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.

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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