Factors Associated With The Location Of Acute Appendicitis Care In Children
*Christina Georgeades1, *Manzur R Farazi1, *Hailey Gainer1, *Katherine Flynn-O'Brien1, *Charles Leys2, *David Gourlay1, Kyle J Van Arendonk1
1Children's Wisconsin & Medical College of Wisconsin, Milwaukee, WI;2University of Wisconsin, Madison, WI
Objectives. Acute appendicitis in children is managed by both general and pediatric surgeons and at both community and children’s hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with the location of surgical care.
Methods. Children <18 years undergoing appendectomy for appendicitis at facilities in Wisconsin from 2018-2020 were identified through ICD-10 and CPT codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status (SES).
Results. Among 3349 children with appendicitis, 36.1% had appendectomy at two major children’s hospitals (CHs) and 63.9% at 101 non-children’s hospitals (NCHs). The median number of appendectomies performed annually was 201.5 (interquartile range [IQR] 146.1-256.9) at CHs compared to 5.0 (IQR 1.8-8.2) at NCHs. Pediatric surgeons performed all appendectomies at CHs and 7.2% at NCHs. NCHs disproportionally cared for older children (median 13.0 vs. 11.0 years, p<0.001) and those with uncomplicated appendicitis (78.7% vs. 62.5%, p<0.001) compared to CHs. However, NCHs still managed 36.6% of children ≤5 years and 50.2% of complicated appendicitis cases. Children at NCHs more frequently lived in rural areas (37.6% vs. 4.1%, p<0.001) and a greater distance from a CH (median 62.4 vs. 9.2 miles, p<0.001). Only 34.2% of patients received care at the hospital closest to their home. Of those not receiving care at the closest hospital, 51.2% went to a CH. Overall, receipt of surgical care at CHs was associated with younger age, complicated appendicitis, shorter distance to a CH, urban residence, and higher SES (Table 1).
Conclusion. Nearly two-thirds of surgical care for pediatric appendicitis occurred at NCHs, especially among older children, those living in rural areas far from a CH, and those of lower SES. Future work is necessary to determine which children benefit most from care at CHs and which can safely receive care at NCHs to avoid unnecessary time and resource utilization associated with travel to a CH.
|Table 1. Associations between patient characteristics and receipt of surgical care at a major children’s hospital among children with appendicitis in Wisconsin.|
|Adjusted OR*||95% CI||P-value|
|Age (per year increase)||0.87||0.84 - 0.90||< 0.001|
|Complicated appendicitis (versus uncomplicated)||1.87||1.47 - 2.37||< 0.001|
|Distance from nearest children’s hospital (per mile increase)||0.94||0.93 - 0.94||< 0.001|
|Urban residence (versus rural residence)||3.71||2.61 - 5.39||< 0.001|
|Socioeconomic status (per increase in decile of ADI)||0.93||0.89 - 0.97||0.001|
|OR = odds ratio; CI = confidence interval; ADI = Area Deprivation Index, with higher deciles representing greater disadvantage; *From multivariable logistic regression model|
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