Differential access to care: The role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates

Surgery. 2016 Nov;160(5):1145-1154. doi: 10.1016/j.surg.2016.06.002. Epub 2016 Jul 30.


Background: Differences in perforated appendix admission rates (PAAR) are an ambulatory-sensitive measure of access to care. While pediatric studies report disparities in PAAR, initial adult investigations suggest a lack of racial/ethnic inequity. The objectives of this study were to (1) assess for risk-adjusted, racial/ethnic differences in PAAR among adults on a national scale, (2) consider the extent to which variations (or lack thereof) are explained by age, insurance, and income, and (3) compare results within the United States population to a national segment of the population who are completely insured.

Methods: According to the Agency for Healthcare Research and Quality definition of PAAR, adults (aged 18-64 years) in the 2006-2010 Nationwide Inpatient Sample were queried for the occurrence and perforation of acute appendicitis. Risk-adjusted differences were compared by race/ethnicity over 5-year age increments using logistic regression with reweighted estimating equations. Noting disparate outcomes between younger (aged 18-34 years) versus older (aged 35-64 years) adults, age-stratified variations were further considered. Results were compared relative to differences among national military/civilian-dependent patients with universal insurance and were assessed for the extent to which disparities could be explained by variations in insurance and income.

Results: A total of 129,257 (weighted: 638,452) patients were included. Despite a lack of differences overall, significantly worse outcomes among younger (odds ratio point-estimates ranged from 1.11-1.32) and better outcomes among older (0.78-0.93) minority patients were found. This observation contrasted a lack of differences among completely insured military/civilian-dependent patients (n = 12,154). A total of 22.4% (non-Hispanic black versus non-Hispanic white) and 39.0% (Hispanic versus non-Hispanic white) of younger adult differences were explained by insurance-12.2% and 13.6% by income, 29.8% and 44.0% combined.

Conclusion: This national assessment of differences in access to care among adults with acute appendicitis demonstrated the existence of racial/ethnic disparities in PAAR that varied with age and were partially, although incompletely, explained by variations in insurance and income.

Publication types

  • Comparative Study

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Appendicitis / diagnosis
  • Appendicitis / ethnology
  • Appendicitis / surgery*
  • Confidence Intervals
  • Ethnicity
  • Female
  • Health Care Surveys
  • Health Services Accessibility / economics*
  • Health Services Accessibility / statistics & numerical data
  • Healthcare Disparities / ethnology*
  • Humans
  • Income
  • Insurance Coverage / economics*
  • Insurance Coverage / statistics & numerical data
  • Male
  • Middle Aged
  • Odds Ratio
  • Outcome Assessment, Health Care*
  • Patient Admission / economics*
  • Patient Admission / statistics & numerical data
  • Racial Groups
  • Risk Assessment
  • Role
  • United States
  • Young Adult