Effect of transfer on outcome in patients with appendicitis

To determine whether transfer of patients with appendicits from one hospital to another because of lack of insurance is a risk factor for rupture.

We identified the charts of all male patients ages 15 to 50 with appendicitis who presented from 1990 through 1994 at a county hospital that commonly accepts transfers of uninsured patients with a presumptive diagnosis of appendicitis. We retrospectively reviewed the charts of 69 consecutive transferred patients and 154 randomly selected controls. We then compared rupture rates by transfer status, time from onset of symptoms to initial presentation to a hospital, time from initial presentation to arrival in the operating room, primary language, race, and birth country by univariate chi 2 and multivariate logistic regression.

Transferred patients were less likely than controls to be ruptured at the time of operation (25% versus 45%, respectively; delta, 20%; 95% confidence interval [CI], 8% to 34%). Transferred patients did take slightly longer to get to the operating room but tended to present much earlier in the course of their illness. Sixty-four percent of transferred patients but only 49% of controls presented within 24 hours of symptom onset (delta, 15%; 95% CI, 2% to 29%), a difference that accounted for most but not all of the higher rupture rate in controls. Of the above-mentioned independent variables, only the time from symptom onset to initial presentation (odds ratio [OR], 4.2; 95% CI, 2.3 to 7.5) and transfer status (OR, 4; 95% CI .2 to .8) were significantly predictive of rupture. The delay before presentation was at least 10 hours longer in non-transferred patients than average delays reported in other studies, whereas the delay in transferred patients was similar to those reported elsewhere.

Contrary to our hypothesis, transferred patients were less likely to be ruptured, primarily because they presented earlier. Even after controlling for this factor, transferred patients were less likely to rupture, presumably because sicker patients were not transferred. Further research should examine why patients delay going to the county hospital, because this may represent decreased access to care.