Association of Appendicitis Incidence With Warmer Weather Independent of Season

Abstract

Importance: Acute appendicitis is a common cause of abdominal pain and the most common reason for emergency surgery in several countries. Increased cases during summer months have been reported.

Objective: To investigate the incidence of acute appendicitis by considering local temperature patterns in geographic regions with different climate over several years.

Design, setting, and participants: This cohort study used insurance claims data from the MarketScan Commercial Claims and Encounters Database and the Medicare Supplemental and Coordination of Benefits Database from January 1, 2001, to December 31, 2017. The cohort included individuals at risk for appendicitis who were enrolled in US insurance plans that contribute data to the MarketScan databases. Cases of appendicitis in the inpatient, outpatient, and emergency department settings were identified using International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. Local weather data were obtained for individuals living in a metropolitan statistical area (MSA) from the Integrated Surface Database. Associations were characterized using a fixed-effects generalized linear model based on a negative binomial distribution. The model was adjusted for age, sex, and day of week and included fixed effects for year and MSA. The generalized linear model was fit with a piecewise linear model by searching each 0.56 °C in temperature for change points. To further isolate the role of temperature, observed temperature was replaced with the expected temperature and the deviation of the observed temperature from the expected temperature for a given city on a given day of year. Data were analyzed from October 1, 2021, to July 31, 2022.

Main outcomes and measures: The primary outcome was the daily number of appendicitis cases in a given city stratified by age and sex, with mean temperature in the MSA over the previous 7 days as the independent variable.

Results: A total of 450 723 744 person-years at risk and 689 917 patients with appendicitis (mean [SD] age, 35 [18] years; 347 473 male [50.4%] individuals) were included. Every 5.56 °C increase in temperature was associated with a 1.3% increase in the incidence of appendicitis (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) when temperatures were 10.56 °C or lower and a 2.9% increase in incidence (IRR, 1.03; 95% CI, 1.03-1.03) for temperatures higher than 10.56 °C. In terms of temperature deviations, a higher-than-expected temperature increase greater than 5.56 °C was associated with a 3.3% (95% CI, 1.0%-5.7%) increase in the incidence of appendicitis compared with days with near-0 deviations.

Conclusions and relevance: Results of this cohort study observed seasonality in the incidence of appendicitis and found an association between increased incidence and warmer weather. These results could help elucidate the mechanism of appendicitis.

Figure 1.. Incidence of Appendicitis by Previous Week Temperature

Points are shaded according to the number of person-years at risk in that stratum. Dashed line represents a smooth estimate of the mean incidence at each temperature.

Figure 2.. Estimated Outcome of Temperature in Piecewise Linear Model

The solid line represents the estimated fit of the linear spline model for temperatures ranging from –17.78 °C to 37.78 °C. Note the change of slope at 10.56 °C. Reference was 4.44 °C. IRR indicates incidence rate ratio.

Figure 3.. Estimated Association of Temperature Deviation With Incidence of Appendicitis

Model was adjusted for year and metropolitan statistical area fixed effects, age, sex, day of week, and expected temperature. Vertical lines denote the 95% CIs using robust SEs adjusted for metropolitan statistical area clusters, and horizontal lines denote the size of the temperature bin. A dose-response association was observed between deviations in observed temperature from expected temperatures and incidence of appendicitis, with days after higher-than-normal-temperature periods having increased risk and days after lower-than-normal-temperature periods having decreased risk. Reference was –0.56 to 0 °C higher-than-expected temperature. IRR indicates incidence rate ratio.