Abdominal pain and appendicitis: Is there a difference in referrals between HMO pediatricians and private pediatricians?

Background: In the last few years, there have been many reports of the risi ng incidence of late appendicitis and perforated appendicitis. The rise of managed care medicine has been blamed for this, because the health maintena nce organizations (HMO) and gatekeepers allegedly want to keep the child aw ay from the surgeon and hospital to save costs. Methods: The authors were in a unique position a number of years ago becaus e they had only a single HMO in their area of practice (New Brunswick, NJ) employing 14 pediatricians, and 86 pediatricians were in private practice o r on the medical school staff. The HMO had a yearly contract with the pedia tric surgeons, and all visits and surgeries were covered by a yearly agreem ent (capitated agreement). The authors compared the number of children with appendicitis, perforated appendicitis, or just abdominal pain (not requiri ng surgery), between both groups over a 5-year period (1991 to 1996). Results: A total of 492 patients were referred with abdominal pain over a 5 -year period. Two hundred eight (42%) had appendicitis, and 284 (58%) had j ust abdominal pain and eventually were sent home. The HMO pediatricians dia gnosed appendicitis accurately in 46% of their patients (55 of 118), and 54 % were abdominal pain that was not appendicitis (63 of 118). For the privat e pediatricians, the percentages were: 40% of their patients had appendicit is (153 of 374), and 60% had abdominal pain without appendicitis (221 of 37 4), The incidence of perforated appendicitis was similar (28% HMO v 30s% pr ivate), and the incidence of negative explorations were similar (8% HMO v 9 % private). Conclusions: The results are very similar in both groups, with a similar pe rcentage of abdominal pain not being appendicitis (60% v 54%). HMO patients did not pay for consultations, and the HMO was not charged for any consult ations. However, it does not appear that they overused the consultations fo r abdominal pain that were not appendicitis. Their accuracy for correct dia gnosis of appendicitis was similar to the private group (46% v 40%), and th e incidence of perforated appendicitis for both groups was 28% to 30%. The authors cannot draw any conclusions from their experience that HMOs in gene ral do refer patients to surgeons in a timely fashion, and do not delay the referrals to avoid the cost of consultation, because the authors had a cap itated agreement with their HMO, and consultations were free. Both groups o f pediatricians, the HMO and the private pediatricians, did not realize fin ancial gain or loss by sending children to the pediatric surgeon and were n ot penalized by sending patients with abdominal pain to the surgeon. On the contrary, their referral habits and judgments were similar and did not app ear to change by being part of an HMO. Copyright (C) 2000 by W.B. Saunders Company.