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Ponsky TA, Huang ZJ, Kittle K, et al. Hospital- and Patient-Level Characteristics and the Risk of Appendiceal Rupture and Negative Appendectomy in Children. JAMA. 2004;292(16):1977–1982. doi:https://doi.org/10.1001/jama.292.16.1977
Author Affiliations: Departments of Surgery
(Drs Ponsky, Eichelberger, Gilbert, Brody, and Newman) and Biostatistics (Dr
Huang), Children’s National Medical Center and George Washington University
Medical Center, Washington, DC; and Child Health Corporation of America, Overland
Park, Kan (Mr Kittle).
Context The rates of appendiceal rupture and negative appendectomy in children
remain high despite efforts to reduce them. Both outcomes are used as measures
of hospital quality. Little is known about the factors that influence these
Objective To investigate the association between hospital- and patient-level characteristics
and the rates of appendiceal rupture and negative appendectomy in children.
Design, Setting, and Patients Retrospective review using the Pediatric Health Information System database
containing information on 24 411 appendectomies performed on children aged
5 to 17 years at 36 pediatric hospitals in the United States between 1997
Main Outcome Measures Rates of negative appendectomy and appendiceal rupture; the odds ratio
(OR) of negative appendectomy and appendiceal rupture by hospital, patient
age, race, and health insurance status, and hospital fiscal year and appendectomy
volume. Negative appendectomy rate was defined as the number of patients with
appendectomy but without appendicitis divided by the total number of appendectomies.
Results The median negative appendectomy rate was 3.06% (range, 1%-12%) and
the median appendiceal rupture rate was 35.08% (range, 22%-62%). The adjusted
OR for appendiceal rupture was higher in Asian children (1.66; 95% confidence
interval [CI], 1.24-2.23) and black children (1.13; 95% CI, 1.01-1.30) compared
with white children. Children without health insurance and children with public
insurance had increased odds of appendiceal rupture compared with children
who had private health insurance (adjusted OR, 1.36; 95% CI, 1.22-1.53 for
self-insured; adjusted OR, 1.48; 95% CI, 1.34-1.64 for public insurance).
No correlation existed between negative appendectomy rate and race, health
insurance status, or hospital appendiceal rupture rate. The negative appendectomy
rate improved as the hospital appendectomy volume increased.
Conclusion The rate of appendiceal rupture in school-aged children was associated
with race and health insurance status and not with negative appendectomy rate
and therefore is more likely to be associated with prehospitalization factors
such as access to care, quality of care, and patient or physician education.
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