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Insurance-related differences in the presentation of pediatric appendicitis
I n s u r a n c e - R e l a t e d Differences in the Presentation of Pediatric Appendicitis By Stuart J. O'Toole, Hratch L. Karamanoukian, James E. Allen, Michael G. CaW, Deborah O'Toole, Richard G. Azizkhan, and Philip L. Glick Buffalo, New York • In the pediatric population, there is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perforation. However, it is not clear whether this delay arises from the parent seeking medical advice, the referring physician seeking surgical consultation, or the surgeon deciding to operate. To resolve this issue, the authors performed a retrospective chart review of all cases of confirmed acute appendicitis that presented to the pediatric surgical service of the Children's Hospital of Buffalo during a 4-year period (January 1990 through December 1993). All children (_<16 years of age} were categorized with respect to type of insurance coverage: Medicaid (or uninsured), health maintenance organization (HMO), or private fee-for-service. Their time until emergency room (ER) presentation, operating room (OR) presentation, and hospital discharge were recorded and compared. Their complications and perforation rates also were noted. Two hundred eighty-eight cases were reviewed. The rate of appendiceal perforation was significantly higher among the Medicaid patients (Medicaid, 44%; HMO, 27%; private, 23%; P < .05); their duration of symptoms before presentation was significantly longer (Medicaid, 47.3 _+ 4.1 hours; HMO, 29.3 -+ 1.9 hours; private, 23.1 - 2.5 hours; P < .01), and their hospital stay was longer (Medicaid, 7.9 -+ 0.9 days; HMO, 4.8 -+ 0.27 days; private, 4.6 -+ 0.44 days; P < .01). However, there were no significant differences in the time from presentation to the ER until definitive surgery in the OR. Children covered by Medicaid (or uninsured} presented later, had a higher risk of appendiceal perforation, and required a longer hospital stay. The parents of these children either failed to recognize the significance of their children's symptoms, or delayed seeking medical advice because of financial or logistical reasons. The gatekeeper consultation, required by the health maintenance organizations (HMO) did not result in a delay in presentation or have a negative impact on morbidity. Providing easier access to a primary care physician and improving parental health education/awareness may shorten the time until presentation for the uninsured/Medicaid patient. Copyright © 1996 by W.B. Saunders Company
PPENDICITIS is the most common surgical emergency of childhood. Despite improvements in the mortality rate over the past 4 decades, 1 appendicitis is still one of the major causes of hospitalization among children between 1 and 14 years of age. 2 Although the number of deaths related to appendicitis has been decreasing, the morbidity rate associated with this condition has remained high and has been linked to the rate of appendiceal perforation, 3 which varies from as low as 20% 4 to as high as 73%. 5 The incidence of appendiceal perforation, at least in the pediatric population, has been shown to correlate with the time from the onset of symptoms until definitive surgical management.5,6 Therefore, high rates of appendiceal rupture have been attributed to delays in presentation and delays in diagnosis.5,6 Recently, Braveman et al7 reported on the incidence of perforation as it relates to the insurance status of adult patients. They concluded that the increased rate of ruptured appendicitis among Medicaid and uninsured patients was caused by financial and organizational barriers to hospital admission. The present study was performed to assess the insurance-related differences in the presentation of appendicitis in the pediatric population. We were interested in the intervals between onset of symptoms, presentation, and definitive treatment for the variously insured groups, and the subsequent incidences of appendiceal perforation among the groups. MATERIALS AND METHODS
From the Children's Hospital of Buffalo, and the Departments of Surgery and Pediatrics, State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, NY. Presented at the 1995 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, San Francisco, California, October 13-15, 1995. Address reprint requests to Philip L. Glick, MD, The Buffalo Institute of Fetal Therapy, Department of Pediatric Surgery, The Children's Hospital of Buffalo, 219 Bryant St, Buffalo, N Y 14222. Copyright © 1996 by W.B. Saunders Company 0022-3468/96/3108-0006503.00/0
A retrospective chart review was performed of all the cases of acute appendicitis that presented to the Children's Hospital of Buffalo between January 1, 1990 and December 31, 1993. Only histologically proven cases of acute appendicitis that occurred in children aged 16 years or younger were included in the analysis. The cases of perforated appendicitis were managed similarly, according to a protocol previously described by this institution,s An appendix was deemed perforated based on the surgeon's operating note and histology report confirmation. Cases of microperforation that did not have signs of peritoneal soiling during surgery were not included. Children with an appendiceal mass, in whom interval appendectomywas performed, were excluded. Two hundred ninetyfour children were identified, and charts were available for 288 of them. The following information was obtained from the charts (the chart reviewers were blinded to the insurance status at this time): age at time of diagnosis, gender, duration of symptoms before presentation to the emergency room (ER), time until presentation to the ER, white blood cell count at time of admission, time of arrival in the operating room (OR), histological diagnosis, compli-
1032
Journal of Pediatric Surgery, Vo131, No 8 (August), 1996: pp 1032-1034
INDEX WORDS: Appendicitis, health care reform, HMO, health insurance, Medicaid.
APPENDICITIS: INSURANCE-RELATED DIFFERENCES
1033
cations, and length of hospital stay were recorded. These data were then divided according to insurance status. Group 1 (HMO) contained all cases that were covered by a health maintenance organization that required contact with a gatekeeper before an ER visit. Group 2 (private) consisted of all patients with private fee-for-service coverage. Group 3 (Medicaid) contained the children covered by Medicaid and the small number of children who had no insurance coverage. Intergroup variables were analyzed by an unpaired t test. The rate of perforation between the two groups was compared using Fisher's exact test. As a guide to the economic impact, the cost of each case of appendicitis was ascertained for the year January 1, 1992 to January 1, 1993, and a mean hospital cost per case was calculated (physician fees and/or any home care charges were excluded).
RESULTS
The mean age at time of presentation for the children with acute appendicitis was 10.38 years; the youngest was 16 months old. The mean ages for the individual groups (years _ SD) were as follows: Medicaid, 9.6 -+ 3.8; HMO, 11 _+ 3.5; private, 9.9 _+ 3.8. The male:female ratio was 1.8:1. Table 1 shows that the Medicaid patients had the longest duration of symptoms before presentation, the highest perforation rate, and the lengthiest hospital stay. However, the time from presentation until definitive treatment in the OR did not differ significantly between the groups. There were 13 documented complications during the review period, which included one death. The latter patient had cerebral palsy and presented in extremis. There was one documented pelvic abscess that required drainage. There was the suspicion of wound infection in eight children, but in only four of these was there documented pus from the wound. All four documented cases of wound infection occurred in patients who had perforated appendicitis; thus, the wound infection rate associated with appendiceal perforation is 4.4%. No intergroup variations were noted. The white blood cell count at the time of admission was recorded for all patients. The mean count for Children with uncomplicated appendicitis was 17.4 __ 0.4; for those with perforated appendicitis it was 18.3 _+ 0.6. There were no significant differences between insurance groups.
DISCUSSION
Our chart review demonstrates that when cases of acute appendicitis treated at the Children's Hospital of Buffalo are grouped according to insurance status, significant differences are found with respect to presentation and perforation. Those who are covered by Medicaid or are uninsured have had a significantly longer duration of symptoms at the time of their presentation. Subsequently, these children have a higher incidence of appendiceal perforation, which means, as a group, their hospital stay is longer and the cost of their hospitalization is higher. There is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perforation. 5,6Some investigators have suggested that this delay is caused by diagnostic delay on behalf of the surgeon9; others have suggested that the new health care environment and the primary care physicians are responsible. 1° Our results do not support either of these assumptions. The children covered by capitated insurance (HMO) require at least a telephone consultation with their primary care provider (gatekeeper) before ER presentation, yet their duration of symptoms before presentation is significantly shorter than that of Medicaid children who can present directly, and not significantly different from that of the private fee-for-service children who have this option. Once in the hospital, it appears that all three groups of children are treated in a similar fashion. The time from arrival in the ER until definitive treatment in the OR does not differ significantly between the groups. The latter findings suggest that a delay in diagnosis by the attending surgeon is not responsible for the observed differences in the perforation rate. Our results suggest that a major cause of delay in the treatment for children with appendicitis is the initial delay in seeking medical attention. If we assume that the progression and symptoms of appendicitis are similar for the various groups studied, then we must conclude that the parents of the Medicaid children either fail to recognize the significance of their children's symptoms or delay seeking medical
Table 1. Insurance-Related Differences According to Duration of Symptoms Before Presentation, Perforation Rate, and Hospital Stay Insurance Medicaid or uninsured HMO Private fee-for-service * P < .001. t P < .05. ~P < .01.
No. of Patients
Duration of Symptoms (h)
Time Until Surgery (h)
Perforation Rate (no.)
Length of Hospital Stay (d)
Costin US Dollars (1992-1993) 5,738 + 573
86
47.3 -+ 4.1"
8.2 +- 0.62
44% (37)t
7,9 _+ 0.95
142
29.3 ± 1.9
8.1 _+ 0.62
27% (38)
4,8 _+ 0.27
5,104 -+ 332
60
23.1 --+ 2,5
6.9 -+ 0.53
23% (14)
4.6 _+ 0.44
4,654 -+ 718
1034
O'TOOLE ET AL
advice because of financial or logistical reasons. Brender et al 6 showed that the risk of appendiceal perforation was lower among children who had a family history of appendicitis. This suggests that previous exposure to the disease increases awareness of its symptoms and progression, and indicates that parental health education may have a role to play in decreasing appendiceal perforation. If financial or logistical problems contribute to the delay in presentation, then the availability of a primary care physician may be beneficial. A gatekeeper physician may prove more accessible than the hospital E R and may be consulted at an earlier stage of disease. This may facilitate the prompt referral of Children with a high suspicion of a surgical pathology and may prevent unnecessary E R visits for the remaining children. The cost benefits of this strategy already have been real-
ized in New York State, where attempts are being made to enroll children eligible for Medicaid into a managed health care plan. n The low incidence of complications in the present study shows that the contemporary treatment of perforated appendicitis is very effective.4,8a2 However, this does not mean that we should be complacent. Apart from the obvious financial costs of increased hospitalization, Mueller et a113have demonstrated a convincing link between appendiceal perforation and subsequent tubal infertility. Therefore we should continue to strive for a lower incidence of appendiceal perforation. However, we must realize that education and increased access to health care may be more effective in achieving this goal than are improvements in surgical diagnosis and management.
REFERENCES 1. Pledger HG. Fahy LT. van Mourik GA. et al: Deaths in children with a diagnosis of acute appendicitis in England and Wales 1980-4. Br Med J 295:1233-1235, 1987 2. Henderson J. Goldacre M J, Fairweather JM: Conditions accounting for substantial time spent in hospital in children age 1-14 years of age. Arch Dis Child 67:83-86, 1992 3. Berry J, Malt RA: Appendicitis near its centenary. Ann Surg 200:567-575, 1984 4. Pearl RH, Hale DA, Molloy M, et al: Pediatric appendectomy. J Pediatr Surg 30:173-178, 1995 5. Rappaport WD, Peterson M, Stanton C: Factors responsible for ttie high perforation rate seen in early childhood appendicitis. Am Surg 55:602-605, 1989 6. Brender JD, Marcuse EK, Koepsell TD, et al: Childhood appendicitis: Factors associated with perforation. Pediatrics 76:301306, 1985 7. Braveman P, Schaaf M, Egerter S, et al: Insurance related differences in the risk of ruptured appendicitis. N Engl J Med 331:444-449, 1994
8. Karp MP, Caldarola VA, Cooney DR, et al: The avoidable excesses in the management of perforated appendicitis in children. J Pediatr Surg 21:506-510, 1986 9. Buchman TG, Zuidema GD: Reasons for delay in the diagnosis of acute appendicitis. Surg Gynecol Obstet 158:260-266, 1984 10. Linz DN, Hrabovsky EE, Franceschi D, et al: Does the current health care environment contribute to increase morbidity and mortality of acute appendicitis in children. J Pediatr Surg 28:321-326, 1993 11. Goldman B: Improving access to the underserved through Medicaid managed care. J Health Care Poor Underserved 4:290298, 1993 12. Schwartz MZ, Tapper D, Solenberger RI: Management of perforated appendicitis in children. Ann Surg 197:407-411, 1983 13. Mueller BA, Daling JR, Moore DE, et al: Appendectomy and the risk of tubal infertility. N Engl J Med 315:1506-1508, 1986
Discussion A.G. Coran (Ann Arbor, MI): This was a very nice presentation. I have one question regarding the H M O group. What percentage of those patients had an actual gatekeeper? That is, how many of the patients had to go to a primary care physician first, before they accessed your health care facility? The essence of the question you are asking is: Do we have a delay because somebody else, less qualified to evaluate the child, has to be put into the loop initially?
S.J. O'Toole (response): When we looked at the HMO consultations, there was such a small number who actually had been seen personally by their H M O provider. Most of the children had had some sort of telephone conversations with either their primary care provider or a nurse involved with the primary care provider. These health care personnel heard about the child's symptoms and suggested referral to our hospital.
PPENDICITIS is the most common surgical emergency of childhood. Despite improvements in the mortality rate over the past 4 decades, 1 appendicitis is still one of the major causes of hospitalization among children between 1 and 14 years of age. 2 Although the number of deaths related to appendicitis has been decreasing, the morbidity rate associated with this condition has remained high and has been linked to the rate of appendiceal perforation, 3 which varies from as low as 20% 4 to as high as 73%. 5 The incidence of appendiceal perforation, at least in the pediatric population, has been shown to correlate with the time from the onset of symptoms until definitive surgical management.5,6 Therefore, high rates of appendiceal rupture have been attributed to delays in presentation and delays in diagnosis.5,6 Recently, Braveman et al7 reported on the incidence of perforation as it relates to the insurance status of adult patients. They concluded that the increased rate of ruptured appendicitis among Medicaid and uninsured patients was caused by financial and organizational barriers to hospital admission. The present study was performed to assess the insurance-related differences in the presentation of appendicitis in the pediatric population. We were interested in the intervals between onset of symptoms, presentation, and definitive treatment for the variously insured groups, and the subsequent incidences of appendiceal perforation among the groups. MATERIALS AND METHODS
From the Children's Hospital of Buffalo, and the Departments of Surgery and Pediatrics, State University of New York at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, NY. Presented at the 1995 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, San Francisco, California, October 13-15, 1995. Address reprint requests to Philip L. Glick, MD, The Buffalo Institute of Fetal Therapy, Department of Pediatric Surgery, The Children's Hospital of Buffalo, 219 Bryant St, Buffalo, N Y 14222. Copyright © 1996 by W.B. Saunders Company 0022-3468/96/3108-0006503.00/0
A retrospective chart review was performed of all the cases of acute appendicitis that presented to the Children's Hospital of Buffalo between January 1, 1990 and December 31, 1993. Only histologically proven cases of acute appendicitis that occurred in children aged 16 years or younger were included in the analysis. The cases of perforated appendicitis were managed similarly, according to a protocol previously described by this institution,s An appendix was deemed perforated based on the surgeon's operating note and histology report confirmation. Cases of microperforation that did not have signs of peritoneal soiling during surgery were not included. Children with an appendiceal mass, in whom interval appendectomywas performed, were excluded. Two hundred ninetyfour children were identified, and charts were available for 288 of them. The following information was obtained from the charts (the chart reviewers were blinded to the insurance status at this time): age at time of diagnosis, gender, duration of symptoms before presentation to the emergency room (ER), time until presentation to the ER, white blood cell count at time of admission, time of arrival in the operating room (OR), histological diagnosis, compli-
1032
Journal of Pediatric Surgery, Vo131, No 8 (August), 1996: pp 1032-1034
INDEX WORDS: Appendicitis, health care reform, HMO, health insurance, Medicaid.
APPENDICITIS: INSURANCE-RELATED DIFFERENCES
1033
cations, and length of hospital stay were recorded. These data were then divided according to insurance status. Group 1 (HMO) contained all cases that were covered by a health maintenance organization that required contact with a gatekeeper before an ER visit. Group 2 (private) consisted of all patients with private fee-for-service coverage. Group 3 (Medicaid) contained the children covered by Medicaid and the small number of children who had no insurance coverage. Intergroup variables were analyzed by an unpaired t test. The rate of perforation between the two groups was compared using Fisher's exact test. As a guide to the economic impact, the cost of each case of appendicitis was ascertained for the year January 1, 1992 to January 1, 1993, and a mean hospital cost per case was calculated (physician fees and/or any home care charges were excluded).
RESULTS
The mean age at time of presentation for the children with acute appendicitis was 10.38 years; the youngest was 16 months old. The mean ages for the individual groups (years _ SD) were as follows: Medicaid, 9.6 -+ 3.8; HMO, 11 _+ 3.5; private, 9.9 _+ 3.8. The male:female ratio was 1.8:1. Table 1 shows that the Medicaid patients had the longest duration of symptoms before presentation, the highest perforation rate, and the lengthiest hospital stay. However, the time from presentation until definitive treatment in the OR did not differ significantly between the groups. There were 13 documented complications during the review period, which included one death. The latter patient had cerebral palsy and presented in extremis. There was one documented pelvic abscess that required drainage. There was the suspicion of wound infection in eight children, but in only four of these was there documented pus from the wound. All four documented cases of wound infection occurred in patients who had perforated appendicitis; thus, the wound infection rate associated with appendiceal perforation is 4.4%. No intergroup variations were noted. The white blood cell count at the time of admission was recorded for all patients. The mean count for Children with uncomplicated appendicitis was 17.4 __ 0.4; for those with perforated appendicitis it was 18.3 _+ 0.6. There were no significant differences between insurance groups.
DISCUSSION
Our chart review demonstrates that when cases of acute appendicitis treated at the Children's Hospital of Buffalo are grouped according to insurance status, significant differences are found with respect to presentation and perforation. Those who are covered by Medicaid or are uninsured have had a significantly longer duration of symptoms at the time of their presentation. Subsequently, these children have a higher incidence of appendiceal perforation, which means, as a group, their hospital stay is longer and the cost of their hospitalization is higher. There is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perforation. 5,6Some investigators have suggested that this delay is caused by diagnostic delay on behalf of the surgeon9; others have suggested that the new health care environment and the primary care physicians are responsible. 1° Our results do not support either of these assumptions. The children covered by capitated insurance (HMO) require at least a telephone consultation with their primary care provider (gatekeeper) before ER presentation, yet their duration of symptoms before presentation is significantly shorter than that of Medicaid children who can present directly, and not significantly different from that of the private fee-for-service children who have this option. Once in the hospital, it appears that all three groups of children are treated in a similar fashion. The time from arrival in the ER until definitive treatment in the OR does not differ significantly between the groups. The latter findings suggest that a delay in diagnosis by the attending surgeon is not responsible for the observed differences in the perforation rate. Our results suggest that a major cause of delay in the treatment for children with appendicitis is the initial delay in seeking medical attention. If we assume that the progression and symptoms of appendicitis are similar for the various groups studied, then we must conclude that the parents of the Medicaid children either fail to recognize the significance of their children's symptoms or delay seeking medical
Table 1. Insurance-Related Differences According to Duration of Symptoms Before Presentation, Perforation Rate, and Hospital Stay Insurance Medicaid or uninsured HMO Private fee-for-service * P < .001. t P < .05. ~P < .01.
No. of Patients
Duration of Symptoms (h)
Time Until Surgery (h)
Perforation Rate (no.)
Length of Hospital Stay (d)
Costin US Dollars (1992-1993) 5,738 + 573
86
47.3 -+ 4.1"
8.2 +- 0.62
44% (37)t
7,9 _+ 0.95
142
29.3 ± 1.9
8.1 _+ 0.62
27% (38)
4,8 _+ 0.27
5,104 -+ 332
60
23.1 --+ 2,5
6.9 -+ 0.53
23% (14)
4.6 _+ 0.44
4,654 -+ 718
1034
O'TOOLE ET AL
advice because of financial or logistical reasons. Brender et al 6 showed that the risk of appendiceal perforation was lower among children who had a family history of appendicitis. This suggests that previous exposure to the disease increases awareness of its symptoms and progression, and indicates that parental health education may have a role to play in decreasing appendiceal perforation. If financial or logistical problems contribute to the delay in presentation, then the availability of a primary care physician may be beneficial. A gatekeeper physician may prove more accessible than the hospital E R and may be consulted at an earlier stage of disease. This may facilitate the prompt referral of Children with a high suspicion of a surgical pathology and may prevent unnecessary E R visits for the remaining children. The cost benefits of this strategy already have been real-
ized in New York State, where attempts are being made to enroll children eligible for Medicaid into a managed health care plan. n The low incidence of complications in the present study shows that the contemporary treatment of perforated appendicitis is very effective.4,8a2 However, this does not mean that we should be complacent. Apart from the obvious financial costs of increased hospitalization, Mueller et a113have demonstrated a convincing link between appendiceal perforation and subsequent tubal infertility. Therefore we should continue to strive for a lower incidence of appendiceal perforation. However, we must realize that education and increased access to health care may be more effective in achieving this goal than are improvements in surgical diagnosis and management.
REFERENCES 1. Pledger HG. Fahy LT. van Mourik GA. et al: Deaths in children with a diagnosis of acute appendicitis in England and Wales 1980-4. Br Med J 295:1233-1235, 1987 2. Henderson J. Goldacre M J, Fairweather JM: Conditions accounting for substantial time spent in hospital in children age 1-14 years of age. Arch Dis Child 67:83-86, 1992 3. Berry J, Malt RA: Appendicitis near its centenary. Ann Surg 200:567-575, 1984 4. Pearl RH, Hale DA, Molloy M, et al: Pediatric appendectomy. J Pediatr Surg 30:173-178, 1995 5. Rappaport WD, Peterson M, Stanton C: Factors responsible for ttie high perforation rate seen in early childhood appendicitis. Am Surg 55:602-605, 1989 6. Brender JD, Marcuse EK, Koepsell TD, et al: Childhood appendicitis: Factors associated with perforation. Pediatrics 76:301306, 1985 7. Braveman P, Schaaf M, Egerter S, et al: Insurance related differences in the risk of ruptured appendicitis. N Engl J Med 331:444-449, 1994
8. Karp MP, Caldarola VA, Cooney DR, et al: The avoidable excesses in the management of perforated appendicitis in children. J Pediatr Surg 21:506-510, 1986 9. Buchman TG, Zuidema GD: Reasons for delay in the diagnosis of acute appendicitis. Surg Gynecol Obstet 158:260-266, 1984 10. Linz DN, Hrabovsky EE, Franceschi D, et al: Does the current health care environment contribute to increase morbidity and mortality of acute appendicitis in children. J Pediatr Surg 28:321-326, 1993 11. Goldman B: Improving access to the underserved through Medicaid managed care. J Health Care Poor Underserved 4:290298, 1993 12. Schwartz MZ, Tapper D, Solenberger RI: Management of perforated appendicitis in children. Ann Surg 197:407-411, 1983 13. Mueller BA, Daling JR, Moore DE, et al: Appendectomy and the risk of tubal infertility. N Engl J Med 315:1506-1508, 1986
Discussion A.G. Coran (Ann Arbor, MI): This was a very nice presentation. I have one question regarding the H M O group. What percentage of those patients had an actual gatekeeper? That is, how many of the patients had to go to a primary care physician first, before they accessed your health care facility? The essence of the question you are asking is: Do we have a delay because somebody else, less qualified to evaluate the child, has to be put into the loop initially?
S.J. O'Toole (response): When we looked at the HMO consultations, there was such a small number who actually had been seen personally by their H M O provider. Most of the children had had some sort of telephone conversations with either their primary care provider or a nurse involved with the primary care provider. These health care personnel heard about the child's symptoms and suggested referral to our hospital.