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      Incidence of Appendicitis over Time: A Comparative Analysis of an Administrative Healthcare Database and a Pathology-Proven Appendicitis Registry

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          Abstract

          Importance

          At the turn of the 21 st century, studies evaluating the change in incidence of appendicitis over time have reported inconsistent findings.

          Objectives

          We compared the differences in the incidence of appendicitis derived from a pathology registry versus an administrative database in order to validate coding in administrative databases and establish temporal trends in the incidence of appendicitis.

          Design

          We conducted a population-based comparative cohort study to identify all individuals with appendicitis from 2000 to2008.

          Setting & Participants

          Two population-based data sources were used to identify cases of appendicitis: 1) a pathology registry (n = 8,822); and 2) a hospital discharge abstract database (n = 10,453).

          Intervention & Main Outcome

          The administrative database was compared to the pathology registry for the following a priori analyses: 1) to calculate the positive predictive value (PPV) of administrative codes; 2) to compare the annual incidence of appendicitis; and 3) to assess differences in temporal trends. Temporal trends were assessed using a generalized linear model that assumed a Poisson distribution and reported as an annual percent change (APC) with 95% confidence intervals (CI). Analyses were stratified by perforated and non-perforated appendicitis.

          Results

          The administrative database (PPV = 83.0%) overestimated the incidence of appendicitis (100.3 per 100,000) when compared to the pathology registry (84.2 per 100,000). Codes for perforated appendicitis were not reliable (PPV = 52.4%) leading to overestimation in the incidence of perforated appendicitis in the administrative database (34.8 per 100,000) as compared to the pathology registry (19.4 per 100,000). The incidence of appendicitis significantly increased over time in both the administrative database (APC = 2.1%; 95% CI: 1.3, 2.8) and pathology registry (APC = 4.1; 95% CI: 3.1, 5.0).

          Conclusion & Relevance

          The administrative database overestimated the incidence of appendicitis, particularly among perforated appendicitis. Therefore, studies utilizing administrative data to analyze perforated appendicitis should be interpreted cautiously.

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          Most cited references22

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          The epidemiology of appendicitis and appendectomy in the United States.

          DAVID G ADDISS, NATHAN SHAFFER, BARBARA S. FOWLER … (1990)
          To describe the epidemiology of appendicitis and appendectomy in the United States, the authors analyzed National Hospital Discharge Survey data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in the United States during this period, accounting for an estimated 1 million hospital days per year. The highest incidence of primary positive appendectomy (appendicitis) was found in persons aged 10-19 years (23.3 per 10,000 population per year); males had higher rates of appendicitis than females for all age groups (overall rate ratio, 1.4:1). Racial, geographic, and seasonal differences were also noted. Appendicitis rates were 1.5 times higher for whites than for nonwhites, highest (15.4 per 10,000 population per year) in the west north central region, and 11.3% higher in the summer than in the winter months. The highest rate of incidental appendectomy was found in women aged 35-44 years (43.8 per 10,000 population per year), 12.1 times higher than the rate for men of the same age. Between 1970 and 1984, the incidence of appendicitis decreased by 14.6%; reasons for this decline are unknown. A life table model suggests that the lifetime risk of appendicitis is 8.6% for males and 6.7% for females; the lifetime risk of appendectomy is 12.0% for males and 23.1% for females. Overall, an estimated 36 incidental procedures are performed to prevent one case of appendicitis; for the elderly, the preventive value of an incidental procedure is considerably lower.
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            Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management.

            David Haley, Edward Livingston, Amanda L. Woodward … (2007)
            Appendicitis has been declining in frequency for several decades. During the past 10 years, its preoperative diagnosis has been made more reliable by improved computed tomography (CT) imaging. Thresholds for surgical exploration have been lowered by the increased availability of laparoscopic exploration. These innovations should influence the number of appendectomies performed in the United States. We analyzed nationwide hospital discharge data to study the secular trends in appendicitis and appendectomy rates. All appendicitis and appendiceal operations reported to the National Hospital Discharge Survey (NHDS) 1970-2004 were classified as perforated, nonperforated, negative, and incidental appendectomies and analyzed over time and by various demographic measures. Secular trends in the population-based incidence rates of nonperforated and perforated appendicitis and negative and incidental appendectomy were examined. Nonperforated appendicitis rates decreased between 1970 and 1995 but increased thereafter. The 25-year decreasing trend was accounted for almost entirely by a decreasing incidence in the 10-19 year age group. The rise after 1995 occurred in all age groups above 5 years and paralleled increasing rates of CT imaging and laparoscopic surgery on the appendix. Since 1995 the negative appendectomy rate has been falling, especially in women, and incidental appendectomies, frequent in prior decades, have been rarely performed. Despite these large changes, the rate of perforated appendicitis has increased steadily over the same period. Although perforated and nonperforated appendicitis rates were correlated in men, they were not significantly correlated in women nor were there significant negative correlations between perforated and negative appendectomy rates. The 25-year decline in nonperforated appendicitis and the recent increase in appendectomies coincident with more frequent use of CT imaging and laparoscopic appendectomies did not result in expected decreases in perforation rates. Similarly, time series analysis did not find a significant negative relationship between negative appendectomy and perforation rates. This disconnection of trends suggests that perforated and nonperforated appendicitis may have different pathophysiologies and that nonoperative management with antibiotic therapy may be appropriate for some initially nonperforated cases. Further efforts should be directed at identifying preoperative characteristics associated with nonperforating appendicitis that may eventually allow surgeons to defer operation for those cases of nonperforating appendicitis that have a low perforation risk.
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              Changing epidemiology of acute appendicitis in the United States: study period 1993-2008.

              Michelle Buckius, Vanita Ahuja, Jordana Bell … (2012)
              Addis et al. [5] described the epidemiology of appendicitis in the United States from 1970 to 1984. He reported that while overall incidence decreased, the highest incidence of appendicitis occurred in 10- to 19-y-olds. This study examines if the incidence of appendicitis and mean age of diagnosis has changed, and whether demographics are related to the frequency of admissions and incidence rate of acute appendicitis (AA). Study questions were assessed using the Nationwide Inpatient Sample (NIS) discharge data and US Census data from 1993-2008. Operatively managed, uncomplicated, and complex cases of AA were included. Incidental appendectomy and right hemicolectomy were excluded. Descriptive, ANOVA, χ(2), and test of proportion statistics were used to evaluate frequency of admissions, incidence rate, and demographic changes in appendicitis. The annual rate of AA increased from 7.62 to 9.38 per 10,000 between 1993 and 2008. The highest frequency of AA was found in the 10-19 y age group, however occurrence in this group decreased by 4.6%. Persons between ages 30 and 69 y old experienced an increase of AA by 6.3%. AA rates remained higher in males. Hispanics, Asians, and Native Americans saw a rise in the frequency of AA, while the frequencies among Whites and Blacks decreased. While AA is most common in persons 10- to 19-y old, the mean age at diagnosis has increased over time. Minorities are experiencing an increase in the frequency of appendicitis. The changing demographics of the US plays a role in the current epidemiology of appendicitis, but is not solely responsible for the change observed. Copyright © 2012 Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Neil R. Smalheiser: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 7 November 2016
                Publication date Collection: 2016
                Volume: 11
                Issue: 11
                Electronic Location Identifier: e0165161
                Affiliations
                [1 ]Department of Medicine, University of Calgary, Calgary, AB, Canada
                [2 ]Community Health Sciences, University of Calgary, Calgary, AB, Canada
                [3 ]Information Management and Dissemination, Medicine, Alberta Health Services, Calgary, Alberta, Canada
                [4 ]Department of Surgery, University of Calgary, Calgary, AB, Canada
                University of Illinois-Chicago, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: SC HK ED CGB SJH SG GGK.

                • Data curation: SC SZ GGK.

                • Formal analysis: SC SJH SZ GGK.

                • Investigation: SC HK SZ GGK.

                • Methodology: SC FC ED CGB SG MS GGK.

                • Project administration: GGK.

                • Software: SZ.

                • Supervision: GGK.

                • Validation: SC HK ED CGB GGK.

                • Visualization: SC.

                • Writing – original draft: SC HK GGK.

                • Writing – review & editing: FC SZ ED CGB SJH MS SG.

                Author information
                http://orcid.org/0000-0003-2719-0556
                Article
                Publisher ID: PONE-D-15-51291
                DOI: 10.1371/journal.pone.0165161
                PMC ID: 5098829
                PubMed ID: 27820826
                SO-VID: b36381b5-bba3-4b45-a5c6-58eb59a72edb
                Copyright © © 2016 Coward et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 13 December 2015
                Date accepted : 7 October 2016
                Page count
                Figures: 2, Tables: 3, Pages: 12
                Funding
                Dr. Kaplan is supported through a New Investigator Award from the Canadian Institute of Health Research and a Population Health Investigator Award from Alberta-Innovates Health-Solutions. Stephanie Coward is supported by an Eyes High Doctoral Recruitment Scholarship from the University of Calgary. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Gastroenterology and Hepatology
                Subject: Appendicitis
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Services Administration and Management
                Subject: Biology and Life Sciences
                Subject: Cell Biology
                Subject: Cellular Types
                Subject: Animal Cells
                Subject: Immune Cells
                Subject: Antigen-Presenting Cells
                Subject: Biology and Life Sciences
                Subject: Immunology
                Subject: Immune Cells
                Subject: Antigen-Presenting Cells
                Subject: Medicine and Health Sciences
                Subject: Immunology
                Subject: Immune Cells
                Subject: Antigen-Presenting Cells
                Subject: Medicine and Health Sciences
                Subject: Surgical and Invasive Medical Procedures
                Subject: Digestive System Procedures
                Subject: Appendectomy
                Subject: People and places
                Subject: Geographical locations
                Subject: North America
                Subject: Research and Analysis Methods
                Subject: Database and Informatics Methods
                Subject: Database Searching
                Subject: Research and Analysis Methods
                Subject: Mathematical and Statistical Techniques
                Subject: Statistical Methods
                Subject: Physical Sciences
                Subject: Mathematics
                Subject: Statistics (Mathematics)
                Subject: Statistical Methods
                Subject: Medicine and Health Sciences
                Subject: Pathology and Laboratory Medicine
                Subject: Clinical Pathology
                Custom metadata
                Data Availability All aggregate level data are available in the manuscript and appendices. Individual data are not available for open access due to legal and ethics restrictions on patient privacy contained in the Health Information Act ( http://www.health.alberta.ca/about/health-legislation.html). Data is derived from administrative data that is restricted by the data custodians: The Analytics unit of Alberta Health Services. The Alberta SPOR Support Unit can be contacted for information on access to this data including appropriate ethical approval and data sharing agreements. To contact the Alberta SPOR Support Unit visit their website at https://sporresources.researchalberta.ca/.

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