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County Versus Private Hospitals: Access of Care, Management and Outcomes for Patients with Appendicitis

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      Abstract

      Adult patients with appendicitis treated at a safety-net hospital were of lower socioeconomic background and had higher appendiceal perforation rates and longer lengths of hospitalization.

      Abstract

      Background and Objectives:

      Race/ethnicity and socioeconomic status may affect healthcare access (higher appendiceal perforation [AP] rates), management (lower laparoscopic appendectomy [LA] rates), and outcomes in patients with appendicitis. This study determines if disparities exist between county and private hospitals.

      Methods:

      A review of patients ≥18 years treated for appendicitis from 1998 through 2007 was performed. Data from a county hospital were compared to data from 12 private hospitals. Study outcomes included length of hospitalization (LOH), and rates of AP, LA, and abscess drainage. Predictor variables collected included age, sex, race/ethnicity, per-capita income, and hospital type.

      Results:

      For this study, 16,512 patients were identified (county=1,293, private=15,219). On univariate analysis, patients at the county hospital had lower mean per-capita incomes ($13,412 vs. $17,584, P<.0001), similar AP rates at presentation (26% vs. 24%, P=.10), and lower abscess drainage (0.2% vs. 2.1%, P<.0001). However, multivariate analysis demonstrated a higher AP (OR 1.4, CI 1.2–1.6) and LA rate (OR 1.9, CI 1.7–2.2), a lower abscess drainage rate (0.07, 95%CI 0.02–0.27), and longer LOH (parameter estimate = 0.4, P<.0001) at the county hospital. Within the county hospital cohort, LOH and rates of AP, LA, and abscess drainage were similar across all races/ethnicities and income levels.

      Conclusions:

      When compared to private hospital patients, adults with appendicitis treated at a county hospital were of lower socioeconomic background, had higher AP rates and longer LOH, but were more likely to undergo LA and less likely to require abscess drainage. Since racial and socioeconomic disparities were no longer apparent once within the county hospital cohort, these differences may be due to differences in access to healthcare.

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      Most cited references 15

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      Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology.

       John Krieger (1992)
      Most US medical records lack socioeconomic data, hindering studies of social gradients in health and ascertainment of whether study samples are representative of the general population. This study assessed the validity of a census-based approach in addressing these problems. Socioeconomic data from 1980 census tracts and block groups were matched to the 1985 membership records of a large prepaid health plan (n = 1.9 million), with the link provided by each individual's residential address. Among a subset of 14,420 Black and White members, comparisons were made of the association of individual, census tract, and census block-group socioeconomic measures with hypertension, height, smoking, and reproductive history. Census-level and individual-level socioeconomic measures were similarly associated with the selected health outcomes. Census data permitted assessing response bias due to missing individual-level socioeconomic data and also contextual effects involving the interaction of individual- and neighborhood-level socioeconomic traits. On the basis of block-group characteristics, health plan members generally were representative of the total population; persons in impoverished neighborhoods, however, were underrepresented. This census-based methodology offers a valid and useful approach to overcoming the absence of socioeconomic data in most US medical records.
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        Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children.

        The rates of appendiceal rupture and negative appendectomy in children remain high despite efforts to reduce them. Both outcomes are used as measures of hospital quality. Little is known about the factors that influence these rates. To investigate the association between hospital- and patient-level characteristics and the rates of appendiceal rupture and negative appendectomy in children. Retrospective review using the Pediatric Health Information System database containing information on 24,411 appendectomies performed on children aged 5 to 17 years at 36 pediatric hospitals in the United States between 1997 and 2002. Rates of negative appendectomy and appendiceal rupture; the odds ratio (OR) of negative appendectomy and appendiceal rupture by hospital, patient age, race, and health insurance status, and hospital fiscal year and appendectomy volume. Negative appendectomy rate was defined as the number of patients with appendectomy but without appendicitis divided by the total number of appendectomies. The median negative appendectomy rate was 3.06% (range, 1%-12%) and the median appendiceal rupture rate was 35.08% (range, 22%-62%). The adjusted OR for appendiceal rupture was higher in Asian children (1.66; 95% confidence interval [CI], 1.24-2.23) and black children (1.13; 95% CI, 1.01-1.30) compared with white children. Children without health insurance and children with public insurance had increased odds of appendiceal rupture compared with children who had private health insurance (adjusted OR, 1.36; 95% CI, 1.22-1.53 for self-insured; adjusted OR, 1.48; 95% CI, 1.34-1.64 for public 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. The rate of appendiceal rupture in school-aged children was associated with race and health insurance status and not with negative appendectomy rate and therefore is more likely to be associated with prehospitalization factors such as access to care, quality of care, and patient or physician education.
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          Insurance-related differences in the risk of ruptured appendix.

          We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage. In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989. After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]). Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.
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            Author and article information

            Affiliations
            Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
            Department of Surgery, UCLA, Los Angeles, California, USA
            Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
            Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.
            Author notes

            Presented at the 20 th Society of Laparoendoscopic Surgeons Anniversary Meeting and Endo Expo 2011, Los Angeles, California, USA, September 14–17, 2011.

            Address correspondence to: Steven L. Lee, MD, Division of Pediatric Surgery, Harbor-UCLA Medical Center, 1000 W Carson Street, Box 25, Torrance, CA, 90509, USA., Telephone: (310) 222-2706; Fax: (310) 782-1562, E-mail: slleemd@ 123456yahoo.com
            Contributors
            Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
            ,
            Department of Surgery, UCLA, Los Angeles, California, USA
            Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
            Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.
            Journal
            JSLS
            JSLS
            jsls
            jsls
            JSLS
            JSLS : Journal of the Society of Laparoendoscopic Surgeons
            Society of Laparoendoscopic Surgeons (Miami, FL )
            1086-8089
            1938-3797
            Apr-Jun 2012
            : 16
            : 2
            : 283-286
            3481221
            11-09-141
            10.4293/108680812X13427982376509
            © 2012 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

            This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

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            Categories
            Scientific Papers

            Surgery

            healthcare disparities, appendicitis, laparoscopic appendectomy

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