Shortage of general surgeons may be linked to higher rate of perforated appendix in rural areas

People who live in rural areas may run a greater risk of having perforated appendix than those in suburban and urban areas, according to a new study out of Dartmouth Medical School, Lebanon, NH. Not having enough general surgeons in rural regions may explain the disparity, according to researchers who presented their findings at the 95th annual Clinical Congress of the American College of Surgeons. "This study indirectly looks at workforce issues in surgery," according to study coauthor Ian Paquette, MD. "We need to create incentives for surgeons to practice in rural areas."

Approximately 325,000 people in the United States are hospitalized each year for appendicitis and an estimated one in 15 people will get appendicitis in their lifetime, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Appendicitis is an inflammation of the appendix, a small organ projecting from the large intestine near where it connects with the small intestine. The condition causes sudden and extreme abdominal pain and sends most sufferers to the hospital for emergency surgical treatment before the appendix ruptures or perforates. A perforated appendix can spill contaminated contents of the digestive tract into the body cavity and raise the risk for internal infection and organ damage, but the risk of death is very low. The disease is most common between the ages of 10 and 30.

The study team at the Dartmouth Hitchcock Medical Center in Lebanon, NH, determined that 32 percent of all patients who went to the hospital with appendicitis presented with perfora-tion. However, approximately 36 percent of rural patients entered the hospital with perforated appendix compared with 31 percent of urban patients. Even rural patients transferred to urban hospitals had slightly higher, but not statistically significant, rates of perforated appendix.

Dr. Paquette cited a recent report by the American College of Surgeons Health Policy Research Institute. "This study looked at small, isolated rural communities and found that there were 4.6 surgeons per 100,000 people, whereas that number in an urban community is 6.5 per 100,000," he said. "That number doesn't sound very big, but when you take into account a lower population density spread over a larger geographic area, the magnitude of the disparity in rural areas increases."

The study authors chose to analyze data on appendicitis because it affects all population groups consistently despite biological, socioeconomic, or behavioral factors, or other health problems a person may have. "Appendicitis has a consistent natural history that ultimately leads to perforation if untreated," Dr. Paquette said. "Virtually all patients who get appendicitis will eventually come to get medical attention, whether they decide to initially wait or not. We have seen this as an effective model to gauge access to timely health care."


Dartmouth Hitchcock Medical Center


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