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Effect of Language and Ethnicity On Rate of Appendiceal Perforation

Friday, October 19, 2012
Room 272-273 (Morial Convention Center)
Michael N. Levas, MD, FAAP, Pediatrics, Medical College of Wisconsin, Milwaukee, WI, Peter S. Dayan, Pediatric Emergency Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, Manoj K. Mittal, M.D., Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia, PA, Michelle Stevenson, MD, MS, Dept of Pediatrics, University of Louisville, Louisville, KY, Nanette C. Dudley, MD, Department of Pediatrics, University of Utah, Salt Lake City, UT, Lalit Bajaj, Pediatrics- Section of Emergency Medicine, The Children's Hospital, University of Colorado Denver, Aurora, CO, Charles G. Macias, MD, MPH, Pediatrics, Section of Emergency Medicine, Baylor College of Medicine - Texas Children's Hospital, Houston, TX, Richard G. Bachur, MD, Department of Emergency Medicine, Children's Hospital Boston, Boston, MA, Jonathan E. Bennett, MD, A.I. duPont Hospital for Children, Wilmington, DE, M. Denise Dowd, MD, MPH, Division of Emergency and Urgent Care Services, The Children's Mercy Hospital, Kansas City, MO, Avis J. Thomas, MS, Biostatistics, University of Minnesota, Minneapolis, MN and Anupam Kharbanda, MD, MSc, Pediatrics, University of Minnesota, Minneapolis, MN


For both children and adults, limited English proficiency (LEP) and ethnicity are recognized as important obstacles to equity in health care.  Despite this, there are few pediatric studies that assess the impact of language difficulties and ethnicity on emergency department (ED) care.  The aim of this study was to examine the associations between LEP, ethnicity, and rate of appendiceal perforation (AP).


We performed a secondary analysis of data from a prospective, multi-center, cross-sectional study of children aged 3-18 years presenting to the ED with abdominal pain and possible appendicitis.  Patients/parents self-reported their ethnicity (Hispanic vs. non-Hispanic) and guardian's primary language (English vs. LEP).  Presence or absence of perforation (AP) was determined from the attending surgeon’s written operative report.   AP rates were compared between the groups using simple logistic regression and  multivariate regression models to control for gender, age, and duration of pain prior to arrival.  Site specific clustering effects were also analyzed.


Of 2,624 patients enrolled, 1,017 (39%) had appendicitis. 782(30%) were Hispanic, and 451 (16%) had LEP.  37% of non-Hispanics and 43% of Hispanics were diagnosed with appendicitis.   Among patients with appendicitis, 24% of non-Hispanics and 33% of Hispanics were further diagnosed with AP.  In univariate analysis both LEP (OR 1.44, 95% CI 1.04-2.00) and Hispanic ethnicity (OR 1.52, 95% CI 1.14-2.03) were associated with increased AP.  When Hispanics were further divided into English-speaking and LEP subgroups, Hispanics with LEP had the highest perforation rates (OR 1.65, 95% CI 1.17-2.31) as compared to non-Hispanics.  Due to substantial correlation between LEP and ethnicity, only ethnicity was used in multivariate modeling.  Hispanic ethnicity remained significantly associated with increased AP in a multivariate analysis adjusted for age, gender, and hours of pain.(OR 1.41, 95% CI 1.04-1.92).  General Estimating Equations with clustering defined by site showed no material site effect.


Among pediatric patients who present to the ED with abdominal pain suspicious for appendicitis, both Hispanic ethnicity and guardian’s LEP were identified as important risk factors for AP, though highly correlated.  This evidence of health care disparity based on English proficiency and ethnicity requires further investigation to understand barriers and enablers to equitable care.