Insurance-related differences in the presentation of pediatric appendicitis
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S J O'Toole1, H L Karamanoukian, J E Allen
1Children's Hospital of Buffalo, NY 14222, USA.
Insights
Children with Medicaid insurance experienced longer delays in appendicitis treatment, leading to higher perforation risks. Improving access to care and parental education can reduce these delays for uninsured and Medicaid patients.
Area of Science:
- Pediatric Surgery
- Health Services Research
- Public Health
Background:
- Delayed treatment for pediatric appendicitis increases perforation risk.
- The source of treatment delays (parental, referring physician, or surgeon) is unclear.
- Insurance status may influence access to timely care for pediatric appendicitis.
Purpose of the Study:
- To identify the factors contributing to delayed treatment in pediatric appendicitis.
- To compare treatment delays and outcomes based on insurance type.
- To evaluate the impact of insurance on appendiceal perforation rates and hospital stay.
Main Methods:
- Retrospective chart review of pediatric appendicitis cases (1990-1993).
- Categorization of children by insurance: Medicaid (or uninsured), HMO, private fee-for-service.
- Comparison of time to ER and OR presentation, hospital stay, complications, and perforation rates.
Main Results:
- Medicaid patients had significantly higher perforation rates (44%) compared to HMO (27%) and private (23%) patients.
- Medicaid patients experienced longer symptom duration before presentation (47.3 hours) and longer hospital stays (7.9 days).
- No significant difference in time from ER to OR presentation was observed across insurance groups.
Conclusions:
- Children with Medicaid/uninsured status present later, face higher perforation risk, and have longer hospitalizations.
- Delays in seeking medical advice by parents, possibly due to financial/logistical reasons, are implicated.
- Health maintenance organization (HMO) gatekeeper consultations did not cause delays or increase morbidity.
Abstract:
In the pediatric population, there is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perforation. However, it is not clear whether this delay arises from the parent seeking medical advice, the referring physician seeking surgical consultation, or the surgeon deciding to operate. To resolve this issue, the authors performed a retrospective chart review of all cases of confirmed acute appendicitis that presented to the pediatric surgical service of the Children's Hospital of Buffalo during a 4-year period (January 1990 through December 1993). All children (< or = 16 years of age) were categorized with respect to type of insurance coverage:Medicaid (or uninsured), health maintenance organization (HMO), or private fee-for-service. Their time until emergency room (ER) presentation, operating room (OR) presentation, and hospital discharge were recorded and compared. Their complications and perforation rates also were noted. Two hundred eighty-eight cases were reviewed. The rate of appendiceal perforation was significantly higher among the Medicaid patients (Medicaid, 44%; HMO, 27%; private, 23%; P < .05); their duration of symptoms before presentation was significantly longer (Medicaid, 47.3 +/- 4.1 hours; HMO, 29.3 +/- 1.9 hours; private, 23.1 +/- 2.5 hours; P < .01), and their hospital stay was longer (Medicaid, 7.9 +/- 0.9 days; HMO, 4.8 +/- 0.27 days; private, 4.6 +/- 0.44 days; P < .01). However, there were no significant differences in the time from presentation to the ER until definitive surgery in the OR. Children covered by Medicaid (or uninsured) presented later, had a higher risk of appendiceal perforation, and required a longer hospital stay. The parents of these children either failed to recognize the significance of their children's symptoms, or delayed seeking medical advice because of financial or logistical reasons. The gatekeeper consultation, required by the health maintenance organizations (HMO) did not result in a delay in presentation or have a negative impact on morbidity. Providing easier access to a primary care physician and improving parental health education/awareness may shorten the time until presentation for the uninsured/Medicaid patient.