| | - Scott Friedlander
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Rie Sakai-Bizmark
- Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Christian de Virgilio
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA
| | - Steven L Lee
- Department of Surgery, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Department of Pediatrics, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 461, Torrance, CA, 90502, USA; Los Angeles Biomedical Research Institute, 1124 West Carson Street, Torrance, CA, 90502, USA.
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Regional variations in outcomes and cost of appendectomy in the United States. J Surg Res 2017; 219:319-324. [DOI: 10.1016/j.jss.2017.06.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/31/2017] [Accepted: 06/16/2017] [Indexed: 11/22/2022]
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Chaudhary MA, Shah AA, Zogg CK, Changoor N, Chao G, Nitzschke S, Havens JM, Haider AH. Differences in rural and urban outcomes: a national inspection of emergency general surgery patients. J Surg Res 2017; 218:277-284. [DOI: 10.1016/j.jss.2017.06.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/20/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Sarda S, Short HL, Hockenberry JM, McCarthy I, Raval MV. Regional variation in rates of pediatric perforated appendicitis. J Pediatr Surg 2017; 52:1488-1491. [PMID: 28259382 DOI: 10.1016/j.jpedsurg.2017.02.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown. METHODS A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications. RESULTS National PA rates per 1000 admissions for 2006, 2009, and 2012 were 313.9, 279.2, and 309.1, respectively. Similarly, all regions demonstrated a statistically significant decrease in PA rates between 2006 and 2009 (p<0.001), where the increase in rates between 2009 and 2012 was only statistically significant in the Midwest [Odds Ratio (OR) 1.07; 95% Confidence Interval (95%CI) 1.03-1.12] and West (OR 1.10; 95% CI 1.07-1.14). The Northeast consistently experienced the lowest PA rates. The odds of PA were highest among uninsured patients (OR 1.35; 95% CI 1.31-1.29). The South had the highest proportion of uninsured children, and these patients had the highest odds of perforation (OR 1.57; 95% CI 1.21-2.02). CONCLUSIONS For children with appendicitis, geographic region and insurance status appear to be associated with perforation upon presentation. Understanding regional variation in pediatric PA rates may inform health policymakers in the constantly evolving insurance coverage landscape. LEVELS OF EVIDENCE RATING Level III Treatment Study - Retrospective comparative study of appendicitis presentation in children by region of the country.
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Affiliation(s)
- Samir Sarda
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Heather L Short
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Ian McCarthy
- Deparment of Economics, Emory University, Atlanta, GA, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Lassiter RL, Hatley RM. Differences in the Management of Perforated Appendicitis in Children by Race and Insurance Status. Am Surg 2017. [DOI: 10.1177/000313481708300937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This study was conducted to assess whether race and socioeconomic status influence the management method used to treat pediatric perforated appendicitis. Nonelective pediatric admissions with a primary diagnosis of appendicitis were analyzed using data from the 2001–2010 Nationwide Inpatient Sample. Bivariate and multivariate analyses were used to determine the association between race, insurance status, median household income, rural/metropolitan location, and the risk adjusted odds of undergoing surgery, laparoscopic appendectomy, percutaneous drainage, or neither surgery nor percutaneous drainage. A total of 46,211 admissions of perforated appendicitis were identified. Surgery was performed in 90.5 per cent of them. Black children were less likely to have surgery [adjusted odds ratio (AOR) = 0.53] and more likely to be managed non-surgically with percutaneous drainage (AOR = 1.79). Self-pay patients were less likely to have laparoscopic surgery (AOR = 0.80). Children from rural counties were more likely to undergo surgery than those from larger metropolitan areas (AOR = 1.30). Higher estimated household income did not predict the method of treatment. Although previous studies have attributed racial disparities in outcomes for appendicitis to different rates of perforation and access to care, these findings demonstrate significantly dissimilar management strategies for patients presenting with a similar disease process.
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Abstract
BACKGROUND The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act allowed young adults to remain on their parents' health insurance plans until age 26 years. Although the provision improved coverage and survey-reported access to care, little is known regarding its impact on timely access for acute conditions. This study aims to assess changes in insurance coverage and perforation rates among young adults with acute appendicitis-an established metric for population-level health care access-after the DCP. METHODS The National Inpatient Sample and difference-in-differences linear regression were used to assess prepolicy/postpolicy changes for policy-eligible young adults (aged 19-25 y) compared with a slightly older, policy-ineligible comparator group (aged 26-34 y). RESULTS After adjustment for covariates, 19-25 year olds experienced a 3.6-percentage point decline in the uninsured rate after the DCP (baseline 22.5%), compared with 26-34 year olds (P<0.001). This coincided with a 1.4-percentage point relative decline in perforated appendix rate for 19-25 year olds (baseline 17.5%), compared with 26-34 year olds (P=0.023). All subgroups showed significant reductions in uninsured rates; however, statistically significant reductions in perforation rates were limited to racial/ethnic minorities, patients from lower-income communities, and patients presenting to urban teaching hospitals. CONCLUSIONS Reductions in uninsured rates among young adults after the DCP were associated with significant reductions in perforated appendix rates relative to a comparator group, suggesting that insurance expansion could lead to fewer delays in seeking and accessing care for acute conditions. Greater relative declines in perforation rates among the most at-risk subpopulations hold important implications for the use of coverage expansion to mitigate existing disparities in access to care.
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ÖZtÜRk A, Korkmaz M, Atalay T, KarakÖSe YÜK, Faruk Akinci ÖM, Bozer M. The Role of Doctors and Patients in Appendicitis Perforation. Am Surg 2017; 83:390-393. [DOI: 10.1177/000313481708300428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
In this study, we aimed to determine factors that cause appendix perforations and to identify the role of physicians and patients in contributing to the cause of these perforations. This study was conducted between April 2010 and May 2015 and included 64 patients with perforated appendicitis. Patients’ medical records were examined for factors that might have contributed to perforation, and the roles of patients and physicians in perforation appendicitis were evaluated. The perforation rate of patients with appendicitis was 16.0 per cent. The average duration from symptom onset to hospital admission was 4.4 days (29 patients were admitted to hospital within two days, 35 were admitted later). In total, 38 patients had visited a different hospital before admission. Furthermore, six out of 26 patients who had not visited any other hospital had consumed analgesics. Factors contributing to appendix perforation included misdiagnosis at the patient's initial visit (56.0%), delayed admission to hospital (11.0%), and use of analgesics (9.0%). The cause of perforation was mostly physician-related in children and adults, and patient-related in older adults.
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Affiliation(s)
| | - Mevlit Korkmaz
- Pediatric Surgery, Fatih University Medical Faculty Hospital, Istanbul, Turkey
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Leberer D, Elliott JO, Dominguez E. Patient characteristics, outcomes and costs following interhospital transfer to a tertiary facility for appendectomy versus patients who present directly. Am J Surg 2017; 214:825-830. [PMID: 28129917 DOI: 10.1016/j.amjsurg.2017.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/06/2017] [Accepted: 01/08/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent healthcare policy changes have emphasized pay-for-performance. Previous studies have not examined outcome differences between primary presenting appendicitis patients and transferred patients. METHODS A retrospective cohort design examined appendicitis patients between March 2011 and 2013. Patients < age 18, were scheduled for an elective appendectomy, who were pregnant or had an interval appendectomy were excluded. RESULTS The transfer cohort (n = 59) had more comorbidities, more severe American Society of Anesthesiologists status, a higher rate of pre-operative abscess/rupture as well as higher rates of perforation, gangrene, intra-operative drain placement and open conversion versus primary presenting patients (n = 622). After statistical regression adjustment, a higher open conversion rate in the transfer cohort, OR = 3.48 (95%CI: 1.04-11.61) and higher total costs $672.47 (95%CI: $68.75-$1276.19) remained. CONCLUSIONS Adjustments in clinical outcome/reimbursement metrics may be needed to address the complexity of transfers and the subsequent higher in-hospital costs on tertiary facilities. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Daniel Leberer
- Department of Surgery, Colon and Rectal Surgery Fellowship, University at Buffalo State, Buffalo, NY, USA.
| | | | - Edward Dominguez
- Department of General Surgery, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA; Department of Medical Education, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA.
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Feng C, Anandalwar S, Sidhwa F, Glass C, Karki M, Zurakowski D, Rangel SJ. Beyond perforation: Influence of peritoneal contamination on clinical severity and resource utilization in children with perforated appendicitis. J Pediatr Surg 2016; 51:1896-1899. [PMID: 27622589 DOI: 10.1016/j.jpedsurg.2016.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of the study was to explore the relationship between the degree of peritoneal contamination and postoperative resource utilization in children with complicated appendicitis. METHODS Intraoperative findings were collected prospectively at a single children's hospital from 2012 to 2014. The degree of peritoneal contamination was categorized as either "localized" (confined to the right lower quadrant and pelvis) or "extensive" (extending to the liver). Imaging utilization, postoperative length of stay (pLOS), hospital cost, and readmission rates were compared between groups. RESULTS Of 88 patients with complicated appendicitis, 38% had extensive contamination. Preoperative characteristics were similar between groups. Patients with extensive contamination had higher rates of postoperative imaging (58.8% vs 27.7%, P<0.01), a 50% longer median pLOS (6days [IQR 4-9] vs 4days [IQR 2-5], P=0.003), a 30% higher median hospital cost ($17,663 [IQR $12,564-$23,697] vs $13,516 [IQR $10,546-$16,686], P=0.004), and a nearly four-fold higher readmission rate (20.6% vs 5.6%, P=0.04) compared to children with localized contamination. CONCLUSION Extensive peritoneal contamination is associated with significantly higher resource utilization compared to localized contamination in children with complicated appendicitis. These findings may have important severity-adjustment implications for reimbursement and readmission rate reporting for hospitals that serve populations where late presentation is common.
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Affiliation(s)
| | | | | | | | - Mahima Karki
- Boston Children's Hospital, Department of Surgery
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Scott JW, Havens JM, Wolf LL, Zogg CK, Rose JA, Salim A, Haider AH. Insurance status is associated with complex presentation among emergency general surgery patients. Surgery 2016; 161:320-328. [PMID: 27712875 DOI: 10.1016/j.surg.2016.08.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/29/2016] [Accepted: 08/29/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients. METHODS Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance. RESULTS A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population. CONCLUSION Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations.
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Affiliation(s)
- John W Scott
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
| | - Joaquim M Havens
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - Lindsey L Wolf
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - John A Rose
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA
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Borgstrom DC, Lopez M, Hoesterey D, Victory J, Urayeneza O. Management of acute appendicitis in a rural population. Am J Surg 2016; 212:451-4. [PMID: 26867479 DOI: 10.1016/j.amjsurg.2015.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 11/29/2022]
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Drake FT, Mottey NE, Castelli AA, Florence MG, Johnson MG, Steele SR, Thirlby RC, Flum DR. Time-of-day and appendicitis: Impact on management and outcomes. Surgery 2016; 161:405-414. [PMID: 27592212 DOI: 10.1016/j.surg.2016.06.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/13/2016] [Accepted: 06/23/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that affect the ability to present for evaluation are influenced by time of day (eg, child care, work, transportation, and office hours of primary care settings). Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time of day. METHODS The study evaluated a prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to operation, imaging use, negative appendectomy, and perforation were compared using univariate and multivariate methodologies. RESULTS Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, comorbid conditions, and white blood cell count did not differ by presentation time. Daytime presenters (6 am to 6 pm) were less likely to undergo imaging (94% vs 98%, P < .05) and had a nearly 50% decrease in median preoperative time (6.0 h vs 8.7 h, P < .001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9 am to 3 pm) had a 30% increase in odds of perforation compared with patients presenting in the early morning/late night (adjusted odds ratio 1.29, 95% confidence interval, 1.05-1.59). Negative appendectomy did not vary by time-of-day. CONCLUSION Most patients with appendicitis presented in the afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared with those who presented early morning or late night. Processes of care differed (both time-to-operation and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this association has implications for the planning of the surgical workforce and efforts directed at quality improvement.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, Division of Endocrine Surgery, University of California, San Francisco Medical Center, San Francisco, CA; Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA.
| | - Neli E Mottey
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Anthony A Castelli
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | | | | | - Scott R Steele
- Department of Surgery, Case Western Reserve University, Cleveland, OH
| | | | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA
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- Surgical Care and Outcomes Assessment Program (SCOAP) and the Comparative Effectiveness Research Translation Network (CERTAIN)
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Sun E, Dexter F, Miller TR. The Effect of “Opt-Out” Regulation on Access to Surgical Care for Urgent Cases in the United States. Anesth Analg 2016; 122:1983-91. [DOI: 10.1213/ane.0000000000001154] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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AbuAlRub R, El-Jardali F, Jamal D, Abu Al-Rub N. Exploring the relationship between work environment, job satisfaction, and intent to stay of Jordanian nurses in underserved areas. Appl Nurs Res 2015; 31:19-23. [PMID: 27397813 DOI: 10.1016/j.apnr.2015.11.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 11/20/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
Abstract
AIMS The aims of this study are to (1) examine the relationships between work environment, job satisfaction and intention to stay at work; and (2) explore the predicting factors of intention to stay at work among nurses in underserved areas. BACKGROUND Developing and fostering creative work environment are paramount especially in underserved areas, where the work conditions present many challenges. METHODS A descriptive correlational design was utilized to collect data from 330 hospital nurses who worked in two underserved governorates in Jordan. A set of instruments were used to measure the variables of the study. RESULTS The results showed a strong positive association between job satisfaction and work environment. The results of logistic regression indicated receiving housing, job satisfaction, and work environment were the predicting variables of the level of intention to stay at work. CONCLUSION It is critical to improve work conditions and create a culture of supportive work environment in underserved area.
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Affiliation(s)
- Raeda AbuAlRub
- Department of Community and mental Health Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan.
| | - Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Diana Jamal
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Influence of hospital and patient location on early postoperative outcomes after appendectomy and pyloromyotomy. J Pediatr Surg 2015; 50:1549-55. [PMID: 25962842 DOI: 10.1016/j.jpedsurg.2015.03.063] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 03/15/2015] [Accepted: 03/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effects of hospital location and designation on postoperative pediatric outcomes remain unclear. We hypothesized that urban hospital outcomes would be superior to rural hospitals, and that outcomes at urban centers would differ for children from rural versus urban counties. METHODS Retrospective cohort study of children undergoing appendectomy (n=129,507) and pyloromyotomy (n=13,452) using the 2006/2009 KID databases. Hospitals were characterized by specialty designation and classified as urban/rural. County of residence was classified as urban/rural. Outcomes included complications and length of stay. Multivariate regression models were used to adjust for confounding. RESULTS Among appendectomy patients, treatment at urban hospitals was associated with reduced odds of any postoperative complication (OR=0.77, 95% C.I. 0.70-0.85) and anesthesia-related complications (OR=0.72, 95% C.I. 0.57-0.91). This association was strongest in the youngest children (<5 years) and at children's hospitals. For pyloromyotomy patients, urban hospitals were associated with reduced odds of any complication (OR=0.43, 95% C.I. 0.24-0.75), anesthesia-related complications (OR=0.14, 95% C.I. 0.05-0.37), and duodenal perforation (OR=0.46, 95% C.I. 0.19-1.07). These associations were most significant at children's hospitals. CONCLUSIONS Postoperative outcomes appear to be improved at urban specialty hospitals relative to rural hospitals for certain common pediatric procedures. Identification of the factors driving this association may help inform resource optimization efforts in pediatric surgery.
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Hauenstein EJ, Glick DF, Kane C, Kulbok P, Barbero E, Cox K. A Model to Develop Nurse Leaders for Rural Practice. J Prof Nurs 2014; 30:463-73. [DOI: 10.1016/j.profnurs.2014.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Indexed: 12/29/2022]
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Drake FT, Mottey NE, Farrokhi ET, Florence MG, Johnson MG, Mock C, Steele SR, Thirlby RC, Flum DR. Time to appendectomy and risk of perforation in acute appendicitis. JAMA Surg 2014; 149:837-44. [PMID: 24990687 DOI: 10.1001/jamasurg.2014.77] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. OBJECTIVE To evaluate whether there is an association between time and perforation after patients present to the hospital. DESIGN, SETTING, AND PARTICIPANTS Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. MAIN OUTCOMES AND MEASURES The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. RESULTS A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance. CONCLUSIONS AND RELEVANCE There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle3Department of Global Health, University of Washington, Seattle
| | - Neli E Mottey
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle
| | - Ellen T Farrokhi
- University of Washington Surgical Outcomes Research Center, Seattle4Providence Regional Medical Center, Everett, Washington
| | | | | | - Charles Mock
- Department of Surgery, University of Washington Medical Center, Seattle3Department of Global Health, University of Washington, Seattle
| | - Scott R Steele
- Department of Surgery, Madigan Army Medical Center, Ft Lewis, Tacoma, Washington
| | - Richard C Thirlby
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - David R Flum
- Department of Surgery, University of Washington Medical Center, Seattle2University of Washington Surgical Outcomes Research Center, Seattle
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Perforated appendicitis: does rural residency really explain the delay? Ann Surg 2014; 259:e58. [PMID: 24608400 DOI: 10.1097/sla.0000000000000303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bailey BA, Manning T, Peiris AN. The impact of living in rural and urban areas: vitamin D and medical costs in veterans. J Rural Health 2013; 28:356-63. [PMID: 23017006 DOI: 10.1111/j.1748-0361.2012.00407.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Living in a rural region is associated with significant health disparities and increased medical costs. Vitamin D deficiency, which is increasingly common, is also associated with many adverse health outcomes. The purpose of this study was to determine whether rural-urban residence status of veterans was related to vitamin D levels, and to determine if this factor also influenced medical costs/service utilization. Additionally explored was whether vitamin D differences accounted for part of the association between area of residence and medical costs/service utilization. METHODS Medical records of 9,396 veterans from 6 Veterans Administration Medical Centers were reviewed for variables of interest including county of residence, vitamin D level, medical costs and service utilization, and background variables. Rurality status was classified as large metropolitan, urban, and rural. FINDINGS The 3 rurality status groups differed significantly in vitamin D levels, with the highest levels observed for urban residents, followed by rural residents, and the lowest for large metro residents. Compared with urban residents, large metro residents were 49% more likely, while rural residents were 20% more likely, to be vitamin D deficient. Both rural and large metro residents had higher medical costs, and they were significantly more likely to be hospitalized. Vitamin D levels explained a statistically significant amount of the relationship between rurality status and medical costs/service utilization. CONCLUSIONS Vitamin D deficiency may be an additional health disparity experienced by both rural and inner-city veterans, and patients residing in these locations should be considered at increased risk for deficiency and routinely tested.
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Affiliation(s)
- Beth A Bailey
- Department of Family Medicine, East Tennessee State University, Johnson City, Tennessee 37684, USA.
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Paquette IM, Finlayson SR. Rural surgical workforce and care of colorectal disease. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2013.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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