Impact of Initial Healthcare Setting and Family Caregiving Structure on Pediatric Appendicitis Outcomes in Resource-Limited Settings: A 10-Year Retrospective Cohort Study With External Validation

Acute appendicitis is a common pediatric surgical emergency worldwide. Misdiagnosis and perforation remain frequent, particularly among younger children in low- and middle-income countries. Prior studies have explored healthcare access or caregiving structures separately, but few long-term, large-sample retrospective studies in resource-limited settings have assessed their combined impact.

We retrospectively analyzed 1839 children (0-14 years) undergoing appendectomy at a tertiary hospital in southwestern China (2008-2017). Exposures included initial healthcare facility level (tertiary vs non-tertiary) and caregiving structure (biparental, single-parent, non-parental). Multivariable logistic regression evaluated predictors of misdiagnosis and perforation, adjusting for age, sex, year, and imaging. Phi coefficient assessed correlation between misdiagnosis and perforation. All key findings were validated in an independent external 2018cohort. Nomograms were subsequently constructed based on significant predictors identified in the primary cohort.

Initial presentation to non-tertiary facilities was associated with higher odds of misdiagnosis (aOR 2.39, 95 % CI 1.89-3.02) and perforation (aOR 2.97, 95 % CI 2.38-3.72). Non-biparental caregiving increased the risk of diagnostic error and complications: single-parent caregiving (misdiagnosis: aOR 2.57; perforation: aOR 2.54), non-parental caregiving (misdiagnosis: aOR 5.26; perforation: aOR 2.94). A significant interaction between non-parental caregiving and non-tertiary healthcare increased risks of misdiagnosis (OR 7.52) and perforation (OR 8.19). Younger age, particularly 0-3 years, was the strongest predictor. Additionally, lack of imaging was independently associated with increased risk of both misdiagnosis (aOR 1.78, 95 % CI 1.34-2.36) and perforation (aOR 2.06, 95 % CI 1.50-2.83). Misdiagnosis and perforation were moderately correlated (ϕ = 0.352). These findings were statistically significant and validated in an external cohort.

Younger age, no imaging, non-traditional caregiving, and lower-level initial healthcare independently and interactively contribute to misdiagnosis and perforation in pediatric appendicitis.