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Original Investigation
Pacific Coast Surgical Association
July 5, 2017

Outcomes and Costs of Managing Appendicitis at Safety-Net Hospitals

Author Affiliations
  • 1Department of Surgery, Harbor–University of California Los Angeles Medical Center, Torrance, California
  • 2Los Angeles Biomedical Research Institute, Torrance, California
  • 3Department of Pediatrics, Harbor–University of California Los Angeles Medical Center, Torrance, California
JAMA Surg. Published online July 5, 2017. doi:10.1001/jamasurg.2017.2209
Key Points

Question  Do safety-net hospitals have poorer outcomes and higher costs associated with common, urgent general surgical procedures such as appendectomy?

Findings  In this database review, safety-net hospitals had lower rates of laparoscopy vs non–safety-net hospitals. Safety-net hospitals had higher rates of perforated appendicitis, yet maintained similar rates of negative appendectomy and postoperative morbidity; safety-net hospitals also had longer lengths of stay, but no difference in overall cost.

Meaning  Safety-net hospitals may be well equipped to perform common, urgent general surgical procedures such as appendectomy.

Abstract

Importance  Safety-net hospitals serve vulnerable populations with limited resources. Although complex, elective operations performed at safety-net hospitals have been associated with inferior outcomes and higher costs, it is unclear whether a similar association has been seen with common emergency general surgery performed at safety-net hospitals.

Objective  To evaluate the association of safety-net burden with the outcomes of appendectomy.

Design, Setting, and Participants  A retrospective review was conducted of all nonfederally funded hospitals in the California state inpatient database that performed appendectomies from January 1, 2005, to December 31, 2011. A total of 349 hospitals performing 274 405 nonincidental appendectomies were stratified based on safety-net burden; low-burden hospitals had the lowest quartile of patients who either had Medicaid or were uninsured (0%-14%), medium-burden hospitals had the middle 2 quartiles (15%-41%), and high-burden hospitals had the highest quartile (>42%). Data analysis was performed from August 27 to September 8, 2016.

Main Outcomes and Measures  Rates of laparoscopy, perforation, negative appendectomy, morbidity, length of stay, and cost.

Results  Among the 349 hospitals in the study, high-burden hospitals treated a larger proportion of black patients than did medium- and low-burden hospitals (4.5% vs 2.4% vs 2.9%; P = .01), as well as Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and patients with perforated appendicitis (27.6% vs 23.6% vs 23.6%; P = .005). High-burden hospitals were less likely than medium- or low-burden hospitals to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). There were no differences in morbidity, length of stay, or cost. Multivariable regression analysis confirmed that high-burden hospitals were more likely than low-burden hospitals to treat perforated appendicitis (log %, 0.07; 95% CI, 0.03-0.12; P = .04) and less likely to use laparoscopy (–16.9% difference; 95% CI, –26.1% to –7.6%; P < .001), while achieving similar complication rates. Multivariable analysis also confirmed that high-burden hospitals have similar costs, despite being associated with longer length of stay (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001).

Conclusions and Relevance  Safety-net hospitals treat a disproportionate number of patients with advanced appendicitis while falling behind in the use of laparoscopy. Nonetheless, safety-net hospitals treat this common surgical emergency with morbidity and cost similar to that seen at other hospitals. Additional research is needed to evaluate how these outcomes are achieved to improve all surgical outcomes at underresourced hospitals.

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