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Original Investigation
March 4, 2020

Geographic Association Between Incidence of Acute Appendicitis and Socioeconomic Status

Author Affiliations
  • 1Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
  • 2Department of Geography, San Francisco State University, San Francisco, California
  • 3Department of Surgery, University of Washington School of Medicine, Seattle
JAMA Surg. Published online March 4, 2020. doi:10.1001/jamasurg.2019.6030
Key Points

Question  Is the population-based incidence of acute appendicitis (AA) or perforated appendicitis (PA), at the census tract level, uniformly distributed across a densely populated geographic area?

Findings  In this study, AA and PA were clustered geographically into high-incidence and low-incidence regions, but geographic autocorrelation was twice as strong for AA compared with PA. Areas of low AA incidence have significantly increased secondary education and income vs high-incidence areas.

Meaning  These findings challenge the conventional view that AA occurs randomly and has no predisposing characteristics beyond age/sex; higher socioeconomic status is associated with lower incidence of both AA and PA.


Importance  Some studies based on proportions of patients with perforated appendicitis (PA) among all patients with acute appendicitis (AA) have found an association between socioeconomic status (SES) and risk of perforation. A potential limitation is their use of proportions, which assumes that incidence of AA is evenly distributed across populations at risk. This assumption may be invalid, and SES may have a more complex association with both AA and PA.

Objective  To generate population-based incidences of AA and PA and to examine geographic patterns of incidence alongside geographic patterns of SES.

Design, Setting, and Participants  Retrospective study of data from Washington’s Comprehensive Hospital Abstract Reporting System and the 2010 US census. Geographic methods were used to identify patterns of age- and sex-standardized incidence in Washington State between 2008 and 2012. The study included all patients discharged with International Classification of Diseases, Ninth Revision codes for AA or PA. Data were analyzed between November 2016 and December 2018.

Exposures  Location of primary residence.

Main Outcomes and Measures  Age- and sex-standardized incidence for AA and PA was generated for each census tract (CT). Global spatial autocorrelation was examined using Moran index (0.0 = completely random incidence; 1.0 = fully dependent on location). Clusters of low-incidence CTs (cold spots) and high-incidence CTs (hot spots) were identified for AA. Census-based SES data were aggregated for hot spots and cold spots and then compared.

Results  Statewide, over the 5-year study period, there were 35 730 patients with AA (including 9780 cases of PA), of whom 16 574 were women (46.4%). Median age of the cohort was 29 years (IQR, 16-48 years). Statewide incidence of AA and PA was 106 and 29 per 100 000 person-years (PY), respectively. Crude incidence was higher within the male population and peaked at age 10 to 19 years. Age- and sex-standardized incidence of AA demonstrated significant positive spatial autocorrelation (Moran index, 0.30; P < .001), but autocorrelation for PA was only half as strong (0.16; P < .001). Median incidence of AA was 118.1 per 100 000 PY among hot spots vs 86.2 per 100 000 PY among cold spots (P < .001). Socioeconomic status was higher in cold spots vs hot spots: mean proportion of college-educated adults was 56% vs 26% (P < .001), and mean per capita income was $44 691 vs $30 027 (P < .001).

Conclusions and Relevance  Age- and sex-standardized incidence of appendicitis is not randomly distributed across geographic subunits, and geographic clustering of AA is twice as strong as PA. Socioeconomic advantages, such as higher income and secondary education, are strongly associated with lower incidence of AA. These findings challenge conventional views that AA occurs randomly and has no predisposing characteristics beyond age/sex. Socioeconomic status, and likely other geographically circumscribed factors, are associated with incidence of AA.

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