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Postdischarge Racial and Ethnic Disparities in Pediatric Appendicitis: A Mediation Analysis

Published:October 26, 2022DOI:https://doi.org/10.1016/j.jss.2022.09.027

      Highlights

      • Children of minority race/ethnicity had higher odds of postdischarge emergency department visits after appendicitis treatment, but Hispanic/Latinx patients were not more likely to be readmitted.
      • Inverse Odds Weighted Mediation analyses were used to measure the influence of complicated disease, insurance, socioeconomic status, and urbanicity.
      • Different patterns of disparity mediation were demonstrated for non-Hispanic Black and Hispanic/Latinx patients.
      • Modifiable factors driving postdischarge surgical disparities in children demand focused study.

      Abstract

      Introduction

      Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge.

      Materials and Methods

      We performed a retrospective cohort study of children (aged < 18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status– mediated disparate outcomes.

      Results

      A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively.

      Conclusions

      Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.

      Keywords

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      References

        • Ingram M.E.
        • Calabro K.
        • Polites S.
        • et al.
        Systematic review of disparities in care and outcomes in pediatric appendectomy.
        J Surg Res. 2020; 249: 42-49
        • Jablonski K.A.
        • Guagliardo M.F.
        Pediatric appendicitis rupture rate: a national indicator of disparities in healthcare access.
        Popul Health Metr. 2005; 3: 4
        • Zogg C.K.
        • Scott J.W.
        • Jiang W.
        • et al.
        Differential access to care: the role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates.
        Surgery. 2016; 160: 1145-1154
        • Lee S.L.
        • Stark R.
        • Yaghoubian A.
        • et al.
        Does age affect the outcomes and management of pediatric appendicitis?.
        J Pediatr Surg. 2011; 46: 2342-2345
        • Salö M.
        • Ohlsson B.
        • Arnbjörnsson E.
        • et al.
        Appendicitis in children from a gender perspective.
        Pediatr Surg Int. 2015; 31: 845-853
        • Guagliardo M.F.
        • Teach S.J.
        • Huang Z.J.
        • et al.
        Racial and ethnic disparities in pediatric appendicitis rupture rate.
        Acad Emerg Med. 2003; 10: 1218-1227
        • Kokoska E.R.
        • Bird T.M.
        • Robbins J.M.
        • et al.
        Racial disparities in the management of pediatric appenciditis.
        J Surg Res. 2007; 137: 83-88
        • Lee S.L.
        • Shekherdimian S.
        • Chiu V.Y.
        Effect of race and socioeconomic status in the treatment of appendicitis in patients with equal health care access.
        Arch Surg. 2011; 146: 156-161
        • Smink D.S.
        • Fishman S.J.
        • Kleinman K.
        • et al.
        Effects of race, insurance status, and hospital volume on perforated appendicitis in children.
        Pediatrics. 2005; 115: 920-925
        • Nwomeh B.C.
        • Chisolm D.J.
        • Caniano D.A.
        • et al.
        Racial and socioeconomic disparity in perforated appendicitis among children: where is the problem?.
        Pediatrics. 2006; 117: 870-875
        • Livingston E.H.
        • Fairlie R.W.
        Little effect of insurance status or socioeconomic condition on disparities in minority appendicitis perforation rates.
        Arch Surg. 2012; 147: 11-17
        • Putnam L.R.
        • Tsao K.
        • Nguyen H.T.
        • et al.
        The impact of socioeconomic status on appendiceal perforation in pediatric appendicitis.
        J Pediatr. 2016; 170: 156-160.e1
        • Estrella J.B.
        • Carmichael H.
        • Myers Q.W.O.
        • et al.
        Making it complicated: Does disparity in access to care lead to more perforated appendicitis?.
        J Surg Res. 2021; 266: 405-412
        • Camp M.
        • Chang D.C.
        • Zhang Y.
        • et al.
        Provider density and health system facility factors and their relationship to rates of pediatric perforated appendicitis in US counties.
        Arch Surg. 2010; 145: 1139-1144
        • Lassiter R.L.
        • Hatley R.M.
        Differences in the management of perforated appendicitis in children by race and insurance status.
        Am Surg. 2017; 83: 996-1000
        • Pieracci F.M.
        • Eachempati S.R.
        • Barie P.S.
        • et al.
        Insurance status, but not race, predicts perforation in adult patients with acute appendicitis.
        J Am Coll Surg. 2007; 205: 445-452
        • Zogg C.K.
        • Scott J.W.
        • Bhulani N.
        • et al.
        Impact of affordable care act insurance expansion on pre-hospital access to care: changes in adult perforated appendix admission rates after medicaid expansion and the Dependent coverage provision.
        J Am Coll Surg. 2019; 228: 29-43.e1
        • Kelley-Quon L.I.
        • Tseng C.H.
        • Jen H.C.
        • et al.
        Hospital type as a metric for racial disparities in pediatric appendicitis.
        J Am Coll Surg. 2013; 216: 74-82
        • Lee S.L.
        • Yaghoubian A.
        • de Virgilio C.
        A multi-institutional comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals.
        J Surg Educ. 2011; 68: 6-9
        • Lee S.L.
        • Yaghoubian A.
        • Kaji A.
        County versus private hospitals: access of care, management and outcomes for patients with appendicitis.
        Jsls. 2012; 16: 283-286
        • Penfold R.B.
        • Chisolm D.J.
        • Nwomeh B.C.
        • et al.
        Geographic disparities in the risk of perforated appendicitis among children in Ohio: 2001-2003.
        Int J Health Geogr. 2008; 7: 56
        • Paquette I.M.
        • Zuckerman R.
        • Finlayson S.R.
        Perforated appendicitis among rural and urban patients: implications of access to care.
        Ann Surg. 2011; 253: 534-538
        • Sarda S.
        • Short H.L.
        • Hockenberry J.M.
        • et al.
        Regional variation in rates of pediatric perforated appendicitis.
        J Pediatr Surg. 2017; 52: 1488-1491
        • Haider A.H.
        • Dankwa-Mullan I.
        • Maragh-Bass A.C.
        • et al.
        Setting a national agenda for surgical disparities research: recommendations from the national institutes of health and American college of surgeons summit.
        JAMA Surg. 2016; 151: 554-563
        • Agency for Healthcare Research and Quality
        Prevention quality indicator 02 (PQI02) perforated appendix admission rate.
        (Available at:)
        • United States Census Bureau
        American community survey 5-year estimates.
        2015 (Available at:)
        https://www.census.gov/programs-surveys/acs
        Date accessed: December 1, 2021
        • Rural Health Research Center
        Rural-urban commuting area codes.
        University of Washington, 2006 (Available at:)
        • R Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2021
        • Bates D.
        • Mächler M.
        • Bolker B.
        • et al.
        Fitting linear mixed-effects models using lme4.
        J Stat Softw. 2015; 67: 1-48
        • de Jager E.
        • Levine A.A.
        • Udyavar N.R.
        • et al.
        Disparities in surgical access: a systematic literature review, conceptual model, and evidence map.
        J Am Coll Surg. 2019; 228: 276-298
        • Thompson C.G.
        • Kim R.S.
        • Aloe A.M.
        • et al.
        Extracting the variance in flation factor and other multicollinearity diagnostics from typical regression results.
        Basic Appl Social Psychol. 2017; 39: 81-90
        • Huang Y.
        • Li W.
        • Macheret F.
        • et al.
        A tutorial on calibration measurements and calibration models for clinical prediction models.
        J Am Med Inform Assoc. 2020; 27: 621-633
        • Tchetgen Tchetgen E.J.
        Inverse odds ratio-weighted estimation for causal mediation analysis.
        Stat Med. 2013; 32: 4567-4580
        • MacKinnon D.P.
        • Fairchild A.J.
        • Fritz M.S.
        Mediation analysis.
        Annu Rev Psychol. 2007; 58: 593-614
        • Nguyen Q.C.
        • Osypuk T.L.
        • Schmidt N.M.
        • et al.
        Practical guidance for conducting mediation analysis with multiple mediators using inverse odds ratio weighting.
        Am J Epidemiol. 2015; 181: 349-356
        • Shi B.
        • Choirat C.
        • Coull B.A.
        • et al.
        CMAverse: a suite of functions for reproducible causal mediation analyses.
        Epidemiology. 2021; 32: e20-e22
        • Kubicek K.
        • Liu D.
        • Beaudin C.
        • et al.
        A profile of nonurgent emergency department use in an urban pediatric hospital.
        Pediatr Emerg Care. 2012; 28: 977-984
        • Powers R.J.
        • Mokdad A.A.
        • Pezzin L.E.
        • et al.
        Disparities in utilization of outpatient surgical care among children.
        Surgery. 2021; 170: 1815-1821
        • Alpern E.R.
        • Clark A.E.
        • Alessandrini E.A.
        • et al.
        Recurrent and high-frequency use of the emergency department by pediatric patients.
        Acad Emerg Med. 2014; 21: 365-373
        • Denning N.-L.
        • Glick R.D.
        • Rich B.S.
        Outpatient follow-up after pediatric surgery reduces emergency department visits and readmission rates.
        J Pediatr Surg. 2020; 55: 1037-1042
        • Taylor T.
        • Salyakina D.
        Health care access barriers bring children to emergency rooms more frequently: a representative survey.
        Popul Health Manag. 2019; 22: 262-271
        • Goldstein G.P.
        • Pai V.V.
        • Liu J.
        • et al.
        Racial/ethnic disparities and human milk use in necrotizing enterocolitis.
        Pediatr Res. 2020; 88: 3-9
        • Swords D.S.
        • Mulvihill S.J.
        • Brooke B.S.
        • et al.
        Size and importance of socioeconomic status-based disparities in use of surgery in nonadvanced stage gastrointestinal cancers.
        Ann Surg Oncol. 2020; 27: 333-341
        • Kawachi I.
        • Daniels N.
        • Robinson D.E.
        Health disparities by race and class: why both matter.
        Health Aff (Millwood). 2005; 24: 343-352
        • Trent M.
        • Dooley D.G.
        • Dougé J.
        The impact of racism on child and adolescent health.
        Pediatrics. 2019; 144
        • Sweet A.L.
        • Sutton T.L.
        • Curtis K.A.
        • et al.
        Characterizing 30-day postoperative acute care visits: a national surgical quality improvement program collaborative analysis.
        J Surg Res. 2022; 276: 1-9
        • Islam N.S.
        • Khan S.
        • Kwon S.
        • et al.
        Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: historical challenges and potential solutions.
        J Health Care Poor Underserved. 2010; 21: 1354-1381
        • Ro M.J.
        • Yee A.K.
        Out of the shadows: asian Americans, native hawaiians, and pacific islanders.
        Am J Public Health. 2010; 100: 776-778
        • Duraiswamy S.
        • Ignacio A.
        • Weinberg J.
        • et al.
        Comparative accuracy of ICD-9 vs ICD-10 codes for acute appendicitis.
        J Am Coll Surg. 2022; 234: 377-383
        • Tian Y.
        • Ingram M.E.
        • Hall M.
        • et al.
        ICD-10 transition influences trends in perforated appendix admission rate.
        J Surg Res. 2021; 266: 345-351