Uninsured Kids At Higher Risk for Burst Appendix

Diagnosis often comes too late for preventive surgery, study finds

TUESDAY, Oct. 26, 2004 (HealthDayNews) -- For the 70,000 U.S. children who suffer from appendicitis each year, the lack of private insurance can mean the difference between the safe, prompt removal of the appendix or serious complications linked to its rupture, researchers report.

They believe many uninsured children are being diagnosed too late when appendicitis strikes.

"I think we need to take a whole new look at the way we're evaluating kids -- not only with abdominal pain, but with other conditions as well. What are the hurdles to getting those kids into the system and taking care of them properly?" said lead researcher Dr. Kurt D. Newman, a pediatric surgeon at Children's National Medical Center in Washington, D.C.

His team published their findings in the Oct. 27 issue of the Journal of the American Medical Association.

The vermiform appendix is a largely functionless appendage located at the bottom of the large intestine. Appendicitis occurs when the appendix becomes inflamed, at which point surgical removal (appendectomy) is the usual course of treatment. However, if diagnosis and treatment arrive too late the appendix can rupture, spreading its toxic contents throughout the abdomen.

"Then you're dealing with five to 10 days of hospital care, with lots of expense and complications down the line," Newman said. In rare cases, a ruptured appendix can prove fatal, though the combination of surgery and antibiotics have cut the death rate tremendously.

In their study, Newman and his team sought to determine just how well the nation's pediatric centers were caring for kids presenting to emergency departments with appendicitis. To do so, they reviewed data on more than 24,400 appendectomies performed on school-aged children at 36 major U.S. children's hospitals between 1997 and 2002.

According to Newman, minority and uninsured children were at much higher risk for a burst appendix compared to white or privately insured children.

Asian-American children, especially, faced a 66 percent higher risk of ruptured appendix compared to white youngsters, while risks for black children were 18 percent higher than those of whites.

The reasons for these racial disparities remain unclear, although Newman speculated that, especially for Asian-American children, "it may be that there are language or cultural factors that create those barriers."

Also "troubling," he said, were disparities in appendix rupture linked to differences in health-care coverage.

Children with appendicitis from families lacking private insurance were 36 percent more likely to suffer from a burst appendix compared to children covered by private insurance, the researchers report. Children covered by Medicaid fared even worse, with rates of burst appendix 48 percent higher than those of kids from families with private insurance coverage.

Newman speculated that parents without private insurance might tend to delay bringing their children into care, especially since the early signs of appendicitis can often be dismissed as a stomachache. "Or, it could be that parents may be bringing their kids to [clinics] that just aren't as sophisticated -- they're not getting the best tests, they're not as accessible," he said.

Whatever the reason, Newman believes "we need to change the paradigm, be more aggressive about reaching out and educating these populations. Educating the clinics, too, and the doctors that are likely to see these families. Maybe go directly to the families and patients in these at-risk populations and describe what appendicitis is."

Because while it can be confused with run-of-the-mill stomachache, there are symptoms that set appendicitis apart, Newman said.

"If it's a tummy-ache that seems out of proportion to the usual, if it's persisting, if it's localized to the lower right side of the abdomen, or is associated with nausea and vomiting -- those are all real warning signs that the child should be evaluated," he said.

Health-care coverage remains another part of the solution, however. For many children, lack of insurance may be "impacting their ability to get either diagnosed, or to get the care they need," Newman said.

Joyce Johnson, a spokeswoman for the nonprofit Child Welfare League of America, agreed.

"We need to do a much better job in making sure that health care is available to all children that need it," she said.

Johnson said that, in many cases, low-income parents may not even realize existing federal and state programs can provide their children with quality health-care coverage.

"There needs to be more education to let parents know, and states need to reach out to folks," she said. "I just don't think it's being promoted as it should be. I don't think many parents are even aware that these programs are available."

More information

To learn more about pediatric appendicitis, go to the American Academy of Pediatrics.

SOURCES: Kurt D. Newman, M.D., department of surgery, Children's National Medical Center, Washington, D.C.; Joyce Johnson, spokeswoman, Child Welfare League of America, Washington, D.C.; Oct. 27, 2004, Journal of the American Medical Association
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