title: Equal access to healthcare does not eliminate disparities in the management of adults with appendicitis.
abstract: BACKGROUND
  Race and socioeconomic status have led to inequality in access to surgical care, leading to differences in appendiceal perforation rates. However, in a setting of equal health care access, these disparities were not evident. Currently, disparities exist with use of laparoscopic appendectomy (LA) in the treatment of appendicitis. This study determines whether equal health care access eliminates differences in the management and outcomes of appendicitis.
  
  
  METHODS
  A retrospective review from 1998 to 2007 was performed. All members in this single-provider system have equal healthcare access. Socioeconomic data were extracted from the US Census database. Study outcome was use of LA and postoperative morbidity. Independent variables included age (18-44 y, 45-65 y, and >65 y), gender, race, annual mean household income (<40 K, 40-65 K, and >65 K), and education level. Univariate and multivariable (controlling for age, gender, perforation, race/ethnicity, income, and education level) analyses were performed.
  
  
  RESULTS
  A total of 16,196 patients were identified (mean age = 41 y, 54% male). Sixty percent of patients underwent LA. On multivariable analysis, male gender was associated with a decreased use of LA (OR 0.84, CI 0.79-0.89, P < 0.0001). There was a lower use of LA in older patients (age > 65 y) and patients age 45-65 y compared with younger patients (18-44 y). There was a lower use of LA in Blacks and a higher rate in Hispanics compared with Whites. Use of LA was higher in high income and middle income patients compared with low income patients. The use of LA was similar across all education levels. Postoperative morbidity was higher in males, older patients (age > 65 y), and patients age 45-65 y. However, postoperative morbidity was similar across all race/ethnic groups and all income levels and education levels.
  
  
  CONCLUSIONS
  In a setting of equal health care access, there is evidence of gender, racial, age, and socioeconomic disparities for use of LA and worse outcomes for males and older patients. These data suggest that despite equal healthcare access, disparities continue to exist with respect to race and income level for the management of adults with appendicitis.
authors.affiliation: Department of Surgery and Division of Pediatric Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA. slleemd@yahoo.com
authors.forename: Steven L
authors.initials: SL
authors.lastname: Lee
authors.forename: Arezou
authors.initials: A
authors.lastname: Yaghoubian
authors.forename: Rebeca
authors.initials: R
authors.lastname: Stark
authors.forename: Shant
authors.initials: S
authors.lastname: Shekherdimian
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001064:Appendicitis / Q000453:epidemiology* / Q000601:surgery*; D019352:Censuses; D016208:Databases, Factual / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology; D055815:Young Adult