title: Time-of-day and appendicitis: Impact on management and outcomes.
abstract: Observational research has shown that delayed presentation is associated with perforation in appendicitis. Many factors that affect the ability to present for evaluation are influenced by time of day (eg, child care, work, transportation, and office hours of primary care settings). Our objective was to evaluate for an association between care processes or clinical outcomes and presentation time of day.
  
  
  
  The study evaluated a prospective cohort of 7,548 adults undergoing appendectomy at 56 hospitals across Washington State. Relative to presentation time, patient characteristics, time to operation, imaging use, negative appendectomy, and perforation were compared using univariate and multivariate methodologies.
  
  
  
  Overall, 63% of patients presented between noon and midnight. More men presented in the morning; however, race, insurance status, comorbid conditions, and white blood cell count did not differ by presentation time. Daytime presenters (6 am to 6 pm) were less likely to undergo imaging (94% vs 98%, P < .05) and had a nearly 50% decrease in median preoperative time (6.0 h vs 8.7 h, P < .001). Perforation significantly differed by time-of-day. Patients who presented during the workday (9 am to 3 pm) had a 30% increase in odds of perforation compared with patients presenting in the early morning/late night (adjusted odds ratio 1.29, 95% confidence interval, 1.05-1.59). Negative appendectomy did not vary by time-of-day.
  
  
  
  Most patients with appendicitis presented in the afternoon/evening. Socioeconomic characteristics did not vary with time-of-presentation. Patients who presented during the workday more often had perforated appendicitis compared with those who presented early morning or late night. Processes of care differed (both time-to-operation and imaging use). Time-of-day is associated with patient outcomes, process of care, and decisions to present for evaluation; this association has implications for the planning of the surgical workforce and efforts directed at quality improvement.
authors: Department of Surgery, Division of Endocrine Surgery, University of California, San Francisco Medical Center, San Francisco, CA; Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA. Electronic address: Frederick.Drake@ucsf.edu.
authors: Frederick Thurston
authors: FT
authors: Drake
authors: Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA.
authors: Neli E
authors: NE
authors: Mottey
authors: Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA.
authors: Anthony A
authors: AA
authors: Castelli
authors: Department of Surgery, Swedish Medical Center, Seattle, WA.
authors: Michael G
authors: MG
authors: Florence
authors: Department of Surgery, Skagit Valley Hospital, Mt. Vernon, WA.
authors: Morris G
authors: MG
authors: Johnson
authors: Department of Surgery, Case Western Reserve University, Cleveland, OH.
authors: Scott R
authors: SR
authors: Steele
authors: Department of Surgery, Virginia Mason Medical Center, Seattle, WA.
authors: Richard C
authors: RC
authors: Thirlby
authors: Department of Surgery, University of Washington Medical Center, Seattle, WA; Department of Surgery, Virginia Mason Medical Center, Seattle, WA; Surgical Outcomes Research Center (SORCE), Department of Surgery, University of Washington, Seattle, WA.
authors: David R
authors: DR
authors: Flum
authors: Surgical Care and Outcomes Assessment Program (SCOAP) and the Comparative Effectiveness Research Translation Network (CERTAIN).
mesh_terms: D000293:Adolescent; D000328:Adult; D001062:Appendectomy / Q000009:adverse effects / Q000379:methods*; D001064:Appendicitis / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D002940:Circadian Rhythm; D015331:Cohort Studies; D019468:Disease Management; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004638:Emergency Treatment; D005500:Follow-Up Studies; D006801:Humans; D015999:Multivariate Analysis; D010343:Patient Admission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D011446:Prospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014861:Washington; D055815:Young Adult