title: Insurance-related differences in the risk of ruptured appendix.
abstract: BACKGROUND
  We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage.
  
  
  METHODS
  In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989.
  
  
  RESULTS
  After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]).
  
  
  CONCLUSIONS
  Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.
authors.affiliation: Department of Family and Community Medicine, University of California, San Francisco 94143-0900.
authors.forename: P
authors.initials: P
authors.lastname: Braveman
authors.forename: V M
authors.initials: VM
authors.lastname: Schaaf
authors.forename: S
authors.initials: S
authors.lastname: Egerter
authors.forename: T
authors.initials: T
authors.lastname: Bennett
authors.forename: W
authors.initials: W
authors.lastname: Schecter
mesh_terms: D000293:Adolescent; D000328:Adult; D001064:Appendicitis / Q000191:economics* / Q000209:etiology*; D002140:California / Q000453:epidemiology; D016001:Confidence Intervals; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007350:Insurance, Hospitalization / Q000706:statistics & numerical data*; D007416:Intestinal Perforation / Q000191:economics / Q000453:epidemiology / Q000209:etiology*; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D012422:Rupture, Spontaneous / Q000453:epidemiology; D012959:Socioeconomic Factors; D014481:United States