Insurance-related differences in the risk of ruptured appendix

N Engl J Med. 1994 Aug 18;331(7):444-9. doi: 10.1056/NEJM199408183310706.


Background: We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage.

Methods: In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989.

Results: After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]).

Conclusions: Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.

MeSH terms

  • Adolescent
  • Adult
  • Appendicitis / economics*
  • Appendicitis / etiology*
  • California / epidemiology
  • Confidence Intervals
  • Female
  • Health Services Accessibility / economics*
  • Humans
  • Insurance, Hospitalization / statistics & numerical data*
  • Intestinal Perforation / economics
  • Intestinal Perforation / epidemiology
  • Intestinal Perforation / etiology*
  • Male
  • Medicaid / statistics & numerical data
  • Medically Uninsured
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Retrospective Studies
  • Risk Factors
  • Rupture, Spontaneous / epidemiology
  • Socioeconomic Factors
  • United States