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Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols
Leo Andrew Benedict1, Joseph A Sujka2, Justin A Sobrino3
1Department of Surgery, St. Luke's Hospital of Kansas City, Kansas City, MO 64108.
Insights
An evidence-based protocol for pediatric acute appendicitis effectively reduced racial and ethnic disparities in surgical outcomes. This patient-driven approach demonstrated no significant differences in same-day discharge or length of stay across racial groups.
Area of Science:
- Pediatric Surgery
- Health Disparities Research
- Evidence-Based Medicine
Background:
- Racial and ethnic minorities historically face worse outcomes for pediatric acute appendicitis.
- An institution developed an evidence-based, patient-driven protocol for laparoscopic appendectomy in children.
- The protocol's impact on mitigating disparities remained unassessed.
Purpose of the Study:
- To evaluate the influence of a novel patient-driven protocol on surgical outcomes in children with acute appendicitis.
- To assess whether the protocol mitigates existing racial and ethnic disparities.
- To analyze the relationship between race, ethnicity, and outcomes like length of stay and readmission rates.
Main Methods:
- Retrospective review of prospectively collected data from December 2015 to July 2017.
- Inclusion of children undergoing laparoscopic appendectomy at a freestanding children's hospital.
- Comparative analysis of demographic data, post-operative length of stay, same-day discharge, and readmission rates stratified by race and ethnicity.
Main Results:
- A total of 786 children were analyzed; 70% White, 8% Black, 17% Hispanic.
- No significant differences in same-day discharge rates were observed across racial/ethnic groups (p=.126).
- Hispanic children showed higher perforation rates (41%) compared to White (23%) and Black (29%) children (p=.001); however, post-operative length of stay was similar across groups (p=.015).
Conclusions:
- The evidence-based, patient-driven protocol effectively mitigated racial and ethnic disparities in pediatric acute appendicitis outcomes.
- Perforation status, not race or ethnicity, was the primary predictor of elevated post-operative length of stay.
- Further prospective studies on patient-driven protocols for reducing healthcare disparities are recommended.
Purpose:
Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis.
Material And Methods:
A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant.
Results:
A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation.
Conclusion:
Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted.
Levels Of Evidence:
Therapeutic study; Level 3.
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