Insurance status, not race, linked to complications in patients with acute appendicitis

In what is being described as an "unexpected finding," new research suggests no correlation between a patient's race and complications with acute appendicitis.

The study, which will be published in the September issue of The Journal of the American College of Surgeons, found that uninsured or publicly insured patients with acute appendicitis have an increased likelihood of perforation, or rupture, of the appendix in comparison to patients with private insurance. However, the study found no relationship between race and perforation, which contradicts a large body of literature documenting impaired access to health care among minority populations.

The lack of a link between race and perforation was unexpected," said Fredric M. Pieracci, MD, resident in general surgery and preventive medicine at Weill Cornell Medical College. "Based on other research we anticipated our findings would show that minority populations would have increased perforations due to delays in treatment and access to care. Instead, we found evidence for an independent effect of insurance status on the likelihood of perforation in patients with acute appendicitis. Insurance reform may provide one method by which this disparity could be attenuated or eliminated.

Acute appendicitis has been studied widely as a gauge of effective and equitable health care. Appendicitis is an inflammation of the appendix that is considered a medical emergency. If treatment is delayed, the appendix can rupture, causing infection and even death.

Using the New York State Statewide Planning and Research Cooperative System (SPARCS) database, researchers identified 31,245 adult patients (¡Ý18 years) with appendicitis. Race information was available for 29,637 (94.9%). Of these 29,637 patients, 7,969 (26.9%) had perforation of the appendix. Patients lacking race information were excluded from the analysis. Insurance status was also obtained from the SPARCS database.

A multivariable analysis showed no significant differences in the likelihood of perforation when comparing Caucasian, African-American, Hispanic and Asian patients. However, as compared with patients with private insurance, uninsured (OR=1.18, 95% CI [1.07, 1.30], p=0.0005), Medicaid (OR=1.22, 95% CI [1.12, 1.33], p< p.0001) and Medicare patients (OR 1.14, 95% CI [1.03, 1.25], p=0.01) were all more likely to have perforated.

Dr. Pieracci said this effect may be due to several factors. First, because both uninsured and publicly insured patients are less likely to have a usual source of health care, difficulty in consulting a health care provider may delay hospitalization. In addition, longer waiting times once care has been sought may contribute to delayed treatment. Perhaps most importantly, said Dr. Pieracci, uninsured patients may delay seeking care for fear of financial repercussions.

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