Acute Appendicitis in Latino Children: Do Health Disparities Exist?

Journal of Surgical Research 163, 290–293 (2010) doi:10.1016/j.jss.2010.05.018

ASSOCIATION FOR ACADEMIC SURGERY Acute Appendicitis in Latino Children: Do Health Disparities Exist? Laura Boomer, M.D., Jennifer Freeman, M.D., Earl Landrito, B.S., and Alexander Feliz, M.D.1 Department of Surgery, Division of Pediatric Surgery, University of Nevada School of Medicine, Las Vegas, Nevada Submitted for publication January 9, 2010

Background. Significant racial and socioeconomic disparities have been found in the diagnosis and treatment of acute appendicitis in children. There has been little focus on the outcomes of Latino children with appendicitis. This study evaluates whether ethnicity or insurance status are associated with differences in presentation and outcomes of children with acute appendicitis. Materials and Methods. A retrospective analysis was performed for all children between the ages of 2 and 18 y with acute appendicitis between July 1, 2005 and December 31, 2008 at the only teaching hospital in the region. c2 and regression analyses were used to evaluate the impact of ethnicity and insurance status on perforation rates and outcomes. Results. A total of 410 children with acute appendicitis were identified, of whom 259 (63.2%) were Latino. Latino children were on public insurance in greater proportion (34.8% versus 19.9%) compared with nonLatino children (P [ 0.001). The perforation rate for the entire sample was 29.6%. There were no significant differences in perforation rates with respect to ethnicity, insurance status (private, public, none), or age. Once within the medical system, there were no significant differences in radiologic studies performed, types of operations received, length of stay, or number of complications between ethnic groups. Conclusions. There have been multiple reports showing disparities in the rates of perforated appendicitis in children. At our institution, we observed no differences in the presentation and care of children with acute appendicitis with respect to ethnicity and insurance status. Ó 2010 Elsevier Inc. All rights reserved.

1 To whom correspondence and reprint requests should be addressed at Department of Surgery, Division of Pediatric Surgery, University of Nevada School of Medicine, 2040 West Charleston Blvd. no. 601, Las Vegas, NV 89102. E-mail: afeliz@medicine. nevada.edu.

0022-4804/$36.00 Ó 2010 Elsevier Inc. All rights reserved.

Key Words: health disparity; Latino; children; appendicitis.

INTRODUCTION

Appendectomy is one of the most commonly performed surgical procedures in children. Appendicitis is a disease that cannot be prevented, but its treatment is timesensitive in order to achieve optimal results. In the United States, up to 35% of patients with acute appendicitis present with perforation prior to operative intervention [1]. Perforated appendicitis is associated with significant morbidity, longer hospital stays, and higher costs [2]. Thus, reduction of perforation rates is of paramount importance in order to reduce complications and morbidity. Due to its frequency, natural disease progression, and standardized treatment, appendicitis provides a good model to assess disparities in health care utilization and outcome. Health disparities have been well defined and are a political focus of Healthy People 2010 [3]. Barriers to access to quality health care are often related to low socioeconomic status. There is mounting evidence that when controlling for socioeconomic factors such as income and insurance status, health care disparities persist among racial and ethnic minority groups [1, 3–8]. Most of the research on health disparities has not focused on illnesses in children. More recently, several studies on evaluated health disparities in pediatric patients with various diseases such as asthma, diabetes, and appendicitis [2, 5, 9]. Significant disparities in acute appendicitis have been demonstrated based on racial, ethnic, and socioeconomic status, particular in large database, multicenter reviews [5, 6]. Higher perforation rates among children of ethnic and racial minority groups have been well documented [5]. However, few of these

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studies have focused on the Latino population. The purpose of this study is to examine whether there are differences in outcomes for acute appendicitis depending on insurance status among Latino children.

TABLE 1 Social and Demographic Characteristics of Patients with Nonperforated and Perforated Appendicitis Nonperforated

MATERIALS AND METHODS After approval with a waiver of consent was obtained from the Institutional Review Board, a retrospective chart review was performed on all patients diagnosed with acute appendicitis treated at the University Medical Center of Southern Nevada, which is the only teaching hospital in the region. Using the International Classification for Disease, 9th revision (ICD-9) codes for appendicitis (specifically including 540.0, 540.1, 540.9, 541, and 542), were identified. All patients less than 18 y of age who were treated from July 1, 2005 through December 31, 2008 were included. Patients with incidental appendectomies performed during other operations were excluded. Variables of interest were: demographic characteristics of the patients, insurance status, duration of symptoms, pathologic characteristics, total number of hospital days, length of the time the patient had been symptomatic, imaging, type of operation performed, outcomes, and complications. Operative reports and pathology reports were reviewed to determine whether the appendix was perforated or non-perforated. Perforated appendicitis was specifically defined by characteristics reported by our pathologists, including gangrenous perforated appendicitis, transmural necrosis, and gross or microperforation. Patients were grouped by ethnicity (Caucasian, African American, Latino, or Asian) and insurance status (private, public, or none) in order to evaluate for differences in perforation rates. c2 test and logistical regression analyses were used to evaluate the impact of ethnicity and insurance status on outcome (Minitab 15 Statistical Software; Minitab Inc., Stage College, PA). Statistical significance was assigned at P < 0.05.

RESULTS

A total of 410 children with acute appendicitis were identified of whom 259 (63.2%) were Latino (Table 1). The perforation rate for the entire group was 29.6%. No significant differences were noted in perforation rates based on race or ethnic origin (P ¼ 0.780). Similarly, no significant difference was observed for perforation rates based on insurance status (P ¼ 0.436). Furthermore, no differences were noted based upon age (P ¼ 0.242) or gender (P ¼ 0.390). Compared with patients without perforation, patients with perforated appendicitis had significantly more complications (43.44% versus 7.93% for nonperforated appendicitis, P < 0.001) and required significantly longer hospital stays (6.95 6 4.4 d versus 2.67 6 2.41 d; P < 0.001). The mean duration of symptoms was longer in the perforated group than in the nonperforated group, however, the differences were not statistically significant (5.0 6 15.6 d versus 2.38 6 5.7 d, respectively, P ¼ 0.074). Table 2 displays the unadjusted odds ratios for perforation. Compared with privately insured patients, neither public insurance nor uninsured status was associated with a difference in perforation rate (odds ratio of 1.18 for public and 0.79 for uninsured, P ¼ 0.552 and 0.366, respectively). Similarly, no significant differ-

Variable

n

Total 290 Ethnicity Caucasian 65 Latino 179 African American 30 Asian 14 Insurance Private 148 Public 89 None 50 Age 5 24 6–12 120 13–17 146 Gender Male 182 Female 108 Radiology Imaging 241 No imaging 49 Surgeon General 163 Pediatric 127 Operation Laparoscopic 277 Open 13 Complications 23 Duration of symptoms 2.38 6 5.7 Hospital LOS 2.67 6 2.41

Perforated

%

n

%

70.4

122

29.6

69.9 69.1 75.0 77.8

28 80 10 4

30.1 30.9 25.0 22.2

69.5 74.2 65.8

65 31 26

30.5 25.8 34.2

63.2 67.8 74.1

14 57 51

36.8 32.2 25.9

68.9 73.0

82 40

31.1 27.0

68.1 84.5

113 9

31.9 15.5

71.2 69.4

66 56

28.2 30.6

P value

0.780

0.436

0.242

0.390

0.010

0.694

72.0 48.2 7.93

0.010 108 28.0 14 51.9 53 43.44 < 0.001 5.0 6 15.6 0.074 6.95 6 4.4 < 0.001

ences in odds ratios were associated with ethnicity (odds ratios of 1.04 for Latino, P ¼ 0.889; 0.77 for African Americans, P ¼ 0.550; and 0.66 for Asians, P ¼ 0.157). Patients with perforation were 10 times more likely to undergo open operation than those that were not perforated at presentation (P ¼ 0.038). Comparing Latino children and non-Latino children, 62.9% of the Latino children were male and 65.6% of the non-Latino children were male (P ¼ 0.593). Latino children were younger than non-Latinos (11.49 6 3.88 versus 13.2 6 3.31 y, P < 0.001). A greater proportion of Latino children were on public insurance (34.8% versus 19.9%) compared with non-Latino children (P ¼ 0.001). Despite these differences in insurance status, the Latino children did not have a significantly higher perforation rate (30.9% versus 27.8%, P ¼ 0.5111), and there were no differences in duration of symptoms prior to presentation (3.3 6 11.7 d in Latinos versus 2.88 6 5.33 d in non-Latinos, P ¼ 0.600). Once within the medical system, there were no significant differences in care provided (Table 3). Latino children received imaging studies 85.3% of the time and non-Latino children, 87.4% of the time (P ¼ 0.555).

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TABLE 2 Unadjusted Odds Ratio with Perforation

Variable Insurance status Private Public None Ethnicity Caucasian Latino African American Asian Operation Laparoscopy Conversion Open Age group 13–17 y 6–12 y 5 y

Unadjusted odds ratio with perforation

95% confidence interval

P value

1.00 1.18 0.79

(0.68, 2.07) (0.48, 1.31)

0.552 0.366

1.00 1.04 0.77 0.66

(0.62, 1.74) (0.33, 1.80) (0.62, 1.74)

0.889 0.550 0.157

1.00 2.14 10.26

(0.90, 5.09) (1.13, 92.83)

0.086 0.038

1.00 1.36 1.67

(0.87, 2.13) (0.80, 3.47)

0.179 0.170

Both Latino children and non-Latino children were most frequently treated using a laparoscopic approach (93.8% versus 92.7%, P ¼ 0.663). Latino children suffered complications more frequently than non-Latinos but the difference was not statistically significant (13.9% of non-Latino children versus 21.2% of Latino children, P ¼ 0.65). There were no differences in hospital length of stay between groups (3.92 6 3.47 d in Latinos versus 3.99 6 4.06 d in non-Latinos, P ¼ 0.851). Latino children were more likely to be operated on by a pediatric surgeon than non-Latino children (51% versus 33.8%, respectively, P ¼ 0.001). DISCUSSION

Appendicitis provides an excellent model for exploring healthcare disparities for a number of reasons. There is no known biologic or environmental predisposition to the development of the disease. It follows a predictable course and its treatment is standardized (appendectomy). Perforated appendicitis is associated with increased morbidity and healthcare cost [2]. The key observation in this study was that the outcomes for children with appendicitis, including the incidence of perforation, were not significantly associated with ethnicity or insurance status in the population treated at our institution. Our data echoes that reported by Nwomeh et al. in 2006 [2]. In that single institution trial, they also found no significant disparity in regards to race, insurance status, or income level. However, a number of studies have recently demonstrated increased perforation rates in pediatric appendicitis among racial and ethnic minority groups [4, 5]. Furthermore, these studies have suggested that perforation

rates may reflect limited access to quality emergency healthcare services. The majority of these studies employed large, multi-center databases [5]. Unfortunately, database studies may obscure regional and local differences in patient care and disparities. Furthermore, studies based upon these insurance databases can suffer from potential coding inaccuracies and limited patient information, including the inability to confirm pathologic results. The sample size in our study was only 410 children over a 3-y time period. This small sample size may be too underpowered to detect differences that may be present. Perhaps a longer timeframe would provide a more complete assessment of these potential differences. Another limitation of this study may be issues with accuracy of ethnic identification, which may be difficult to control for. Finally, due to our unique patient population and large percentage of Latino patients, our data may not reflect the health care climate in other communities. Guagliardo et al. demonstrated higher perforation rates in Latino and Asian children in California, whereas Asian and African American children experienced higher perforation rates in New York [6]. Some of these differences may have been related to immigration patterns, as immigrants may be at greater risk for delayed access to care. Up to 30% of immigrants are estimated to be illegal [10]. Immigration status may contribute to delayed presentation due to fear of deportation [10–12]. Furthermore, non-citizens, whether legal or undocumented, may have decreased access to health insurance due to eligibility restrictions of public health coverage [10]. The immigration status of the children in this study is difficult to assess in a retrospective manner. Parental information is requested. If this is provided, parental immigration status may not correlate with a child’s naturalization status and U.S. citizenship. In addition, few of their employers offer commercial health care and work for lower-income providers [10]. Lack of insurance also dictates that many lower-income patients do not have a consistent source of primary care, which may also contribute to delays in seeking medical attention. Finally, other economic difficulties, including lack of adequate transportation, may also perpetuate issues with access to medical care. Interestingly, in our community, there is a large population of Latino immigrants, many of whom are illegal immigrants. In spite of this, however, our results suggest that delays in accessing medical care and outcomes for children with appendicitis were no different for children with different ethnic backgrounds or insurance status. Our institution is the only public hospital in the region and has a good standing within the Latino community. We have 24 h in-house Spanish translators, as

BOOMER ET AL.: ACUTE APPENDICITIS IN LATINO CHILDREN

TABLE 3 Characteristic of Latino and Non-Latino Patients in the Study Group Non-Latino

Latino

Variable

n

%

n

%

Total Age Stage Acute Perforated Insurance Private Public None Gender Male Female Radiology Imaging No imaging Surgeon General Pediatric Operation Laparoscopic Open Complications Duration of symptoms Hospital LOS

151 13.2 6 3.31

36.8

259 11.49 6 3.88

63.2

109 42

72.2 27.8

179 80

69.1 30.9

96 30 25

63.6 19.9 16.6

116 89 51

45.3 34.8 19.9

99 52

65.6 34.4

163 96

62.9 37.1

132 19

87.4 12.6

221 38

85.3 14.7

100 51

66.2 33.8

127 132

49.0 51.0

140 11 21 2.88 6 5.33

92.7 7.3 13.9

P value

< 0.001 0.511

0.001

0.593

0.555

0.001

0.663

3.99 6 4.06

243 16 55 3.3 6 11.7 3.92 6 3.47

93.8 6.2 21.2

0.65 0.600 0.851

well as a phone translator service. We also have hospital staff members who reflect the ethnic diversity in the surrounding community. Our patient demographics are not representative of the population at large in this region. We had a significantly higher proportion of Latino children in our patient population than is consistent with the percentage of Latinos in our region. According to the U.S. Census Bureau (2006–2008), the population in Clark County is 27.7% Latino overall, and 39.5% of residents less that 18 y of age are Latino [13]. Pooling data from other institutions treating children in our area may alter the demographics of the sample and produce different results. This may explain the difference in our findings compared with those discussed in previous studies. It is possible that children treated at other hospitals have different insurance payer mixes. Including the data from the other hospitals in the area may yield a more complete picture as to the disparities that may be present in the local Latino community. Further study is required using pooled data from regions that have higher proportion of Latinos in their population. In conclusion, this study adds to the growing literature focusing on Latino populations in the United

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States. Institutions that provide culturally sensitive care and are trusted within the Latino community may facilitate a more timely presentation and thus reduce healthcare disparities in this patient population. Although our results differ from other studies that use administrative data bases, it adds to growing evidence showing that institutions that provide centralized culturally competent care may aid in the reduction of health disparities. The results of our individual center should be considered within a larger social framework. Local and regional differences in patient populations and health care practices should be focused on in order to improve the care for patients on a national level. Additional research looking at the differences in immigration status among the Latinos would provide additional information in defining the causes for differences in care and delays in care when present. More research is required to assess ethnicity associated differences in outcomes to develop interventions aimed at reducing and eventually eliminating disparities. REFERENCES 1. Krajewski SA, Hameed SM, Smink DS, et al. Access to emergency operative care: A comparative study between the Canadian and American health care systems. Surgery 2009;146:300. 2. Nwomeh BC, Chisolm DJ, Caniano DA, et al. Racial and socioeconomic disparity in perforated appendicitis among children: Where is the problem? Pediatrics 2006;117:870. 3. Institute of Medicine, Unequal treatment; confronting racial and ethnic disparities in health care, 2002. www.iom.edu 4. Bratu I, Martens PJ, Leslie WD, et al. Pediatric appendicitis rupture rate: Disparities despite universal health care. J Pediatr Surg 2008;43:1964. 5. Jablonski KA, Guagliardo MF. Pediatric appendicitis rupture rate: A national indicator of disparities in healthcare access. Popul health Metr 2005;3:4. 6. Guagliardo MF, Teach SJ, Huang ZJ, et al. Racial and ethnic disparities in pediatric appendicitis rupture rate. Acad Emerg Med 2003;10:1218. 7. Pieracci FM, Eachempati SR, Barie PS, et al. Insurance status, but not race, predicts perforation in adult patients with acute appendicitis. J Am Coll Surg 2007;205:445. 8. Pieracci FM, Eachempati SR, Christos PJ, et al. Explaining insurance-related and racial disparities in the surgical management of patients with acute appendicitis. Am J Surg 2007; 194:57. 9. Herrod HG, Chang CF. Potentially avoidable pediatric hospitalizations as defined by the agency for healthcare research and quality: What do they tell us about disparities in child health? Clin Pediatr 2008;47:128. 10. The Henry J. Kaiser Family Foundation, Kaiser Commission of Medicaid and the Uninsured; March 2008. www.kff.org 11. Cruz GD, Shulman LC, Kumar JV, et al. The cultural and social context of oral and pharyngeal cancer risk and control among Hispanics in New York. J Health Care Poor Underserved 2007; 18:833. 12. Goel MS, Wee CC, McCarthy EP, et al. Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care. J Gen Intern Med 2003;18:1028. 13. United States Census Bureau, 2006-2008 American Community Survey.