M. E. Ingram1, K. Calabro2, S. Polites3, C. E. McCracken4, G. Aspelund5, B. S. Rich6, R. L. Ricca7, R. Dasgupta3, D. H. Rothstein2, M. V. Raval8 1Emory University School of Medicine,Department Of Surgery,Atlanta, GA, USA 2University at Buffalo Jacobs School of Medicine and Biomedical Sciences and John R. Oishei Children’s Hospital,Department Of Surgery,Buffalo, NY, USA 3Cincinnati Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Cincinnati, OH, USA 4Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA 5Maria Fareri Children’s Hospital,Department Of Surgery,New York, NY, USA 6Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Cohen Children’s Medical Center, New Hyde Park, NY,Division Of Pediatric Surgery,New Hyde Park, NY, USA 7Naval Medical Center,Department Of Surgery,Portsmouth, VA, USA 8Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago,Division Of Pediatric Surgery, Department Of Surgery,,Chicago, IL, USA
Introduction:
The impact of social, racial, and economic disparities on health and surgical outcomes in adults has been well-documented, but little is known about how these sociodemographic variables affect surgical outcomes in children.
Methods:
A systematic review using PubMed search terms related to disparities in care of pediatric appendicitis identified 20 titles that were narrowed to 12 abstracts and then 11 full texts. After final review, 9 retrospective studies were included for analysis. Data included >350,000 cases (simple and complicated) treated across the United States from 1983-2010. Outcomes examined included length of stay (LOS), appendiceal perforation rate (AP), laparoscopic vs open approach, and rate of misdiagnosis.
Results:
Only 2 papers reported the impact of a shared set of variables for any given surgical outcome (Figure 1), limiting the ability to perform a meta-analysis. The 2 most frequently reported outcomes were LOS (6 of 9 studies) and AP (6 of 9 studies). AP was higher for young children (48% for <6yo vs. 25% for >10yo), those in rural settings (42% vs. 26% in urban settings), and for children receiving care at children’s hospitals (35% vs. 22% at non-children’s hospitals). Longer LOS was associated with young age in 3 studies (2-5 days for age <10 years vs 1-3 days for age >11 years), race in 4 studies (1.5-3 days for African American children vs. 1-2 days for other races), and lower family income in 2 studies (2-4 days vs. 1-3 days for highest-income). Disparities based on age and race are also reported in use of laparoscopy, time to surgery, and misdiagnosis. One paper reported on discrepancy in time to surgery being influenced by race. Another paper described age, sex, and children’s hospitals vs non-children’s hospital settings as positively associated with a higher likelihood of misdiagnosis.
Conclusion:
While limited, the existing literature suggests that social, racial, and economic disparities impact surgical management and outcomes in pediatric appendicitis. Specifically, a patient’s race, age and locality correlate with marked disparities in LOS and AP. A paucity of studies limit more robust pooled meta-analysis. More studies are needed to better describe and mitigate disparities in the surgical care of children.
