Non-operative management of Appendicitis: Variations in Racial and Social disparities across the United States

Author(s):
Carmen Fahlen; Chibueze Nwaiwu; Yao Liu; Carla Moreira; Andrew Stephen; Daithi Heffernan

Background:

Racial and social biases affect the distribution of care, as well as willingness of operative intervention. However, very little data compares whether different states demonstrate a greater or lesser degree of inequity. Operative intervention is considered first line care for appendicitis. This study sought to identify whether the degree of racial or social biases differs across differing geographic regions in the United States with respect to non-operative management of appendicitis.

Hypothesis:

The impact of Racial and Social disparities in the management of appendicitis will differ by geographic region.

Methods:

A 17-year retrospective review of the National In-Patient Sample (NIS) dataset of patients with appendicitis. Data extracted included demographics including age, sex, and race Caucasian versus Non-Caucasian (Non-Cauc), insurance (private vs MediCare/MediCaid (MC) vs uninsured), income status, medical history and mortality. Patients were divided by operative(Op) versus non-operative (Non-Op) management. The US was divided into 9 geographic regions defined by HCUP. Multivariate logistic regression analysis was used to predict the effects of race or socioeconomic status upon Non-Op management within each region as well as between regions.

Results:

Over the 17 years 1,014,523 patients presented with appendicitis. The 68,938 patients (6.8%) managed were older (43.7 yrs vs 33.4 yrs; p<0.001) and more likely women (48.5% versus 44.8%;p<0.001). Patients with private insurance were less likely managed Non-Op compared to either MC patients (OR=0.59 (95%CI=0.58-0.61)) or uninsured patients (OR=0.88 (95%CI=0.86-0.90). Throughout the entire US, Non-Cauc patients were more likely managed Non-Op (OR1.29 (95%CI=1.27-1.35). Interestingly, there was significant discrepancy across geographic regions. The odds of Non-Cauc patients being managed Non-Op was highest in the East South-Central region (Kentucky, Tennessee, Mississippi and Alabama) (OR1.56 (95%CI=1.4-1.7) and lowest in the Pacific region (California, Washington, Alaska, Oregon and Hawaii) (OR1.15 (95%=1.14-1.19). Collectively, Non-Cauc patients in East South-Central, South Atlantic and Mid-Atlantic were significantly more likely to be managed Non-Op when compared to Pacific, Mountain, West South-Central and New England (p<0.001). These geographic based racial differences persisted when accounting for insurance and income status.

Conclusions:

We identified that Non-Caucasian patients and uninsured patients were less likely to undergo operative intervention for appendicitis. Racial and social biases are more pronounced in specific regions of the United States.