Patient and Hospital Characteristics Associated With Delayed Diagnosis of Appendicitis

Abstract

ImportanceRacial disparities in timely diagnosis and treatment of surgical conditions exist; however, it is poorly understood whether there are hospital structural measures or patient-level characteristics that modify this phenomenon.ObjectiveTo assess whether patient race and ethnicity are associated with delayed appendicitis diagnosis and postoperative 30-day hospital use and whether there are patient- or systems-level factors that modify this association.Design, Setting, and ParticipantsThis population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project’s state inpatient and emergency department (ED) databases from 4 states (Florida, Maryland, New York, and Wisconsin) for patients aged 18 to 64 years who underwent appendectomy from January 7, 2016, to December 1, 2017. Data were analyzed from January 1, 2016, to December 31, 2017.ExposureDelayed diagnosis of appendicitis, defined as an initial ED presentation with an abdominal diagnosis other than appendicitis followed by re-presentation within a week for appendectomy.Main Outcomes and MeasuresA mixed-effects multivariable Poisson regression model was used to estimate the association of delayed diagnosis of appendicitis with race and ethnicity while controlling for patient and hospital variables. A second mixed-effects multivariable Poisson regression model quantified the association of delayed diagnosis of appendicitis with postoperative 30-day hospital use.ResultsOf 80 312 patients who received an appendectomy during the study period (median age, 38 years [IQR, 27-50 years]; 50.8% female), 2013 (2.5%) experienced delayed diagnosis. In the entire cohort, 2.9% of patients were Asian or Pacific Islander, 18.8% were Hispanic, 10.9% were non-Hispanic Black, 60.8% were non-Hispanic White, and 6.6% were other race and ethnicity; most were privately insured (60.2%). Non-Hispanic Black patients had a 1.41 (95% CI, 1.21-1.63) times higher adjusted rate of delayed diagnosis compared with non-Hispanic White patients. Patients at hospitals with a more than 50% Black or Hispanic population had a 0.73 (95% CI, 0.59-0.91) decreased adjusted rate of delayed appendicitis diagnosis compared with hospitals with a less than 25% Black or Hispanic population. Conversely, patients at hospitals with more than 50% of discharges of Medicaid patients had a 3.51 (95% CI, 1.69-7.28) higher adjusted rate of delayed diagnosis compared with hospitals with less than 10% of discharges of Medicaid patients. Additional factors associated with delayed diagnosis included female sex, higher levels of patient comorbidity, and living in a low-income zip code. Delayed diagnosis was associated with a 1.38 (95% CI, 1.36-1.61) increased adjusted rate of postoperative 30-day hospital use.Conclusions and RelevanceIn this cohort study, non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis and 30-day hospital use than White patients. Patients presenting to hospitals with a greater than 50% Black and Hispanic population were less likely to experience delayed diagnosis, suggesting that seeking care at a hospital that serves a diverse patient population may help mitigate the increased rate of delayed diagnosis observed for non-Hispanic Black patients.

Emergency Department Volume and Delayed Diagnosis of Pediatric Appendicitis

“…The diagnoses at the preceding encounters of patients with delay appeared related to the ultimate diagnosis of appendicitis, with abdominal conditions accounting for more than 90%. Regardless of the threshold of certainty used to define delayed diagnosis, the volume-delay association was consistent, and similar to prior estimates 25 …”

“…Regardless of the threshold of certainty used to define delayed diagnosis, the volume-delay association was consistent, and similar to prior estimates. 25 What can be done to improve diagnostic timeliness for pediatric appendicitis? First, evidence-based abdominal pain protocols for children should be available and applied in all emergency care settings.…”

Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis

“…It was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to subsequent appendectomy encounter. [1][2][3]14 The timing variable (coded as DaysToEvent) was created with the appendectomy encounter day as the day 0. This variable allowed determination of whether a patient had an emergency department or inpatient hospital encounter in the 7 days preceding their appendectomy.…”

Understanding the Social Determinants of Surgical Evaluation—Going Beyond Signs and Symptoms

“…In this issue of JAMA Surgery , Reyes et al investigated a number of social determinants of patients with delayed diagnosis of appendicitis by taking a large data set from the Agency for Healthcare Research and Quality and linking it to the State Emergency Department Databases drawn from 4 US states: Florida, Maryland, New York, and Wisconsin. Cases of delayed diagnosis were defined as patients who had been evaluated and discharged from the emergency department in the 7 days preceding an appendectomy.…”

“…Focusing on race, the study found that Asian/Pacific Islander patients, Hispanic patients, non-Hispanic White patients, and other races had similar rates of delayed diagnosis, whereas non-Hispanic Black patients had a 41% higher rate of delayed diagnosis, independent of the other social determinants evaluated in the study . The robustness of this finding was confirmed in rigorous post hoc sensitivity analysis using first a cohort of patients with low comorbidities and again on another cohort of patients with private insurance in high-income areas.…”