title: Perforated appendicitis among rural and urban patients: implications of access to care.
abstract: OBJECTIVE
  To determine whether rural patients are more likely to present with perforated appendicitis compared with urban patients.
  
  
  BACKGROUND
  Appendiceal perforation has been associated with increased morbidity, length of hospital stay, and overall health care costs. Recent arguments suggest that high rates of appendiceal rupture may be unrelated to the quality of hospital care, and rather associated with inadequate access to surgical care.
  
  
  METHODS
  We performed a retrospective cohort study of 122,990 patients with acute appendicitis from the Nationwide Inpatient Sample from 2003 to 2004. International Classification of Diseases diagnosis 9 (ICD-9) codes were used to determine appendiceal perforation. Urban influence codes from the US Department of Agriculture were used to determine rural versus urban status. Univariate and multivariate analyses were used to determine patient and hospital factors associated with perforation.
  
  
  RESULTS
  Overall, 32.07% of patients presented with perforation. Rural patients were more likely than urban patients to present with perforation (35.76% vs. 31.48%). Factors associated with perforation in multivariate analysis were age more than 40 years, male gender, transfer from another facility, black race, poorest 25th percentile, Charlson score of 3 or higher, and rural residence. Thirty percent of rural patients were treated in urban hospitals. Rural patients treated at urban hospitals were more likely to present with perforation compared with rural patients treated at rural hospitals (OR = 1.23).
  
  
  CONCLUSIONS
  Patients from rural areas have higher rates of perforation with acute appendicitis than urban patients. This difference persists when accounting for other factors associated with perforation. These differences in perforation rates suggest disparities in access to timely surgical care.
authors.affiliation: Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. ipaquett@umn.edu
authors.forename: Ian M
authors.initials: IM
authors.lastname: Paquette
authors.forename: Randall
authors.initials: R
authors.lastname: Zuckerman
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
mesh_terms: D000328:Adult; D001062:Appendectomy / Q000191:economics; D001064:Appendicitis / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology / Q000601:surgery*; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000191:economics; D008297:Male; D012189:Retrospective Studies; D012424:Rural Population / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D014481:United States; D014505:Urban Population / Q000706:statistics & numerical data