Jake Remaly
February 13, 2023
Doctors are more likely to miss appendicitis in patients who are Black, research shows.
This phenomenon, first described in children, occurs in adults as well, according to a study published last month in JAMA Surgery.
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, 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, and her colleagues analyzed data from more than 80,000 men and women in four states ― Florida, Maryland, New York, and Wisconsin ― who underwent appendectomy in 2016–2017.
They identified those 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%, while 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 times higher than for non-Hispanic White patients (95% CI, 1.21 – 1.63).
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 writes.
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 report.
In the 30 days after discharge following 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.
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 not uncommon 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 and hospitals,” he wrote. “We must redouble our efforts to become anti-racist in ourselves, our institutions, and our profession.”
“Our Healthcare System Itself”
Elizabeth Garner, MD, MPH, a pharmaceutical executive who was not involved in the study, commented on Twitter that the study points to an underlying issue that has existed in medicine “for quite some time.”
“Minority populations are not taken as seriously as their white counterparts,” she wrote. “This needs to change.”
Measures of hospital quality need to be tied to health equity, according to Mofya Diallo, MD, MPH, clinical associate professor of anesthesiology at the Children’s Hospital Los Angeles and the Keck School of Medicine of the University of Southern California.
“Top hospitals should take pride in outcomes that do not vary based on race, income or literacy,” she tweeted in response to the study.
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 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.
While 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, “Our 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.
JAMA Surg. Published online January 18, 2023.
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