Delayed Appendicitis Diagnosis Linked to Increased Hospital Care Costs

Patients with a delayed appendicitis diagnosis had 1.23 times increased hospital care costs, according to a new study.¹

“These results suggest that delayed diagnosis may be a more equitable quality metric for payers to construct value-based reimbursement policies…,” wrote investigators led by Dinushi A. Kulasekere, BS, from Feinberg School of Medicine at Northwestern University.

A delayed appendicitis diagnosis is linked to worse outcomes and may lead to a longer hospital stay and a greater likelihood of 30-day readmissions. Other outcomes may include abdominal abscess, small bowel obstruction, sepsis, and bowel resection.² Despite non-Hispanic Black patients often having a delayed appendicitis diagnosis, the hospitals that have a high proportion of non-Hispanic Black patients give lower payer reimbursement for care.¹

Although a study suggested patients with a delayed appendicitis diagnosis may have a longer admission duration, it was unclear whether the increased costs were associated with delayed appendicitis diagnosis or operational delays due to the appendectomy. Thus, investigators wanted to see if a delayed appendicitis diagnosis itself was associated with increased appendicitis hospital care costs.

Kulasekere and colleagues conducted a cohort study of patients aged 18 – 64 years from Florida, Maryland, Massachusetts, New York, and Wisconsin receiving an appendectomy. Investigators leveraged patient data from Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017, with no follow-up. They analyzed the data from January – April 2023.

The team defined delayed diagnosis as having a prior emergency department or inpatient hospital visit with an abdominal diagnosis but not appendicitis. Participants also had no intervention 7 days before the appendectomy admission.

The primary outcome was appendicitis hospital care costs, calculated from a total of encounters 7 days before the appendectomy, the appendectomy encounter, and 30 days postoperatively. Investigators converted the charges to costs using the cost-to-charge ratio, which was adjusted to account for many factors, such as accounting inflation to the wage, and to limit the impact of extreme values in the dataset.

Kulasekere and colleagues analyzed the association of delayed appendicitis diagnosis with healthcare costs using a multivariable Poisson regression, which was controlled for age, sex, race and ethnicity, insurance status, care of discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state.

In total, there were 76,173 patients with 51.1% female, 61.6% non-Hispanic White,18.5% Hispanic, 10.8% non-Hispanic Black, and 2.9% Asian or Pacific Islander, who underwent appendectomy. Of the sample, 2.7% (n = 2045) had a delayed diagnosis.

Patients with a delayed diagnosis had a median unadjusted cost of $11,099 ($6752 - $17,740), compared with $9177 ($5575 - $14,481) for a non-delayed diagnosis (P < .001). An adjusted model revealed patients with a delayed diagnosis were 1.23 times more likely to have an increased appendicitis hospital care cost (95% confidence interval [CI], 1.16 – 1.28 times). The delayed diagnosis resulted in a mean marginal cost of $2712 (95% CI, $2083 - $3342).

After controlling for race, the team observed non-Hispanic Black individuals had 1.22 times (95% CI, 1.17 – 1.28) increased appendicitis hospital care costs compared with non-Hispanic White patients.

“We could postulate that clinicians are less thorough in their assessment of minoritized patients, resulting in higher rates of delayed diagnosis,” investigators wrote. “However, empirically understanding the mechanism of how minoritized patients experience more delayed diagnosis and higher cost of care warrants further study to better understand the social drivers of health in these populations.”

Older age groups (anywhere from 45 – 64 years old) had greater costs than patients aged 18 -24 years, with the age group 55 – 64 years having the greatest increased cost of 1.84 times higher (95% CI, 1.77 – 1.92 times). Patients on Medicare disability had a 1.53 times increased cost (95% CI, 1.46 – 1.61 times), and patients on Medicaid compared to private insurance had a 1.16 times increased cost (95% CI, 1.12 – 1.20).

Investigators wrote the findings were limited by some missing patient encounter linkage variables (10%), missing cost data (9%), and missing demographic data (1%). Other limitations the team highlighted included not considering the implication of the flow of health care dollars, risk of bias with censoring, the VisitLink variable only being state-specific, high variability between hospitals, high rates of inaccurate diagnosis coding, poor capture of diagnostic codes, limitations associated with cost-to-charge ratios, not including data on patients who had nonsurgical management of their appendicitis, and no data on patient-level social drivers.

“This study reaffirms that hospitals serving high proportions of minority populations provided high-quality care because they had lower rates of delayed appendicitis diagnosis compared with hospitals that serve relatively very few patients from racial and ethnic minority groups,” investigators concluded. “Delayed diagnosis may be a more equitable quality metric for payers to construct value-based reimbursement policies.”

^References

^{Kulasekere, D, Royan, R, Shan Y. Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis. JAMA Network Open. 2024;7(4):e246721. doi:10.1001/jamanetworkopen.2024.6721.}

^{Hester, M. Delays in appendicitis diagnosis: Causes and outcomes. Contemporary Pediatrics. September 9, 2021. https://www.contemporarypediatrics.com/view/delays-in-appendicitis-diagnosis-causes-and-outcomes. Accessed April 15, 2024.}