Original Article

Predictors of a Prolonged Length of Stay in Children with Perforated Appendicitis

Authors: Indu S. Pathak, MD, Imran A. Sayed, MD, Laura Wise, MD, Michael Sippel, MD, Loretta L. Hernandez, MPH, Zuber D. Mulla, PhD

Abstract

Objectives: Little is known about the factors that affect the length of stay (LOS) of children hospitalized for perforated appendicitis. The objective of this study was to identify clinical and demographic factors associated with a prolonged LOS (PLOS) in children with perforated appendicitis.

Methods: A retrospective cohort study was conducted using the records of 197 children 0 to 17 years old with perforated appendicitis. The children were hospitalized at one of two teaching hospitals located in El Paso, Texas, and were discharged between January 2008 and January 2014. PLOS was defined as an LOS greater than the 75th percentile value in our patient cohort, which was 7 days. An initial log-binomial regression model failed to converge, and hence logistic regression was used to calculate adjusted incidence odds ratios (OR) for PLOS, 95% confidence intervals, P values, and a receiver operating characteristic curve. The best subset method was used to identify predictors for inclusion in the final model.

Results: The overall risk of PLOS was 23.4% (46/197). Approximately 76% of the children who experienced PLOS and 94% of those who did not have PLOS were Hispanic. After adjusting for insurance status, presence of an abscess, asthma, consulting interventional radiology, and various antibiotics, Hispanics were less likely than non-Hispanics to experience PLOS (adjusted OR 0.20; P = 0.003). Children whose providers consulted the interventional radiologist had an increased odds of PLOS (adjusted OR 3.64; P = 0.01).

Conclusions: Hispanic ethnicity was associated with a lower odds of PLOS, whereas children who required the services of an interventional radiologist were more likely to experience PLOS.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007;31:86-92.
 
2. Addis DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-925.
 
3. Morrow SE, Newman KD. Current management of appendicitis. Semin Pediatr Surg 2007;16:34-40.
 
4. Siddique K, Mirza S, Harinath G. Appendiceal inflammation affects the length of stay following appendicectomy amongst children: a myth or reality? Front Med 2013;7:264-269.
 
5. Hardin DM Jr. Acute appendicitis: review and update. Am Fam Physician 1999;60:2027-2034.
 
6. Bickell NA, Aufses AH Jr, Rojas M, et al. How time affects the risk of rupture in appendicitis. J Am Coll Surg 2006;202:401-406.
 
7. Livingston EH, Woodward WA, Sarosi GA, et al. Disconnect between incidence of nonperforated and perforated appendicitis: implications for pathophysiology and management. Ann Surg 2007;245:886-892.
 
8. Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997. Surg Infect (Larchmt) 2004;5:160-165.
 
9. Barrett ML, Hines AL, Andrews RM. Trends in Rates of Perforated Appendix 2001-2010. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs No. 159. Rockville, MD: Agency for Health Care Policy and Research; 2013.
 
10. International Classification of Diseases, Ninth Revision, Clinical Modification Codes. https://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx. Accessed February 14, 2016.
 
11. St Peter SD, Sharp SW, Holcomb GW 3rd, et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Pediatr Surg 2008;43:2242-2245.
 
12. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia: link between quality of care and resource utilization. Arch Intern Med 2002;162:682-688.
 
13. Mulla ZD, Gonzalez-Sanchez JL, Nuwayhid BS. Descriptive and clinical epidemiology of preeclampsia and eclampsia in Florida. Ethn Dis 2007;17:736-741.
 
14. Robbins AS, Chao SY, Fonseca VP. What’s the relative risk? A method to directly estimate risk ratios in cohort studies of common outcomes. Ann Epidemiol 2002;12:452-454.
 
15. Hosmer DW, Lemeshow S. Model-building strategies and methods for logistic regression. In: Applied Logistic Regression. 2nd ed. New York: Wiley & Sons; 2000:91-142.
 
16. Harrell F. Binary logistic regression. In: Regression Modeling Strategies: With Application to Linear Models, Logistic Regression, and Survival Analysis. New York: Springer; 2001:247.
 
17. Cheong LH, Emil S. Outcomes of pediatric appendicitis: an international comparison of the United States and Canada. JAMA Surg 2014;149:50-55.
 
18. Lariscy JT, Hummer RA, Hayward MD. Hispanic older adult mortality in the United States: new estimates and an assessment of factors shaping the Hispanic paradox. Demography 2015;52:1-14.
 
19. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: John Wiley & Sons; 2000:162.