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CME / ABIM MOC / CE

Is Appendicitis Diagnosed Equally in Diverse Populations?

  • Authors: News Author: Jake Remaly; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 3/24/2023
  • Valid for credit through: 3/24/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for internists, gastroenterologists, family medicine/primary care clinicians, nurses, physician assistants, and other members of the healthcare team for patients with symptoms suggesting appendicitis.

The goal of this activity is for learners to be better able to describe the association of patient race and ethnicity with delayed appendicitis diagnosis and postoperative 30-day hospital use and patient- or systems-level factors modifying this association, according to a population-based, retrospective cohort study using data from the Healthcare Cost and Utilization Project’s state inpatient and emergency department databases from 4 states.

Upon completion of this activity, participants will:

  • Describe the association of patient race and ethnicity with delayed appendicitis diagnosis and postoperative 30-day hospital use and patient- or systems-level factors modifying this association, according to a population-based, retrospective cohort study
  • Identify clinical implications of the association of patient race and ethnicity with delayed appendicitis diagnosis and postoperative 30-day hospital use and patient- or systems-level factors modifying this association, according to a population-based, retrospective cohort study
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Jake Remaly

    Freelance writer, Medscape

    Disclosures

    Jake Remaly has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 03/24/2024. PAs should only claim credit commensurate with the extent of their participation.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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CME / ABIM MOC / CE

Is Appendicitis Diagnosed Equally in Diverse Populations?

Authors: News Author: Jake Remaly; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/24/2023

Valid for credit through: 3/24/2024

processing....

Clinical Context

High-quality health care requires timely and accurate diagnosis. Delayed surgical diagnosis and treatment likely results in increased health system costs and worse patient outcomes.

Racial and ethnic disparities exist in acute appendicitis presentation, treatment, and outcomes. No study to date has documented rates of delayed diagnosis of acute appendicitis in adults at the population level.

Clinicians are more likely to miss appendicitis in patients who are Black, research shows.

This phenomenon, first described in children,[1] occurs in adults as well, according to a study published last month in JAMA Surgery.[2]

Study Synopsis and Perspective

Some hospitals fare better than others: Those with more diverse patient populations were less likely to have missed the diagnosis, the researchers found.

"We don't think the amount of melanin in your skin predicts how you present with appendicitis," said Jonathan Carter, MD, professor of surgery at the University of California, San Francisco.

"There's no biological explanation," Carter, who wrote an invited commentary on the research,[3] told Medscape Medical News. "It's really what's going on in the social environment of those emergency rooms."

For the study, Anne Stey, MD, assistant professor of surgery at Northwestern University Feinberg School of Medicine in Chicago, Illinois, and her colleagues analyzed data from more than 80,000 men and women in 4 states ― Florida, Maryland, New York, and Wisconsin ― who underwent appendectomy in 2016 to 2017.

They identified persons who had been seen for abdominal complaints at a hospital in the week before surgery but did not receive a diagnosis of appendicitis at that time, indicating a missed opportunity to intervene sooner.

Among Black patients, the proportion who had experienced this type of delay was 3.6%, whereas for White patients, it was 2.5%. For Hispanic patients, the share was 2.4%, whereas for Asian or Pacific Islander patients, the figure was 1.5%.

An analysis that controlled for patient and hospital variables found that among non-Hispanic Black patients, the rate of delayed diagnosis was 1.41 (95% CI: 1.21, 1.63) times higher than for non-Hispanic White patients.

Other patient factors associated with delayed diagnosis included female sex, comorbidities, and living in a low-income zip code.

A key factor was where patients sought care. A delayed diagnosis of appendicitis was 3.51 times more likely for patients who went to hospitals where most patients are insured by Medicaid. Prior research has shown that "safety-net hospitals have fewer resources and may provide lower-quality care than hospitals with a larger private payer population," Stey's group wrote.

On the other hand, going to a hospital with a more diverse patient population reduced the odds of a delayed diagnosis.

"Patients presenting to hospitals with a greater than 50% Black and Hispanic population were 0.73 (95% CI: 0.59, 0.91) times less likely to have a delayed diagnosis compared with patients presenting to hospitals with a less than 25% Black and Hispanic population," the researchers reported.

In the 30 days after discharge after appendectomy, Black patients returned to the hospital at a higher rate than White patients did (17.5% vs 11.4%), indicating worse outcomes.

"Delayed diagnosis may account for some of the racial and ethnic disparities observed in outcomes after appendicitis," according to the authors.

"It may be hospitals that are more used to serving racial-ethnic minority patients are better at diagnosing them, because they're more culturally informed and have a better understanding of these patients," Stey said in a news release about their findings.[4]

Great Masquerader

Diagnosing appendicitis can be challenging, Carter said. The early signs can be subtle, and the condition is sometimes called the "great masquerader." It is common for patients to be diagnosed with gastroenteritis or pain associated with their menstrual period, for example, and sent home.

Scoring systems based on patients' symptoms and liberal use of imaging have improved detection of appendicitis, but "no physician or health care system is perfect in the diagnosis," he said.

The increased odds of delayed diagnosis for Black patients remained when the researchers focused on healthier patients who had fewer comorbidities, and it also held when they considered patients with private insurance in high-income areas, Carter noted.

"Once again, with this study we see the association of structural and systematic racism with access to health care, especially for Black patients, in emergency departments [(ED)] and hospitals," he wrote. "We must redouble our efforts to become anti-racist in ourselves, our institutions, and our profession."

"Our Healthcare System Itself"

To better understand possible reasons for delayed diagnosis, future researchers could assess whether patients who are Black are less likely to receive a surgical consultation, imaging studies, or lab work, Carter told Medscape. He pointed to a recent analysis[5] of patients insured by Medicare that found that Black patients were less likely than White patients to receive a surgical consultation after they were admitted with colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal diagnoses.

Although social determinants of health, such as income, education, housing, early childhood development, employment, and social inclusion, may account for a substantial portion of health outcomes, "[o]ur health care system itself can be viewed as another social determinant of health," Carter wrote. "Insurance coverage, health care professional availability, health care professional linguistic and cultural competency, and quality of care all have an effect on health outcomes."

Stey was supported by grants from the American College of Surgeons and the National Institutes of Health.

Study Highlights

  • This population-based, retrospective cohort study used data from the Healthcare Cost and Utilization Project’s state inpatient and ED databases from Florida, Maryland, New York, and Wisconsin for 80,312 patients aged 18 to 64 years who underwent appendectomy from January 7, 2016 to December 1, 2017.
  • Median age was 38 (interquartile range, 27-50) years; 50.8% were female; 62% privately insured; 2.9% Asian or Pacific Islander, 18.8% Hispanic, 10.9% non-Hispanic Black, 60.8% non-Hispanic White, and 6.6% other race/ethnicity.
  • Investigators defined delayed diagnosis of appendicitis (n = 2013 [2.5%]) as initial ED presentation with abdominal diagnosis other than appendicitis followed by representation within a week for appendectomy.
  • Among these patients, 43.2% had care discontinuity, undergoing appendectomy at a different hospital from that where they initially presented.
  • Delayed diagnosis rate was 3.6% in non-Hispanic Black patients, 1.5% in Asian or Pacific Islander patients, 2.4% in Hispanic patients, 2.5% in non-Hispanic White patients, and 2% in patients with other race/ethnicity.
  • Rate of postoperative 30-day hospital use was 17.5% in non-Hispanic Black and 11.4% in non-Hispanic White patients; 16% and 9.2%, respectively, had long length of stay (LOS).
  • Mixed-effects multivariable Poisson regression allowed estimation of the association of delayed diagnosis with race/ethnicity, controlling for patient and hospital variables, and with postoperative 30-day hospital use.
  • Adjusted rate of delayed diagnosis was 1.41 (95% CI: 1.21, 1.63) times higher in non-Hispanic Black patients than in non-Hispanic White patients; 0.73 (95% CI: 0.59, 0.91) times lower in patients at hospitals with > 50% vs < 25% Black or Hispanic population; and 3.51 (95% CI: 1.69, 7.28) times higher at hospitals with > 50% vs < 10% of discharges of Medicaid patients.
  • Additional factors associated with delayed diagnosis included female sex (62.4% vs 37.6%), higher patient comorbidity levels, and residing in a low-income zip code.
  • Delayed diagnosis was associated with 1.38 (95% CI: 1.36, 1.61) times increased adjusted rate of postoperative 30-day hospital use.
  • The investigators concluded that when controlling for patient and hospital characteristics, non-Hispanic Blacks had higher rates of delayed appendicitis diagnosis, 30-day hospital use, and hospital LOS than Whites.
  • Still, delayed diagnosis was less likely among patients presenting to hospitals with > 50% Black and Hispanic population.
  • Seeking care at a hospital serving a diverse patient population may help mitigate the increased rate of delayed diagnosis in non-Hispanic Black patients.
  • Higher delayed diagnosis rate among patients presenting to hospitals with most patients covered by Medicaid suggests that safety-net hospitals have fewer resources and may provide lower-quality care than hospitals with a larger private payer population.
  • As delayed diagnosis was associated with increased postoperative 30-day hospital use, it may explain some racial and ethnic disparities in appendicitis outcomes.
  • Still, outcomes were worse for non-Hispanic Black patients even when diagnosis was not delayed.
  • As increased rate of delayed diagnosis in non-Hispanic Black patients was mitigated in hospitals with more diverse patient population, future research should examine the impact of culturally informed care mechanisms on improving diagnostic accuracy, including racial and ethnic or language concordance, which has been shown to improve patient experience and outcomes.
  • The investigators recommend policymakers work to ensure parity in reimbursement for care provided in hospitals with diverse patient populations.
  • Study limitations include possible underestimates of disparities because of unmeasured confounding.

Clinical Implications

  • Non-Hispanic Black patients had higher rates of delayed appendicitis diagnosis, 30-day hospital use, and hospital LOS than Whites.
  • Seeking care at a hospital serving a diverse patient population may help mitigate increased rate of delayed diagnosis in non-Hispanic Blacks.
  • Implications for the Healthcare Team: Efforts should be made to increase medical workforce diversity and enhance clinician education about cultural competence and antiracism to improve patient outcomes.

 

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