Children in Areas with Few Pediatricians at Higher Risk for Serious Appendix Ruptures

“Our analysis shows that the most potent predictor of outcome in children with appendicitis was the number of pediatricians available in an area, emphasizing the pivotal role they play as the point of first contact in the care of a sick child,” said lead investigator Fizan Abdullah, M.D., Ph.D., a pediatric surgeon at Hopkins Children’s.

A ruptured appendix is a serious complication of appendicitis that often results from delays in diagnosis and surgery to remove the inflamed or infected organ.

The new study’s findings, based on an analysis of nearly 250,000 hospital records of children with appendicitis over 17 years, are published online in the December issue of JAMA-Archives of Surgery.

The analysis showed that children with appendicitis living in counties with the most pediatricians per capita were the least likely to develop complications, and the more pediatricians in a geographic area, the fewer the instances of ruptured appendix. For every 100 children with appendicitis, 12 more children (12 percent more) would end up with ruptured appendix in the area with the fewest pediatricians than in the area with the most pediatricians.

Factors such as the number of hospitals in the area, the number of hospitals with emergency rooms, the availability of a CT scanner and the number of surgeries performed in a county each year did not affect the risk for an appendix rupture, the study found. Neither did factors such as the number of emergency room physicians, surgeons or radiologists in the area. In their statistical analysis, the investigators also accounted for insurance coverage, race, age, gender and household income to ensure that the discrepancy in outcomes did not stem from such factors. It didn’t.

The findings, the investigators say, underscore the central role that a family pediatrician plays in the timely diagnosis and treatment of children with appendicitis.            

Of the 241,301children with appendicitis in the study, 77,097 ended up with a ruptured appendix. The death rate was seven times higher among children with a ruptured appendix than in children with uncomplicated appendicitis (0.01 percent vs. 0.07 percent).  The Hopkins study also found that children with perforated appendixes were hospitalized for twice as long — five days instead of two — as children with uncomplicated appendicitis, doubling the cost of care, from $10,385 to $20,581, on average.

The investigators say that health officials and policymakers should pay special attention to geographic areas with severe shortages of pediatricians and high rates of appendicitis complications and take steps to address the shortages as a life-saving and cost-cutting measure.

The appendix is a small tube extending from the large intestine, and infections and inflammation of the organ can be dangerous. Each year, 77,000 children develop appendicitis, and an estimated one-third of them suffer a ruptured appendix before they reach the operating room.

Co-investigators on the study included Melissa Camp, M.D. M.P.H., David Chang, Ph.D. M.P.H. M.B.A., Yiyi Zhang, M.H.S., Meghan Arnold, M.D., Leilani Sharpe, B.S., Alodia Gabre-Kidan, M.D., and Melinda Bathurst, M.S. M.B.A., all of Hopkins.

The research was funded by the Robert Garrett Fund for the Surgical Treatment of Children.

Related Information:

Surgical Instruments Left in Children Rarely Fatal, But Dangerous
Lack of Insurance May Have Figured In Nearly 17,000 Childhood Deaths, Study Shows
Burst Appendix or Stomach Flu? Hopkins Children’s Experts Say Doctors and Parents Can Sort Out Symptoms with a Checklist
Does This Child Have Appendicitis? Watch Out for Key Signs

Founded in 1912 as the children’s hospital of the Johns Hopkins Medical Institutions, the Johns Hopkins Children’s Center offers one of the most comprehensive pediatric medical programs in the country, with more than 92,000 patient visits and nearly 9,000 admissions each year. Hopkins Children’s is consistently ranked among the top children’s hospitals in the nation. Hopkins Children’s is Maryland’s largest children’s hospital and the only state-designated Trauma Service and Burn Unit for pediatric patients. It has recognized Centers of Excellence in dozens of pediatric subspecialties, including allergy, cardiology, cystic fibrosis, gastroenterology, nephrology, neurology, neurosurgery, oncology, pulmonary, and transplant. Hopkins Children’s will celebrate its 100th anniversary and move to a new home in 2012. For more information, please visit

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