Appendicitis racial disparities mostly unexplained
Poverty and unfavorable health insurance account for only a small portion of the gap in the number of white versus Hispanic or black children who end up with a burst appendix, according to a new study.
Some previous research has explained the fact that black and Hispanic children are more likely to have their appendix rupture by pointing to signs of poor health care access, including being uninsured, having public assistance insurance or having a low socioeconomic status.
But the latest report finds that the main reasons for these disparities “are anybody’s guess,” said lead author Dr. Edward Livingston, a professor at the University of Texas Southwestern Medical Center in Dallas who analyzed more than half a million hospital admissions for appendicitis.
The condition means inflammation of the appendix, a pocket of tissue attached to the intestine, and in some cases the little organ can rupture. To prevent severe infections, quick surgery is needed to remove the appendix before it bursts.
Among adults, Livingston and a colleague found no differences between white, black or Hispanic patients in the proportion of those whose appendix had burst before they could get surgery.
Children, however, did show differences depending on their race: 27 out of every 100 white kids, 35 out of every 100 black kids, and 36 out of every 100 Hispanic kids had a ruptured appendix.
Medicaid insurance - the government-subsidized health insurance for the poor - was associated with having a burst appendix, as was poverty itself.
But when Livingston and his partner looked at the numbers more closely, they found that health insurance explained only 12 percent and family income explained only seven percent of the difference between the white and black children.
Results There were no disparities observed in adult appendicitis perforation rates. The perforation rate for white children was 26.7%; black children, 35.5%; and Latino children, 36.5%. Gap analysis showed that only 12.0% of the difference in perforation rates between black and white children was explained by insurance status and only 12.7% of the difference between Latino and white children was explained. Income level only accounted for 7.2% of the gap for black children and 6.1% for Latino children. Age explained one-third of the gap for Latino children and one-third was not accounted for by measurable variables. Two-thirds of the difference between appendicitis perforation rates between black and white children was not explained by measurable factors.
Conclusions A very small amount of the gap between minority and white children’s appendicitis rates is explained by the proxy factors for health insurance and poverty status that might relate to health care access. Appendicitis perforation rates are not an appropriate indicator of health care access.
Between white and Hispanic kids, age explained about one third of the difference, with Hispanic children’s younger ages putting them at a higher risk of having a ruptured appendix.
Income and health insurance contributed about the same to the differences as between white and black kids.
Adult Appendicitis Symptoms
Researchers have yet to figure out if the appendix actually serves a purpose in the body. They believe it has no function, but it can cause many problems, particularly for people between the ages of 10 and 30. The appendix is a small sack on the colon at the right side of the body. When it becomes inflamed, the Mayo Clinic reports that it usually needs to be surgically removed.
Pain
The most obvious symptom of appendicitis is pain that increases to severe levels in less than one day. It often starts near the naval and moves to the abdominal region’s lower right. The pain gradually increases over the period from inception. A person may also experience tenderness when pressing the affected abdominal region. “Rebound pain” may occur if one presses in and then releases the pressure rapidly. Pain may intensify if the person moves jarringly, walks or even coughs, and it may prevent a person from remaining calm and motionless. The Mayo Clinic states that a patient experiencing this level of pain requires emergency medical aid.
Stomach Symptoms and Body Temperature
The affects of appendicitis can cause some symptoms in the stomach. The person may first experience a loss of appetite. He may also feel nauseous and begin vomiting. These are common symptoms during the period of increasing pain. Because appendicitis is an infection, it can also cause such symptoms as chills and fever.
Intestines
Appendicitis may cause a person to experience swelling in the abdomen. There may also be direct intestinal problems such as constipation or diarrhea. The person may not be able to pass gas through the intestines despite an urgent need to do so.
Other Symptoms
If the appendix bursts, an infection that was originally caused by the organ becoming blocked may spread throughout the body. The spread of the infection may affect the abdominal wall lining known as the peritoneum, which produces secondary peritonitis, a life-threatening problem. The University of Maryland Medical Center reports that some symptoms of peritonitis are similar to those of appendicitis, such as fever and chills, but there are also others, including decreased urination and thirst.
“Using a very large database we found that the factors that go along with health care access, like minority status or low socioeconomic status or unfavorable health insurance, really didn’t explain the difference in perforation rates at all,” Livingston told Reuters Health.
Livingston said it’s unclear what might be the main contributors to the higher rates of appendix rupture, but that genetics could be a culprit.
Certain genes might make people more susceptible to having a burst appendix, and perhaps those genes are more frequent among black or Hispanic populations, he speculated.
Dr. Benedict Nwomeh, a pediatric surgeon at Nationwide Children’s Hospital in Columbus, Ohio, said there is little evidence at this point to support the idea that biological differences put black or Hispanic kids at a higher risk of a ruptured appendix.
“The useful contribution of this paper is to say, ‘we have this disparity, and if we’re trying to solve this, we shouldn’t be looking only at correcting disparities in insurance or income,’” said Nwomeh, who was not involved in this study.
The researchers write in their report, published in the Archives of Surgery, that appendix rupture has been used as an indicator of poor health care access.
Livingston said that a more appropriate marker of health care barriers is preventive services, such as cancer screening and counseling to quit smoking.
“Those are the kinds of rates that will be sensitive to access,” he said.
SOURCE: Archives of Surgery, January 2012.
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Little Effect of Insurance Status or Socioeconomic Condition on Disparities in Minority Appendicitis Perforation Rates
Edward H. Livingston, MD; Robert W. Fairlie, PhD
Arch Surg. 2012;147(1):11-17. doi:10.1001/archsurg.2011.746