Brodie Elliott is a general surgical research registrar who works in Whangarei Hospital in Northland. He has a passion for equity in healthcare and looks to develop a career involving paediatric and academic surgery.

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Paediatric Appendicitis: Increased Disease Severity and Complication Rates in Rural Northland Children

Aims: Appendicitis is the most common surgical emergency affecting children. Internationally, rurality and prehospital patient factors are associated with appendiceal perforation and complicated surgical outcomes.1,2 We sought to define the effect of rural patient status and travel distance on the severity and outcomes of paediatric appendicitis.

Methods: Paediatric patients (≤16 years) who underwent appendicectomy for acute appendicitis in Northland, New Zealand between 2007-2017 were reviewed. Clinical, operative and histologic data were recorded. Individual road travel distance was calculated using GIS software. The primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien–Dindo complication rate.

Results: A total of 470 children underwent appendicectomy during this period. The median distance from treating hospital was 43.2 km and the overall perforation rate was 22.6%. On multivariate analysis, an increased AAST grade was twice as likely in rural patients (OR 2.04). Post-operatively, rural children had a higher median Clavien–Dindo complication grade (P = 0.001); increased rates of intra-abdominal collection (19% vs 4%; P=0.018), 30-day readmission (19% vs 4%; P=0.020) and perforation (27% vs 19%; P=0.031). Māori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade on multivariate analysis.

Conclusions: Accounting for ethnicity, socio-economic deprivation and age, we implicate rural patient status as being associated with increased severity and complication rates in paediatric appendicitis. This work adds to the evolving description of inequities in  New Zealand’s rural health outcomes and has led to a prospective, multicentre study investigating this finding nationally.

References:
1) 
Govind, S.K.,et al., 2019. Geographic Variation in Appendiceal Perforation Rates in Canada: a Population-Based Cohort Study. Journal of Gastrointestinal Surgery, pp.1-8.
2) Hernandez, M.C., et al., 2018. Appendicitis: rural patient status is associated with increased duration of prehospital symptoms and worse outcomes in high-and low-middle-income countries. World journal of surgery42(6), pp.1573-1580.

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