According to background information in the article, the primary adverse outcome of appendicitis is appendiceal (appendix) rupture. Patients with a ruptured appendix at the time of surgical exploration have as high as a 39 percent chance of having a postsurgical complication, such as intra-abdominal abscess or wound infection, compared with an approximately 8 percent chance if the appendix is not perforated. It has been assumed that the natural history of appendix rupture is within the control of the hospital or physician and that a high rate of rupture reflects a failure of medical care.
Given the difficulty of diagnosing appendicitis in both children and adults, the traditional approach by hospitals to decrease the rupture rate has been to encourage early surgical exploration. In fact, high rates of negative exploration for appendicitis have been tolerated to lessen the likelihood of ruptured appendicitis and its complications. In essence, one complication (a negative exploration) is encouraged to decrease the incidence of another complication (appendiceal rupture). Rates for both of these in children remain high despite efforts to reduce them. Little is known about the factors that influence these rates.
Todd A. Ponsky, M.D., of Children's National Medical Center and George Washington University Medical Center, Washington, D.C., and colleagues examined the patterns of diagnosis and care of children aged 5 to 17 years with appendicitis at 36 major children's hospitals to assess the contributions of race, health insurance status, age, sex, and hospital volume on the ruptured appendicitis rate. They also evaluated the correlation between rupture rate and negative appendectomy rate (surgical removal of a nondiseased appendix). The researchers reviewed a database containing information on 24,411 appendectomies performed on children in the United States between 1997 and 2002.
The researchers found that the average negative appendectomy rate was 3 percent and the average appendix rupture rate was 35 percent. The rupture rate was 66 percent higher in Asian children and 13 percent higher in black children compared with white children. Children without health insurance had a 36 percent increased likelihood for an appendix rupture and children with Medicaid insurance had a 48 percent increased likelihood compared with children who had private health insurance. No correlation existed between negative appendectomy rate and race, health insurance status, or hospital appendiceal rupture rate. The negative appendectomy rate improved as the hospital appendectomy volume increased.
"These findings present a dual challenge for improving the outcomes of children with appendicitis. The low negative appendectomy rates and the relationship between hospital volume and negative appendectomy rate suggest potential opportunities for improvement at the hospital level. Efforts to reduce the incidence of appendiceal rupture should focus on prehospital care. The findings of disparate care by race and health insurance status are troubling. A public health paradigm with concentration on access to care and quality-of-care issues as well as family and physician education might facilitate earlier diagnosis and intervention. The excessively high rates of appendiceal rupture in children should no longer be tolerated," the authors conclude.
(JAMA. 2004; 292:1977-1982. Available post-embargo at www.jama.com.)
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