The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

• Published in: ANZ journal of surgery Vol. 93; no. 7-8; pp. 1978 - 1986
• Main Authors: Elliott, Brodie M., Bissett, Ian P., Harmston, Christopher, Vierboom, Liam, Meiyappan, Vivek, Sprosen, Holly, Hunter, Alice, Temara, Hinerangi, Taylor, Gregory Marc, Lu, Chuan Li, Crichton, James, Castle, Cameron, Mishra, Prabal R., Hobson, Andrew, Barnes, Tracy, Pau, Samuel, Hamill, James K., Kukkady, Askar, Rossaak, Jeremy, Prasad, Jagdish, Ing, Andrew, Kyle, Stephen M., Lill, Marianne, Daynes, Christopher, Tietjens, James, Stringer, Mark D., Beasley, Spencer W., Woodfield, John C., Samson, Paul B., Kommunuri, Jophia, Witcomb‐Cahill, Henry, Lane, Rosemary, Rout, Alexandra, Shetty, Shishira, Tawhai, Pagan, Varghese, Chris, Xu, William, Beedie, Alexandra R., McLaughlin, Scott J.P., Moxham, Mercy, Thorn, Joshua, Palmer, Chloe, Lai, Cindy, Pondicherry, Ashwini, Beckmann, Christina, Bai, Michelle, Chu, Agnes, Murray, Mark, Nicholas, Ella, Liu, Yi‐Zhuo, Chan, Annie, Amer, Mostafa, Cha, Ryan, Quon, Joshua, Thomas, Sophie
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01.07.2023; Blackwell Publishing Ltd
• Subjects: access; Appendicitis; Children; Cohort analysis; Delay; equity; Hospitals; Multivariate analysis; paediatric appendicitis; paediatric surgery; Pediatrics; rural; Surgery; Symptomology; New Zealand; paediatric surgery; access; paediatric appendicitis; equity; rural
• ISSN: 1445-1433; 1445-2197
• DOI: 10.1111/ans.18615

Background Appendicitis is the most common reason children undergo acute general surgery but international, population‐level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown. Methods A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee‐led collaborative group. Across 14 participating hospitals, 264 patients aged ≤16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade. Results Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and Māori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in‐hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78–7.25; P < 0.001), and Māori children (OR 2.39, 95% CI 1.24–5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology. Conclusion Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and Māori children. Understanding the pre‐hospital factors that influence the timing of presentation can better inform health‐system improvements. This trainee‐led project prospectively studied 182 children with appendicitis across New Zealand, with data supplemented by a parental survey. We found that delay in surgical treatment is primarily a result of prehospital delay, rather than differential in‐hospital management. Rural and Maori children were at higher risk of complicated appendicitis and more severe outcomes.