Appendicitis Outcomes Tied to Kids’ Neighborhoods

Children from neighborhoods with lower scores on the Child Opportunity Index (COI) had higher odds of developing complicated appendicitis, a retrospective cohort study found.

Compared with kids from neighborhoods with a very high COI, those from neighborhoods with a very low COI had 28% higher odds of presenting with complicated appendicitis (95% CI 1.20-1.35), reported Megan Bouchard, MD, MPH, of Ann & Robert H. Lurie Children’s Hospital in Chicago, and colleagues.

In addition, children from neighborhoods that had a high, moderate, or low COI had 5%, 16%, and 20% higher odds of developing complicated appendicitis compared with a very high COI, they noted in JAMA Network Open.

“Our findings suggest the importance of neighborhood-level SDOH [social determinants of health] and their association with access to care of a common pediatric surgical condition,” the researchers wrote. They noted that delays in care increase the risk of complicated appendicitis, which can lead to surgical complications, higher costs, longer hospital stays, and increased rates of readmission.

Notably, there was no significant difference in post-discharge healthcare usage between neighborhoods with different COI levels (20.8% for very high COI vs 19.1% for very low COI). This suggests that regardless of neighborhood, once patients have reached healthcare, they are connected to resources that can support them post discharge, Bouchard and team said.

However, certain groups with simple appendicitis did have higher odds of unplanned post-discharge healthcare usage:

• Black patients (OR 1.24, 95% CI 1.07-1.43)
• Hispanic patients (OR 1.21, 95% CI 1.09-1.33)
• Publicly insured patients (OR 1.23, 95% CI 1.13-1.33)
• Those ages 0-4 years (OR 1.58, 95% CI 1.34- 1.85)

For complicated appendicitis cases, Hispanic patients (OR 1.11, 95% CI 1.02-1.22) and those ages 0-4 years (OR 1.40, 95% CI 1.24-1.57) also had higher odds of unplanned healthcare usage, the group noted.

Appendicitis is the most common acute pediatric surgical condition, with up to 80,000 cases per year. Simple appendicitis can progress into complicated appendicitis when the appendix becomes gangrenous or perforates.

Previous research has found higher rates of complicated appendicitis among patients who are low-income, from a rural community, of an ethnic or racial minority group, or are publicly insured.

The COI includes 29 indicators of neighborhood characteristics that may influence a child’s health and development, such as access to and quality of education, healthcare, green space, and nutritious food. When COI factors were divided into three subdomains — education, health/environment, and social/economic — the same pattern of increasing odds of complicated appendicitis with each lower level of COI was seen within each subdomain, the study group said.

“Reducing appendicitis disparities may involve addressing neighborhood SDOH through neighborhood-focused investment, reallocation of community resources, and improved access to care in underserved communities,” Bouchard and colleagues wrote. “Furthermore, it may be useful for health professionals to continue patient screening for SDOH and refer patients to appropriate resources when unmet social needs are identified.”

This study used data from 49 tertiary pediatric centers that are part of the Pediatric Health Information System (PHIS) database, and included 67,489 children (mean age 10.5 years, 60% boys) who presented with appendicitis from October 2015 through September 2018. Overall, 46.3% of children in this study presented with complicated appendicitis.

The study period was chosen for consistent ICD-10-CM coding, as appendicitis diagnostic codes were changed beginning in October 2018.

Of the included children, 2.5% were Asian, 35.9% were Hispanic, 6.6% were Black, and 43.3% were white. Approximately 48% were publicly insured.

Bouchard and colleagues noted that the PHIS database only includes children’s hospitals, which “may include a higher proportion of complicated appendicitis cases compared with community hospitals.”