INSURANCE-RELATED DIFFERENCES IN THE PRESENTATION OF PEDIATRIC APPENDICITIS

In the pediatric population, there is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perfo ration. However, it is not clear whether this delay arises from the pa rent seeking medical advice, the referring physician seeking surgical consultation, or the surgeon deciding to operate. To resolve this issu e, the authors performed a retrospective chart review of all cases of confirmed acute appendicitis that presented to the pediatric surgical service of the Children's Hospital of Buffalo during a 4-year period ( January 1990 through December 1993). All children (less than or equal to 16 years of age) were categorized with respect to type of insurance coverage: Medicaid (or uninsured), health maintenance organization (H MO), or private fee-for-service. Their time until emergency room (ER) presentation, operat ing room (OR) presentation, and hospital discharg e were recorded and compared. Their complications and perforation rate s also were noted. Two hundred eighty-eight cases were reviewed. The r ate of appendiceal perforation was significantly higher among the Medi caid patients (Medicaid, 44%; HMO, 27%; private, 23%; P < .05); their duration of symptoms before presentation was significantly longer (Med icaid, 47.3 +/- 4.1 hours; HMO, 29.3 +/- 1.9 hours; private, 23.1 +/- 2.5 hours; P < .01), and their hospital stay was longer (Medicaid, 7.9 +/- 0.9 days; HMO, 4.8 +/- 0.27 days; private, 4.6 +/- 0.44 days; P < .01). However, there were no significant differences in the time from presentation to the ER until definitive surgery in the OR. Children c overed by Medicaid (or uninsured) presented later, had a higher risk o f appendiceal perforation, and required a longer hospital stay. The pa rents of these children either failed to recognize the significance of their children's symptoms, or delayed seeking medical advice because of financial or logistical reasons. The gatekeeper consultation, requi red by the health maintenance organizations (HMO) did not result in a delay in presentation or have a negative impact on morbidity. Providin g easier access to a primary care physician and improving parental hea lth education/awareness may shorten the time until presentation for th e uninsured/Medicaid patient. Copyright (C) 1996 by W.B. Saunders Comp any