Hospital- and Patient-Level Characteristics and the Risk of Appendiceal Rupture and Negative Appendectomy in Children

Department of Surgery, Children's National Medical Center, Washington, DC 20010, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 11/2004; 292(16):1977-82. DOI: 10.1001/jama.292.16.1977
Source: PubMed


The rates of appendiceal rupture and negative appendectomy in children remain high despite efforts to reduce them. Both outcomes are used as measures of hospital quality. Little is known about the factors that influence these rates.
To investigate the association between hospital- and patient-level characteristics and the rates of appendiceal rupture and negative appendectomy in children.
Retrospective review using the Pediatric Health Information System database containing information on 24,411 appendectomies performed on children aged 5 to 17 years at 36 pediatric hospitals in the United States between 1997 and 2002.
Rates of negative appendectomy and appendiceal rupture; the odds ratio (OR) of negative appendectomy and appendiceal rupture by hospital, patient age, race, and health insurance status, and hospital fiscal year and appendectomy volume. Negative appendectomy rate was defined as the number of patients with appendectomy but without appendicitis divided by the total number of appendectomies.
The median negative appendectomy rate was 3.06% (range, 1%-12%) and the median appendiceal rupture rate was 35.08% (range, 22%-62%). The adjusted OR for appendiceal rupture was higher in Asian children (1.66; 95% confidence interval [CI], 1.24-2.23) and black children (1.13; 95% CI, 1.01-1.30) compared with white children. Children without health insurance and children with public insurance had increased odds of appendiceal rupture compared with children who had private health insurance (adjusted OR, 1.36; 95% CI, 1.22-1.53 for self-insured; adjusted OR, 1.48; 95% CI, 1.34-1.64 for public insurance). No correlation existed between negative appendectomy rate and race, health insurance status, or hospital appendiceal rupture rate. The negative appendectomy rate improved as the hospital appendectomy volume increased.
The rate of appendiceal rupture in school-aged children was associated with race and health insurance status and not with negative appendectomy rate and therefore is more likely to be associated with prehospitalization factors such as access to care, quality of care, and patient or physician education.

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    • "[24] The incidence of perforated appendicitis in children is also influenced by other factors, including access to care and patient-level factors, i.e. socioeconomic status, insurance status, and race. [25] [26] [27] However, recent studies show that the health impacts of race and socioeconomic status vanish with equal access to care. [28] [29] Children with a perforation are much more likely to have been initially referred to a pediatrician rather than to a surgeon. "
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    ABSTRACT: Introduction: Advanced appendicitis (perforation, mass, or abscess) is a significant cause of morbidity in children. This chapter reviews the risk factors for and the management of children with advanced appendicitis and associated complications. Methods: A search of the literature was conducted and manual cross-referencing was performed. Results: The incidence of perforation and outcomes vary according to age, gender, and geographical region. Advanced appendicitis is unlikely in the presence of a normal white blood cell (WBC) or C-reactive protein (CRP) measurement. The presence of fever, symptom duration > 24h, generalized abdominal tenderness, rebound tenderness and or rigidity, hypoactive and/or absent bowel sounds, right lower quadrant mass, leukocytosis, and fecalith on CT scans may suggest advanced appendicitis. Age, increased BMI, diarrhea, inadequate antibiotic therapy, and certain microbial isolates may predispose an individual to an increased risk of post-appendectomy complications. Discussion: Non-operative, operative, and postoperative management strategies in the treatment of pediatric advanced appendicitis are discussed. The key to reducing complications is early diagnosis of advanced appendicitis, which is aided by robust decision-making, biomarker analysis, and the judicious use of imaging. Conclusion: An up-to-date review of the risk factors for and management of children with advanced appendicitis and complications is presented.
    Appendicitis: Risk Factors, Management Strategies and Clinical Implications, Edited by A. S. Marmo, 08/2014: chapter 5: pages 37-60; Nova Science Publishers, Inc., ISBN: 978-1-63321-526-9
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    • "The key independent variable of interest was surgeon appendectomy caseload volume. Prior studies have used the proportion of cases of perforated appendicitis as a measure of quality of care for appendicitis [16], [17]. Therefore, in this study, we used “whether or not a patient had a perforated appendicitis” as the outcome measure. "
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    ABSTRACT: Although procedures like appendectomy have been studied extensively, the relative importance of each surgeon's surgical volume-to-ruptured appendicitis has not been explored. The purpose of this study was to investigate the rate of ruptured appendicitis by surgeon-volume groups as a measure of quality of care for appendicitis by using a nationwide population-based dataset. We identified 65,339 first-time hospitalizations with a discharge diagnosis of acute appendicitis (International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes 540, 540.0, 540.1 and 540.9) between January 2007 and December 2009. We used "whether or not a patient had a perforated appendicitis" as the outcome measure. A conditional (fixed-effect) logistic regression model was performed to explore the odds of perforated appendicitis among surgeon case volume groups. Patients treated by low-volume surgeons had significantly higher morbidity rates than those treated by high-volume (28.1% vs. 26.15, p<0.001) and very-high-volume surgeons (28.1% vs. 21.4%, p<0.001). After adjusting for surgeon practice location, and teaching status of practice hospital, and patient age, gender, and Charlson Comorbidity Index, and hospital acute appendicitis volume, patients treated by low-volume surgeons had significantly higher rates of perforated appendicitis than those treated by medium-volume surgeons (OR = 1.09, p<0.001), high-volume surgeons (OR = 1.16, p<0.001), or very-high-volume surgeons (OR = 1.54, p<0.001). Our study suggested that surgeon volume is an important factor with regard to the rate of ruptured appendicitis.
    PLoS ONE 12/2012; 7(12):e52539. DOI:10.1371/journal.pone.0052539 · 3.23 Impact Factor
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    • "The perforation rate is high, as well as the number of negative appendectomies [9,14]. Following the introduction of ultrasound scans during the last two decades and computed tomography (CT) in the last decade, the rate of negative appendectomies has decreased [4,15-17], but the perforation rate has remained high (22%-62%) [4,18,19]. Negative appendectomies are one of the burdens facing not only the general surgeon but also the patient her/himself and society as a whole, since appendectomy, as any other operation, results in socio-economic impacts in the form of lost working days and declined productivity. "
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    ABSTRACT: Acute appendicitis is one of the most common surgical emergencies. Accurate diagnosis of acute appendicitis is based on careful history, physical examination, laboratory and imaging investigation. The aim of the study is to analyze the role of C-reactive protein (CRP), white blood count (WBC) and Neutrophil percentage (NP) in improving the accuracy of diagnosis of acute appendicitis and to compare it with the intraoperative assessment and histopathology findings. This investigation was a prospective double blinded clinical study. The study was done on 173 patients surgically treated for acute appendicitis. The WBC, NP, and measurement of CRP were randomly collected pre-operatively from all involved patients. Macroscopic assessment was made from the operation. Appendectomy and a histopathology examination were performed on all patients. Gross description was compared with histopathology results and then correlated with CRP, WBC, and NP. The observational accuracy was 87,3%, as compared to histopathological accuracy which was 85.5% with a total of 173 patients that were operated on. The histopathology showed 25 (14.5%) patients had normal appendices, and 148 (85.5%) patients had acutely inflamed, gangrenous, or perforated appendicitis. 52% were male and 48% were female, with the age ranging from 5 to 59 with a median of 19.7. The gangrenous type was the most frequent (52.6%). The WBC was altered in 77.5% of the cases, NP in 72.3%, and C-reactive protein in 76.9% cases. In those with positive appendicitis, the CRP and WBC values were elevated in 126 patients (72.8%), whereas NP was higher than 75% in 117 patients (67.6%). Out of 106 patients with triple positive tests, 101 (95.2%) had appendicitis. The sensitivity, specificity, and positive predictive values of the 3 tests in combination were 95.3%, 72.2%, and 95.3%, respectively. The raised value of the CRP was directly related to the severity of inflammation (p-value <0.05). CRP monitoring enhances the diagnostic accuracy of acute appendicitis. The diagnostic accuracy of CRP is not significantly greater than WBC and NP. A combination of these three tests significantly increases the accuracy. We found that elevated serum CRP levels support the surgeon's clinical diagnosis.
    World Journal of Emergency Surgery 08/2012; 7(1):27. DOI:10.1186/1749-7922-7-27 · 1.47 Impact Factor
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