title: Differential access to care: The role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates.
abstract: Differences in perforated appendix admission rates (PAAR) are an ambulatory-sensitive measure of access to care. While pediatric studies report disparities in PAAR, initial adult investigations suggest a lack of racial/ethnic inequity. The objectives of this study were to (1) assess for risk-adjusted, racial/ethnic differences in PAAR among adults on a national scale, (2) consider the extent to which variations (or lack thereof) are explained by age, insurance, and income, and (3) compare results within the United States population to a national segment of the population who are completely insured.
  
  
  
  According to the Agency for Healthcare Research and Quality definition of PAAR, adults (aged 18-64 years) in the 2006-2010 Nationwide Inpatient Sample were queried for the occurrence and perforation of acute appendicitis. Risk-adjusted differences were compared by race/ethnicity over 5-year age increments using logistic regression with reweighted estimating equations. Noting disparate outcomes between younger (aged 18-34 years) versus older (aged 35-64 years) adults, age-stratified variations were further considered. Results were compared relative to differences among national military/civilian-dependent patients with universal insurance and were assessed for the extent to which disparities could be explained by variations in insurance and income.
  
  
  
  A total of 129,257 (weighted: 638,452) patients were included. Despite a lack of differences overall, significantly worse outcomes among younger (odds ratio point-estimates ranged from 1.11-1.32) and better outcomes among older (0.78-0.93) minority patients were found. This observation contrasted a lack of differences among completely insured military/civilian-dependent patients (n = 12,154). A total of 22.4% (non-Hispanic black versus non-Hispanic white) and 39.0% (Hispanic versus non-Hispanic white) of younger adult differences were explained by insurance-12.2% and 13.6% by income, 29.8% and 44.0% combined.
  
  
  
  This national assessment of differences in access to care among adults with acute appendicitis demonstrated the existence of racial/ethnic disparities in PAAR that varied with age and were partially, although incompletely, explained by variations in insurance and income.
authors.affiliation: Yale School of Medicine, New Haven, CT; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health, Boston, MA. Electronic address: czogg@jhmi.edu.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: John W
authors.initials: JW
authors.lastname: Scott
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: Wei
authors.initials: W
authors.lastname: Jiang
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: Lindsey L
authors.initials: LL
authors.lastname: Wolf
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School and the Harvard T.H. Chan School of Public Health, Boston, MA.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D001064:Appendicitis / Q000175:diagnosis / Q000208:ethnology / Q000601:surgery*; D016001:Confidence Intervals; D005006:Ethnicity; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D007182:Income; D019458:Insurance Coverage / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000191:economics* / Q000706:statistics & numerical data; D044469:Racial Groups; D018570:Risk Assessment; D012380:Role; D014481:United States; D055815:Young Adult