According to background information in the article, the primary adverse outcome of appendicitis is appendiceal (appendix) rupture. Patients with a ruptured appendix at the time of surgical exploration have as high as a 39 percent chance of having a postsurgical complication, such as intra-abdominal abscess or wound infection, compared with an approximately 8 percent chance if the appendix is not perforated. It has been assumed that the natural history of appendix rupture is within the control of the hospital or physician and that a high rate of rupture reflects a failure of medical care.
Given the difficulty of diagnosing appendicitis in both children and adults, the traditional approach by hospitals to decrease the rupture rate has been to encourage early surgical exploration. In fact, high rates of negative exploration for appendicitis have been tolerated to lessen the likelihood of ruptured appendicitis and its complications. In essence, one complication (a negative exploration) is encouraged to decrease the incidence of another complication (appendiceal rupture). Rates for both of these in children remain high despite efforts to reduce them. Little is known about the factors that influence these rates.
Todd A. Ponsky, M.D., of Children's National Medical Center and George Washington University Medical Center, Washington, D.C., and colleagues examined the patterns of diagnosis and care of children aged 5 to 17 years with appendicitis at 36 major children's hospitals to assess the contributions of race, health insurance status, age, sex, and hospital volu
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