Racial disparities in hospital admissions and surgical management of children with appendicitis

T. M. BirdChild Health Services Research Group

Department of PediatricsUniversity of Arkansas for Medical Sciences

Background

Some evidence to suggest racial/ethnic differences in the rates of hospitalization for appendicitis*.

Literature is dated and based on limited samples.

Does not have a pediatric focus.

Suspected racial/ethnic differences in hospital management of appendicitis.

*Addiss, et al. (1990); Luckmann, et al. (1991)

Objectives

To compare differences in the rates of pediatric hospitalizations for appendicitis among racial/ethnic groups in a large, updated sample.

To compare differences in the hospital management of appendicitis among racial/ethnic groups.

Methods

Kids’ Inpatient Database (KID)*Large, all-payer, nationally representative database of pediatric hospital discharge records.

Years 1997 and 2000 combined.Over 4.4 million discharges.

*Distributed by the Agency for Healthcare Research and Quality (AHRQ).

Methods

Inclusion Criteria

ICD-9 Diagnosis CodesPerforated appendicitis 540.0 & 540.1

Simple appendicitis 540.9, 541 & 542

Management Criteria

ICD-9 Procedure CodesLaparoscopic Appendectomy 47.01

Open Appendectomy 47.0 & 47.09

Rates of appendicitis per 1,000 hospitalizations by ethnic group and year of age

0

20

40

60

80

100

120

140

1 3 5 7 9 11 13 15 17

Age in Years

Ra

te

Caucasian

AfricanAmericanHispanic

Rates of appendicitis per 1,000 hospitalizations by ethnicity and income level

0

5

10

15

20

25

30

35

Low Medium High

Caucasian

AfricanAmerican

Hispanic

Percentage of hospitalizations for appendicitis that are perforated by ethnicity and income level

0

5

10

15

20

25

30

35

40

Low Medium High

Caucasian

AfricanAmerican

Hispanic

Percentage of hospitalizations for appendicitis that undergo laparoscopic surgery by ethnicity and income level

0

5

10

15

20

25

Low Medium High

Caucasian

AfricanAmerican

Hispanic

****

*

* p < 0.05

** p < 0.01

Percentage of postoperative infections by ethnicity and type of surgery, perforated appendix only

0

1

2

3

4

5

6

Open Laparoscopic

Caucasian

AfricanAmerican

Hispanic

*

* p < 0.05

Mean length of stay by ethnicity and type of surgery

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Open Laparoscopic

Caucasian

AfricanAmerican

Hispanic

* p < 0.05

** p < 0.01

**

**

****

Odds ratios and 95% confidence intervals from logistic regression models with Caucasian as the reference group

African American Hispanic

Appendicitis 0.69(0.65-0.74)** 3.08(2.91-3.25)**

Laparoscopy 0.78(0.66-0.91)** 0.95(0.83-1.10)

Perforation1.27(1.17-1.38)** 1.16(1.09-1.23)**

Infection 1.17(0.89-1.55) 1.07(0.88-1.30)

* p < 0.05

** p < 0.01

Models controlled for income level, insurance status, gender, age and region of country.

Conclusions

Hospitalization rates lowest for African Americans, highest for Hispanics.Perforation rates higher for African Americans and HispanicsRates of laparoscopic surgery lower for African Americans and HispanicsRates of postoperative infection higher for African AmericansMean length of stay longer for African Americans and HispanicsDifferences persist across income levels.

Implications

Genetics. Diet/environment. Healthcare preferences. Over management. Does appendicitis subside?

Acknowledgments

Supported by grant # MM-0672-04/04 from Centers for Disease Control

Co-authorsEvan R. Kokoska

James M. Robbins

Negative appendectomy: percentage of appendectomies without corresponding diagnosis code for appendicitis

0

2

4

6

8

10

12

Caucasian AfricanAmerican

Hispanic

* p < 0.05

** p < 0.01

**

*

Total number of appendicitis hospitalizations by ethnic group and year of age.

0

500

1000

1500

2000

2500

3000

3500

4000

0 3 6 9 12 15 18

Years of Age

Nu

mb

er

of

Ho

sp

itali

zati

on

s

Caucasian

AfricanAmerican

Hispanic