Pediatric appendicitis outcomes in Canada not superior to US

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1. Rates of perforated appendicitis in Canada are lower than publicly or noninsured US children, but higher than privately insured US children; Canadian children have higher rate of misdiagnosis of perforated appendix.

2. Children under age 5 and children with perforated appendicitis in Canada have better outcomes than US counterparts.

Evidence Rating Level: 3 (Average)

Study Rundown: This retrospective review of two large, population databases in Canada and the United States analyzed three pediatric appendicitis outcomes: perforation rate, normal appendix rate, and length of hospital stay. Population results showed that Canadian children have higher rate of normal appendix, indicative of a misdiagnosis of a perforated appendix. Furthermore, the rate of perforated appendicitis in Canadian patients is lower compared to publicly or noninsured US children, but higher than privately insured US children. Total length of hospital stay was virtually identical between the two countries. Subgroup analysis revealed that younger patients (<5 years) and patients with perforated appendicitis have better outcomes compared to US patient counterparts. The results highlight the importance of healthcare access in the improved outcomes of pediatric appendicitis, but do not establish superiority of one health system over another. The strength of the study is its large sample size, but the database did not provide information on important outcome measures such as readmission rate or a direct data on post-operative complications.

Click to read the study in JAMA Surgery

Relevant Reading: A systematic review of studies comparing health outcomes in Canada and the United States

In-Depth [retrospective review]: This study performed a population-based comparison of pediatric appendicitis outcomes between Canada and the United States from 2004 to 2010. Overall, 41,292 Canadian and 78,625 US patients met the inclusion criteria. The rate of normal appendix was 50% higher for Canadian versus US children (6.3% vs. 4.3%, p<0.001). Rate of perforated appendicitis in Canadian children is 27.3%, which is significantly lower than publicly insured and noninsured US patients (30.4% and 31.2%, respectively), but higher than privately insured (24.1%). In the 0-5 age group, the perforated appendicitis rate (47.7%) was significant lower in Canadian children versus US children, regardless of insurance status. This was attributed to greater access for this age group to tertiary pediatric care in Canada. Hospital stay in Canada was shorter after perforated appendicitis (4.8 versus 5.3 days; p<0.001), but longer for non-perforated appendicitis (2.0 versus 1.7 days; p<0.001). This was attributed to the wide use of treatment algorithms by Canadian centers in reducing length of hospital stay.

Attempt was made to determine proportion of children with more than 1 appendicitis-related procedure as a marker for post-operative complications. However, the low prevalence (0.37% in Canada, 0.71% US) of this occurrence in the database reduced its validity as a surrogate marker.

By David Wang and Andrew Bishara

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