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Perforated Appendicitis Among Rural and Urban Patients: Implications of Access to Care

Paquette, Ian M. MD*,¶; Zuckerman, Randall MD ‡§; Finlayson, Samuel R. G. MD, MPH*†,¶

doi: 10.1097/SLA.0b013e3182096d68
Original Article

Objective: To determine whether rural patients are more likely to present with perforated appendicitis compared with urban patients.

Background: Appendiceal perforation has been associated with increased morbidity, length of hospital stay, and overall health care costs. Recent arguments suggest that high rates of appendiceal rupture may be unrelated to the quality of hospital care, and rather associated with inadequate access to surgical care.

Methods: We performed a retrospective cohort study of 122,990 patients with acute appendicitis from the Nationwide Inpatient Sample from 2003 to 2004. International Classification of Diseases diagnosis 9 (ICD-9) codes were used to determine appendiceal perforation. Urban influence codes from the US Department of Agriculture were used to determine rural versus urban status. Univariate and multivariate analyses were used to determine patient and hospital factors associated with perforation.

Results: Overall, 32.07% of patients presented with perforation. Rural patients were more likely than urban patients to present with perforation (35.76% vs. 31.48%). Factors associated with perforation in multivariate analysis were age more than 40 years, male gender, transfer from another facility, black race, poorest 25th percentile, Charlson score of 3 or higher, and rural residence. Thirty percent of rural patients were treated in urban hospitals. Rural patients treated at urban hospitals were more likely to present with perforation compared with rural patients treated at rural hospitals (OR = 1.23).

Conclusions: Patients from rural areas have higher rates of perforation with acute appendicitis than urban patients. This difference persists when accounting for other factors associated with perforation. These differences in perforation rates suggest disparities in access to timely surgical care.

We hypothesized that patients from rural areas with acute appendicitis may be more likely to present with perforation compared with urban patients. We performed a retrospective cohort study of 122,990 patients with acute appendicitis from the Nationwide Inpatient Sample from 2003 to 2004. We concluded that patients from rural areas have higher rates of perforation than urban patients.

From the *Dartmouth Hitchcock Medical Center and †The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH; ‡Hospital of Saint Raphael, New Haven, CT; §The Mithoefer Center for Rural Surgery, Cooperstown, NY; and ¶Department of Surgery, North Country Hospital, Newport, VT.

The authors of this article have no commercial relationships to report.

Correspondence: Ian M. Paquette, MD, Dartmouth Hitchcock Medical Center. One Medical Center Drive. Lebanon, NH 03756. E-mail: ipaquett@umn.edu

Copyright © 2011 Wolters Kluwer Health, Inc. All rights reserved.