Ethnic disparities in children with acute appendicitis

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Rhee, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3353222/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Feb, 2024 Read the published version in International Journal of Colorectal Disease → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: Our study assesses if Hispanic children with acute appendicitis experience a more complicated hospital course than non-Hispanic children. Methods: We conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015-2020 using the National Surgical Quality Improvement Program-Pediatric database. Hispanic were compared to non-Hispanic white patients. Results: 65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44 %) non-Hispanic white. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs 25.15%,P<0.0001) and sepsis (25.22% vs 19.02%, P <0.0001) compared to non-Hispanic white. Hispanics had higher rates of serious complications (4.06% vs 3.55%, P =0.001) but not overall complications (5.37% vs 5.09%, P =0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85-1.01,P=0.088); it was associated with less overall complications (OR 0.88, CI 0.81-0.96, P =0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04-1.14, P <0.0001). Conclusion: Hispanic children are more likely to present with complicated appendicitis. This leads to increased postoperative complications in Hispanic children. After adjusting for complicated appendicitis, outcomes may be favorable for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population. Level of evidence: III Appendectomy Acute Appendicitis Ethnic Disparities Hispanic Pediatric surgery Figures Figure 1 Introduction Appendicitis is the most common pediatric surgical emergency, accounting for nearly 30% of all emergency room visits for abdominal pain [ 1 , 2 ]. Timely diagnosis and treatment are imperative in mitigating the risk of perforation and its associated complications. Delayed diagnosis is associated with an increased hospital length of stay, perforation, and risk of multiple operative interventions [ 3 – 5 ]. Racial and ethnic disparities have been well described in the field of surgery, whether in abdominal, cardiac, oncologic, and trauma, with clear associations between minority status and poor surgical outcomes despite advancements in perioperative care [ 6 , 7 ]. In children and in adults undergoing appendectomy, African-American patients experience a higher rate of postoperative complications and longer length of stay than white patients [ 8 – 11 ]. However, differences in surgical outcomes between Hispanic and non-Hispanic patients are not as widely studied but are known to exist: Eguia et al. showed that Hispanics undergoing low- to high-risk surgery have worse outcomes compared to non-Hispanic whites [ 12 ]. Our study aims to compare the initial presentation and postoperative outcomes of Hispanic and non-Hispanic children surgically treated for acute appendicitis, with the goal of better understanding where interventions should be focused to mitigate these disparities. Methods Data source Data were extracted from the American College of Surgeons (ACS) National Surgical Quality Improvement Program- Pediatric (NSQIP-P) from 2015 through 2020. The NSQIP-P is a multi-institutional program that contains risk-adjusted safety outcomes data for surgical patients between 0 to 18 years of age. Reported data included demographics, comorbidities, laboratory values, and outcomes within 30 days after surgery. NSQIP-P data are prospectively collected by trained surgical reviewers at different hospitals, and several methods are in place to ensure high data quality including standardized data collection, data validation and verification, site visits and audits, risk adjustment, and continuous improvement efforts. Study cohort Children aged less than 18 years were included in the analysis if they underwent either open or laparoscopic appendectomy (primary Current Procedural Terminology [CPT] 44950, 44960, 44970) and had a postoperative diagnosis confirming acute appendicitis (International Classification of Diseases [ICD], 9th edition codes 540, 540.0, 540.1, 540.9/ ICD-10 code K35 and its sub-classifications e.g., K35.32, K35. 89). Patients were classified as Hispanic of any race or non-Hispanic White. Non-Hispanic black, Asian, other races and unknown races of children were excluded from the study. Patients were also excluded if they had an appendectomy performed outside their initial hospital presentation. Predictor variables The primary variable of this study was patient ethnicity (Hispanic vs. non-Hispanic White). Demographic and patient factors included age, gender, weight, American Society of Anesthesiologists (ASA) physical status classification, neurologic impairment (including impaired cognitive status, cerebral palsy, seizure disorder, structural central nervous system defect, and neuromuscular disorder), asthma, bleeding disorder, cardiac risk factors (minor, major and severe), wound classification (classified as clean, clean/contaminated, contaminated, dirty/infected), preoperative sepsis (none, systemic inflammatory response syndrome [SIRS], sepsis and septic shock), classification of operation posting (elective vs. urgent vs. emergent), severity of appendicitis (complicated vs. uncomplicated), and surgical approach (open vs. laparoscopic). Outcome variables The primary outcomes were the development of one or more serious postoperative complications, any postoperative complications, and the postoperative length of stay. A serious complication was defined as any of the following: organ or space surgical site infection, wound disruption or dehiscence, bleeding that required transfusion, postoperative sepsis or septic shock and reoperation. Any postoperative complication was defined as ≥ 1 of following: serious complication, superficial surgical site infection, deep incisional surgical site infection, pneumonia, urinary tract infection, unplanned intubation, and Clostridioides difficile (C. diff) infection. Secondary outcomes included placement of percutaneous drainage, peripherally inserted central catheter (PICC) placement, parenteral nutrition, post-op fever, and discharge on oral or parenteral antibiotics. Statistical analysis Continuous variables are reported as median with interquartile range (IQR), whereas categorical variables are reported as frequencies and percentages. Two-sided t-tests or Wilcoxon’s rank-sum tests were used for continuous variables while Chi-squared or Fisher exact tests were used for categorical ones. Postoperative serious and overall complications were compared between Hispanics and non-Hispanic whites using multivariate logistic models. Postoperative length of stay (LOS) was compared using a multivariate generalized linear model. A variety of potential variables that could be confounders (age at operation, Sex, Ethnicity, Weight, Preoperative sepsis, presentation with complicated appendicitis, and surgical approach) were selected. Forward stepwise regression to reduce AIC (Akaike Information Criterion) was used to identify the confounder to be included in the final model. The primary predictor variable (ethnicity) was not forced into the model. A p-value of less than 0.05 was considered statistically significant. All statistical analysis was performed using R Statistical software (version RStudio 2022.07.2 + 576 "Spotted Wakerobin") Results A total of 65,976 children have been included in the analysis with 23,462 (35.56%) Hispanic ethnicity and 42,514 (64.44%) non-Hispanics white. Demographic and preoperative characteristics of patients by ethnicity are presented in Table 1 . The rate of complicated appendicitis was higher in Hispanic patients compared to non-Hispanic white patients (31.75% vs 25.15%, P < 0.0001). Hispanics were less likely to undergo laparoscopic procedures than non-Hispanic white ones (94.07% vs 95.13%, P < 0.0001). Table 1 Demographic and preoperative characteristics of children undergoing appendectomy for acute appendicitis by ethnicity Total, n = 65,976 (%) Hispanic, n = 23,462 (%) Non-Hispanic white, n = 42,514 (%) P-value* Age (Years) (mean +/-SD) 11.3 +/ 3.7 10.7 +/- 3.8 11.5 +/- 3.7 < .0001 Female 26,045 (39.48) 9,067 (38.65) 16,978 (39.94) 0.002 Weight (Pounds) (mean +/-SD) 98.6 +/- 42.8 97.0 +/- 43.3 99.4 +/- 42.2 < .0001 Neurologic impairment 1,779 (2.70) 635 (2.71) 1,144 (2.69) 0.93 Asthma 2,693 (4.08) 940 (4.01) 1,753 (4.12) 0.48 Bleeding disorder 495 (0.75) 163 (0.69) 332 (0.78) 0.24 ASA Class 0.48 1 32,138 (48.71) 11,383 (48.52) 20,755 (48.82) 2 30,902 (46.84) 11,005 (46.91) 19,897 (46.80) 3 2,846 (4.31) 1,037 (4.42) 1,809 (4.26) 4 90 (0.14) 37 (0.16) 53 (0.12) Cardiac Risk factors: 0.07 Minor 526 (0.80) 172 (0.73) 354 (0.83) Major 328 (0.50) 99 (0.42) 229 (0.54) Severe 45 (0.07) 13 (0.06) 32 (0.08) Wound classification < .0001 Clean 1,377 (2.09) 428 (1.82) 949 (2.23) Clean/contaminated 10,144 (15.38) 3,287 (14.01) 6,857 (16.13) Contaminated 37,042 (56.14) 12,868 (54.85) 24,174 (56.86) Dirty/infected 17,413 (26.39) 6,879 (29.32) 10,534 (24.78) Preoperative sepsis < .0001 None 30,664 (46.48) 9,482 (40.41) 21,182 (49.83) SIRS 21,257 (32.22) 8,039 (34.26) 13,218 (31.09) Sepsis 14,002 (21.22) 5,916 (25.22) 8,086 (19.02) Septic shock 52 (0.08) 25 (0.11) 27 (0.06) Case type: < .0001 Elective 6,750 (10.23) 2,168 (9.24) 4,582 (10.78) Urgent 24,878 (37.71) 8,345 (35.57) 16,533 (38.89) Emergent 34,348 (52.06) 12,949 (55.19) 21,399 (50.33) Complicated Appendicitis 18,144 (27.50) 7,450 (31.75) 10,694 (25.15) < .0001 Laparoscopic approach 62,512 (94.75) 22,070 (94.07) 40,442 (95.13) < .0001 ASA American Society of Anesthesiologists; SD Standard deviation; SIRS Systemic inflammatory response syndrome P-values in bold indicate statistical significance Postoperative complications in Hispanic and non-Hispanic white patients are demonstrated in Table 2 . Hispanics were more likely to experience serious complications compared to whites (4.06% vs 3.55%, P = 0.001), however, there was no difference in rates of overall complications between them (5.37% for Hispanics vs 5.09% for whites, P = 0.12). Of the 14 postoperative complications included in our analysis, Hispanics had a significantly higher incidence for 3 (organ/space surgical site infection, Clostridium difficile infection and rate of reoperation) while whites only had a higher incidence of pneumonia. In addition, the rate of postoperative emergency department (ED) visits related to the appendectomy was higher in Hispanics compared to whites (8.78% vs 6.82%, P < 0.0001). However, in the setting of complicated appendicitis, non-Hispanic whites were more likely to experience overall postoperative complications than Hispanics (13.03% for white vs 11.81% for Hispanics, P = 0.016) but not serious complications (P = 0.15). Furthermore, no difference in postoperative complications, whether serious (P = 0.45) or overall (P = 0.79), was found between the 2 groups in the setting of uncomplicated appendicitis (Fig. 1 ). Table 2 30-day postoperative outcomes after appendectomy by patient ethnicity Total, n = 65,976 (%) Hispanic, n = 23,462 (%) Non-Hispanic white, n = 42,514 (%) P-value Overall complications 3,422 (5.19) 1,260 (5.37) 2,162 (5.09) 0.12 Serious complications 2,463 (3.73) 952 (4.06) 1,511 (3.55) 0.001 Superficial SSI 683 (1.04) 232 (0.99) 451 (1.06) 0.40 Deep incisional SSI 90 (0.14) 36 (0.15) 57 (0.13) 0.60 Organ/space SSI* 1,932 (2.92) 744 (3.17) 1,188 (2.79) 0.006 Wound disruption* 27 (0.04) 9 (0.04) 18 (0.04) 0.97 Pneumonia 63 (0.10) 13 (0.06) 50 (0.12) 0.02 Urinary tract infection 62 (0.09) 28 (0.12) 34 (0.08) 0.15 Unplanned intubation 8 (0.01) 3 (0.01) 5 (0.01) 1 Seizure 10 (0.02) 2 (0.01) 8 (0.02) 0.51 Bleeding* 65 (0.1) 30 (0.13) 35 (0.08) 0.09 Sepsis* 196 (0.30) 79 (0.34) 117 (0.28) 0.19 Septic shock* 23 (0.03) 11 (0.05) 12 (0.03) 0.31 Clostridioides difficile infection* 216 (0.32) 56 (0.25) 160 (0.4) 0.003 Rate of reoperation* 621 (0.94) 245 (1.05) 376 (0.88) 0.0009 SSI surgical site infection * These complications were considered serious complications P-values in bold indicate statistical significance In addition, Hispanic patients experienced longer postoperative length of stay (for Hispanics vs Whites: mean 1.56 vs 1.02 days; median 1 vs 1 day; interquartile range [IQR] 0–2 vs 0–1; P < 0.0001) and underwent more postoperative interventions including percutaneous drainage placement (3.65% vs 3.12%, P = .0002), PICC placement (2.57% vs 2.28%, P = 0.02), postoperative imaging with computed tomography (CT) (5.32% vs 4.67%, P = 0.0002) or ultrasound ( 4.84% vs 4.25%, P = 0.0005). Hispanic children were also more likely to develop postoperative fever (2.65% vs 1.81%, P < 0.0001) and to be discharged on oral antibiotics (25.60% vs 20.29%, P < 0.0001) (Tables 3 ). Table 3 Postoperative length of stay and interventions after pediatric appendectomy by patient ethnicity Total, n = 65,976 (%) Hispanic, n = 23,462 (%) Non-Hispanic white, n = 42,514 (%) P-value Post-op length of stay 1 [0–2] 1 [0–2] 1 [0–1] < .0001 Complicated appendicitis 3 [ 2 – 4 ] 3 [ 2 – 5 ] 3 [ 2 – 4 ] < .0001 Uncomplicated appendicitis 1 [0–1] 1 [0–1] 1 [0–1] 0.67 Post-operative pathologic finding < .0001 Normal appendix 980 (1.49) 267 (1.14) 713 (1.68) Appendicitis 63126 (95.68) 22,609 (96.36) 40,517 (95.30) Other appendiceal disease 1799 (2.73) 562 (2.40) 1237 (2.91) Post-operative imaging US 2,943 (4.46) 1,135 (4.84) 1,808 (4.25) 0.0005 CT 3,232 (4.90) 1,248 (5.32) 1,984 (4.67) 0.0002 MRI 199 (0.30) 68 (0.29) 131 (0.31) 0.74 Fever 1,390 (2.11) 621 (2.65) 769 (1.81) < .0001 Percutaneous drainage 2183 (3.31) 857 (3.65) 1,326 (3.12) 0.0002 PICC placement 1,574 (2.39) 604 (2.57) 970 (2.28) 0.02 Parenteral nutrition 1,136 (1.72) 427 (1.82) 709 (1.67) 0.16 Oral antibiotics at discharge 14,631 (22.18) 6,006 (25.60) 8,625 (20.29) < .0001 Parenteral antibiotics at discharge 707 (1.07) 157 (0.67) 550 (1.29) < .0001 Rate of readmission 1,840 (2.79) 667 (2.84) 1,173 (2.76) 0.55 Rate of ED visits 4,959 (7.51) 2,059 (8.78) 2,900 (6.82) < .0001 CT computerized tomography; ED Emergency department; MRI Magnetic Resonance Imaging; PICC Peripherally inserted central catheter; US Ultrasound P-values in bold indicate statistical significance After accounting for potential confounding factors on multivariate analysis (Table 4 ) including age, preoperative sepsis, presentation with a complicated appendicitis, and surgical approach, the association of Hispanic ethnicity with increased incidence of serious complications lost its significance (adjusted odds ratio [OR] 0.93, 95% confidence interval [CI] 0.85–1.01, P = 0.088) while its association with increased postoperative LOS maintained it (OR 1.09; IQR 1.04–1.14; P < 0.0001). In addition, Hispanic ethnicity was associated with a decreased incidence of overall complications (OR 0.88; 95% CI 0.81–0.96; P < 0.004) when accounting for how patients present. Among the various factors studied, complicated appendicitis emerged as the primary cause of postoperative serious complications (OR 6.54; 95% CI 5.77–7.41; P < 0.0001), overall complications (OR 5.55; 95% CI 4.95–6.23; P < 0.0001), and an extended length of stay (OR 10.74, 95% CI 10.08–11.43; P < 0.0001). Table 4 Multivariate analysis of predictors of serious and overall complications and post-operative length of stay in children undergoing appendectomy for acute appendicitis Serious complications P-value Overall complications P-value Post-operative length of stay P-value Hispanic ethnicity 0.93 [0.85–1.01] 0.088 0.88 [0.81–0.96] 0.004 1.09 [1.04–1.14] < .0001 Age (in years) 1 [0.99–1.01] 0.99 [0.99–1.01] 0.81 0.97 [0.97–0.98] < .0001 SIRS 0.94 [0.81–1.1] 0.45 0.95 [0.83–1.08] 0.42 0.97 [0.93–1.02] 0.26 Sepsis 2.43 [2.17–2.73] < .0001 2.35 [2.11–2.62] < .0001 3.24 [3.03–3.48] < .0001 Complicated appendicitis 6.54 [5.77–7.41] < .0001 5.55 [4.95–6.23] < .0001 10.74 [10.08–11.43] < .0001 Laparoscopic approach 0.65 [0.56–0.76] < .0001 0.68 [0.59–0.79] < .0001 0.67 [0.61–0.74] < .0001 SIRS Systemic inflammatory response syndrome Values are presented as odds ratio [95% confidence intervals] P-values in bold indicate statistical significance Discussion Our study aims to better understand ethnic disparities in perioperative outcomes of children undergoing appendectomy. We found that disparities exist in both preoperative appendicitis presentation and postoperative outcomes. We found that Hispanic children were more likely to present with complicated appendicitis than non-Hispanic white children, and this led to an increased overall rate of complications for all acute appendicitis in this population. However, after adjusting for multiple factors including the presence of complicated appendicitis, we found there was no increased risk of serious complications in the Hispanic population, and even findings of decreased overall complications. This suggests that there is not a disparity in the care received once they present to the hospital, and that the disparity is mainly driven by delayed presentation and hence complicated appendicitis. Compared to non-Hispanic white children, Hispanic children had more surgical drains placed, indicating that they had developed an appendiceal abscess, which supports our finding that they present with more complicated appendicitis. In addition, they had more open surgeries, developed more postoperative fevers, received more postoperative imaging including CT scans and ultrasounds, and had a longer length of stay. They also had a higher rate of postoperative ED visits. These findings are consistent with the higher incidence of complicated appendicitis at presentation. A presentation with a high rate of complicated appendicitis and appendiceal perforation have been documented previously in people of Hispanic ethnicity and limited English proficiency [ 13 , 14 ]. These studies suggest that Hispanic patients present with a more severe form of appendicitis, which is then associated with worse outcomes and the further perpetuation of disparity. This difference could be reflective of the social determinants of health, which includes factors such as economic stability, neighborhood and physical environment, education, community and social context, and the health care system. Barriers to care in Hispanic patients such as limited English language proficiency, lower health insurance rates and lack of transportation in conjunction with lower health literacy are factors that may contribute to the delay of care and more complex presentation of appendicitis [ 14 – 17 ]. Studies have also shown that rates of pediatric appendiceal perforation are higher in Medicaid and uninsured patients, as parents of these children are likely delaying care due to financial factors and failure to recognize symptoms [ 18 ]. Thus, a significant amount of disparity in appendicitis outcomes is attributable to the fact that more Hispanic patients present with complicated appendicitis than non-Hispanic white patients. Extended post-operative stay, higher revisit rates, and rate of surgical site infections have been found to be associated with complicated appendicitis across many studies [ 18 – 20 ]. Our data indicates that inpatient care is similar for Hispanic and non-Hispanic, as indicated by our multivariate analysis. Therefore, the higher rate of postoperative complications in Hispanics can be rather attributed to pre-hospital care deficiencies. Education is another social determinant of health and is strongly associated with health outcomes. Studies have found that Hispanics in the US have lower levels of health literacy compared to other populations [ 21 ]. In the context of appendicitis, parental knowledge of the symptoms can influence the timing of care that children receive and adherence to discharge instructions. Providing parents with comprehensive education on monitoring for negative symptoms and the urgency of seeking medical will likely improve outcomes [ 22 ]. Parental health literacy is a strong predictor of childhood health and thus it is critical to deliver quality health education to parents and caregivers to aid in early intervention and improve postoperative outcomes [ 23 ]. There are also many language barriers that Spanish-speaking patients face when seeking care [ 17 ]. Limitations in English proficiency have been found to be associated with longer postoperative length of stay, decreased patient satisfaction, and higher rates of adverse events [ 24 – 26 ]. Language barriers are also associated with decreased discharge instruction comprehension and increased preventable emergency department visits [ 27 , 28 ]. This might be a reason for the higher rate of ED visits observed among Hispanics. Interventions to reduce the language barrier and improve caregiver-physician communication are imperative in improving pediatric appendicitis outcomes. Our study is not without limitations. First, it is a retrospective analysis. Second, detailed demographic data and social determinants of health variables, including socioeconomic status, insurance status, and language preference were not recorded in the database. As previously discussed, these factors might help in understanding the origin of the described disparities. In addition, we were unable to adjust for hospital-level factors, including location and academic status of the hospital, that may influence patient outcomes after appendectomy. Nevertheless, our large sample size provides a clear picture of macroscopic issues that can then be further investigated through more focused research. In conclusion, Hispanic children were more likely to experience postoperative complications and an increased length of stay compared to non-Hispanic white children. This is due to their higher rate of complicated appendicitis at presentation and not to their inpatient management. Therefore, the main issue lies before hospital presentations and efforts should be made to understand what factors, including social determinants of health, access to care, language barrier and hospital level factors, aggravate this situation. Abbreviations ACS American College of Surgeons AIC Akaike Information Criterion ASA American Society of Anesthesiologists C. diff Clostridioides difficile CPT Current Procedural Terminology CT Computed tomography ED emergency department ICD International Classification of Diseases IQR interquartile range LOS length of stay NSQIP-P National Surgical Quality Improvement Program- Pediatric PICC peripherally inserted central catheter SIRS systemic inflammatory response syndrome Declarations Ethical Approval: This study was deemed exempted by the Johns Hopkins Internal Review Boards Competing interests : All of the authors declare that they have no competing interests, whether financial or personal, related to this research. Authors' contributions: Dr. Alejandro Garcia and Dr. Daniel Rhee conceived and designed the study. Dr. Charbel Chidiac and Dr. Daniel Rhee conducted the analysis and interpreted the data. Dr. Charbel Chidiac prepared the tables and figures. The manuscript was drafted by Ms. Olivia Liu, Mr. Rahul Gorijavolu., and Dr. Charbel Chidiac. Dr. Alejandro Garcia and Dr. Daniel Rhee provided critical revisions to the manuscript. All authors reviewed the manuscript. Funding: Not applicable Availability of data and materials: The American College of Surgeons National Surgical Quality Improvement Program- Pediatrics (NSQIP-P) database can be accessed by requesting the database from the American College of Surgeons. The link to the participant use request form is the following: https://www.facs.org/quality-programs/data-and-registries/acs-nsqip/participant-use-data-file/participant-use-request-form/ References Davenport M. Acute abdominal pain in children. 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Parental health literacy and health knowledge, behaviours and outcomes in children: a cross-sectional survey. BMC Public Health 2020;20:1096. https://doi.org/10.1186/s12889-020-08881-5 . John-Baptiste A, Naglie G, Tomlinson G, Alibhai SMH, Etchells E, Cheung A, et al. The Effect of English Language Proficiency on Length of Stay and In-hospital Mortality. J Gen Intern Med 2004;19:221–8. https://doi.org/10.1111/j.1525-1497.2004.21205.x . Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med 1998;152:1119–25. https://doi.org/10.1001/archpedi.152.11.1119 . Flores G, Rabke-Verani J, Pine W, Sabharwal A. The importance of cultural and linguistic issues in the emergency care of children. Pediatr Emerg Care 2002;18:271–84. https://doi.org/10.1097/00006565-200208000-00010 . Dai X, Ryan MA, Clements AC, Tunkel DE, Links AR, Boss EF, et al. The Effect of Language Barriers at Discharge on Pediatric Adenotonsillectomy Outcomes and Healthcare Contact. Ann Otol Rhinol Laryngol 2021;130:833–9. https://doi.org/10.1177/0003489420980176 . Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Language barriers and understanding of hospital discharge instructions. Med Care 2012;50:283–9. https://doi.org/10.1097/MLR.0b013e318249c949 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Feb, 2024 Read the published version in International Journal of Colorectal Disease → Version 1 posted Editorial decision: Major revision 29 Oct, 2023 Reviews received at journal 18 Sep, 2023 Reviewers agreed at journal 18 Sep, 2023 Reviewers invited by journal 18 Sep, 2023 Editor assigned by journal 17 Sep, 2023 Submission checks completed at journal 17 Sep, 2023 First submitted to journal 13 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3353222","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":234255185,"identity":"556b63f4-2f53-48c6-8cd4-2c600366ec47","order_by":0,"name":"Charbel Chidiac","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Charbel","middleName":"","lastName":"Chidiac","suffix":""},{"id":234255186,"identity":"7e7d05db-814e-449d-bbfb-504ffca372bb","order_by":1,"name":"Olivia Liu","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Olivia","middleName":"","lastName":"Liu","suffix":""},{"id":234255187,"identity":"a2414c70-381a-40ea-a019-8788ef38b969","order_by":2,"name":"Rahul Gorijavolu","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Rahul","middleName":"","lastName":"Gorijavolu","suffix":""},{"id":234255188,"identity":"8a9be6dc-8bcb-4554-853c-4a3efa56b54a","order_by":3,"name":"Daniel S. Rhee","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"S.","lastName":"Rhee","suffix":""},{"id":234255189,"identity":"64d92e9c-4041-4292-a5c6-0978d11b10ea","order_by":4,"name":"Alejandro V. Garcia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIie3OsQrCMBCA4StCp2DWCra+QiTQqeirVITOgotjHqDoamdfoOALRES7VLvGzamz4NJBqGmh8+kmmH+64b5LAEymn43ZhEIOEAJY4kPSHw7EdwS8gEnSTjihm135qBY+4YfLKb1D4KYSIY4qeRKziPjyGqkQIo4SUJL3gJ01yX1NjjOUjFT21KQmXLSkxgkr4uYVmzBoicTJWJGlFWvitB9jc55gxCuyPVQve0q3uX+rVhN3jRFwwm5oVhm23kS7o1R8sm4ymUz/2Bumo0gwMEx53gAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Alejandro","middleName":"V.","lastName":"Garcia","suffix":""}],"badges":[],"createdAt":"2023-09-13 20:29:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3353222/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3353222/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00384-024-04598-8","type":"published","date":"2024-02-22T15:01:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":43633664,"identity":"bf5587ef-d512-468d-8eea-d76120f4aa1e","added_by":"auto","created_at":"2023-09-25 13:59:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24583,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRate of serious and overall complications by ethnicity in complicated and uncomplicated appendicitis separately.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChi-Square tests were used were used to compare the rate of complications between Hispanic children and non-Hispanic white children. P-values in bold indicate statistical significance.\u003c/p\u003e","description":"","filename":"Graph1Diparitiesinappendectomy.png","url":"https://assets-eu.researchsquare.com/files/rs-3353222/v1/a0eb8ba7fb0a76bc0f0f5894.png"},{"id":51648931,"identity":"a4ab8705-1dea-4004-a651-abb4f34b65e2","added_by":"auto","created_at":"2024-02-26 15:16:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":536312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3353222/v1/9c9b0fe8-342b-4201-9fdb-bc41c96f63d0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethnic disparities in children with acute appendicitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAppendicitis is the most common pediatric surgical emergency, accounting for nearly 30% of all emergency room visits for abdominal pain [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Timely diagnosis and treatment are imperative in mitigating the risk of perforation and its associated complications. Delayed diagnosis is associated with an increased hospital length of stay, perforation, and risk of multiple operative interventions [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRacial and ethnic disparities have been well described in the field of surgery, whether in abdominal, cardiac, oncologic, and trauma, with clear associations between minority status and poor surgical outcomes despite advancements in perioperative care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In children and in adults undergoing appendectomy, African-American patients experience a higher rate of postoperative complications and longer length of stay than white patients [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, differences in surgical outcomes between Hispanic and non-Hispanic patients are not as widely studied but are known to exist: \u003cem\u003eEguia et al.\u003c/em\u003e showed that Hispanics undergoing low- to high-risk surgery have worse outcomes compared to non-Hispanic whites [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study aims to compare the initial presentation and postoperative outcomes of Hispanic and non-Hispanic children surgically treated for acute appendicitis, with the goal of better understanding where interventions should be focused to mitigate these disparities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source\u003c/h2\u003e \u003cp\u003eData were extracted from the American College of Surgeons (ACS) National Surgical Quality Improvement Program- Pediatric (NSQIP-P) from 2015 through 2020. The NSQIP-P is a multi-institutional program that contains risk-adjusted safety outcomes data for surgical patients between 0 to 18 years of age. Reported data included demographics, comorbidities, laboratory values, and outcomes within 30 days after surgery. NSQIP-P data are prospectively collected by trained surgical reviewers at different hospitals, and several methods are in place to ensure high data quality including standardized data collection, data validation and verification, site visits and audits, risk adjustment, and continuous improvement efforts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy cohort\u003c/h2\u003e \u003cp\u003eChildren aged less than 18 years were included in the analysis if they underwent either open or laparoscopic appendectomy (primary Current Procedural Terminology [CPT] 44950, 44960, 44970) and had a postoperative diagnosis confirming acute appendicitis (International Classification of Diseases [ICD], 9th edition codes 540, 540.0, 540.1, 540.9/ ICD-10 code K35 and its sub-classifications e.g., K35.32, K35. 89). Patients were classified as Hispanic of any race or non-Hispanic White. Non-Hispanic black, Asian, other races and unknown races of children were excluded from the study. Patients were also excluded if they had an appendectomy performed outside their initial hospital presentation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePredictor variables\u003c/h2\u003e \u003cp\u003eThe primary variable of this study was patient ethnicity (Hispanic vs. non-Hispanic White). Demographic and patient factors included age, gender, weight, American Society of Anesthesiologists (ASA) physical status classification, neurologic impairment (including impaired cognitive status, cerebral palsy, seizure disorder, structural central nervous system defect, and neuromuscular disorder), asthma, bleeding disorder, cardiac risk factors (minor, major and severe), wound classification (classified as clean, clean/contaminated, contaminated, dirty/infected), preoperative sepsis (none, systemic inflammatory response syndrome [SIRS], sepsis and septic shock), classification of operation posting (elective vs. urgent vs. emergent), severity of appendicitis (complicated vs. uncomplicated), and surgical approach (open vs. laparoscopic).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome variables\u003c/h2\u003e \u003cp\u003eThe primary outcomes were the development of one or more serious postoperative complications, any postoperative complications, and the postoperative length of stay. A serious complication was defined as any of the following: organ or space surgical site infection, wound disruption or dehiscence, bleeding that required transfusion, postoperative sepsis or septic shock and reoperation. Any postoperative complication was defined as \u0026ge;\u0026thinsp;1 of following: serious complication, superficial surgical site infection, deep incisional surgical site infection, pneumonia, urinary tract infection, unplanned intubation, and \u003cem\u003eClostridioides difficile\u003c/em\u003e (C. diff) infection.\u003c/p\u003e \u003cp\u003eSecondary outcomes included placement of percutaneous drainage, peripherally inserted central catheter (PICC) placement, parenteral nutrition, post-op fever, and discharge on oral or parenteral antibiotics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables are reported as median with interquartile range (IQR), whereas categorical variables are reported as frequencies and percentages. Two-sided t-tests or Wilcoxon\u0026rsquo;s rank-sum tests were used for continuous variables while Chi-squared or Fisher exact tests were used for categorical ones.\u003c/p\u003e \u003cp\u003ePostoperative serious and overall complications were compared between Hispanics and non-Hispanic whites using multivariate logistic models. Postoperative length of stay (LOS) was compared using a multivariate generalized linear model. A variety of potential variables that could be confounders (age at operation, Sex, Ethnicity, Weight, Preoperative sepsis, presentation with complicated appendicitis, and surgical approach) were selected. Forward stepwise regression to reduce AIC (Akaike Information Criterion) was used to identify the confounder to be included in the final model. The primary predictor variable (ethnicity) was not forced into the model. A p-value of less than 0.05 was considered statistically significant. All statistical analysis was performed using R Statistical software (version RStudio 2022.07.2\u0026thinsp;+\u0026thinsp;576 \"Spotted Wakerobin\")\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 65,976 children have been included in the analysis with 23,462 (35.56%) Hispanic ethnicity and 42,514 (64.44%) non-Hispanics white. Demographic and preoperative characteristics of patients by ethnicity are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The rate of complicated appendicitis was higher in Hispanic patients compared to non-Hispanic white patients (31.75% vs 25.15%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Hispanics were less likely to undergo laparoscopic procedures than non-Hispanic white ones (94.07% vs 95.13%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and preoperative characteristics of children undergoing appendectomy for acute appendicitis by ethnicity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;65,976 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHispanic,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;23,462 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Hispanic white,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42,514 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Years) (mean +/-SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.3 +/ 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7 +/- 3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.5 +/- 3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26,045 (39.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,067 (38.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,978 (39.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (Pounds) (mean +/-SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.6 +/- 42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.0 +/- 43.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99.4 +/- 42.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurologic impairment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,779 (2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e635 (2.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,144 (2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,693 (4.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e940 (4.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,753 (4.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e495 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e332 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA Class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32,138 (48.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11,383 (48.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20,755 (48.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30,902 (46.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11,005 (46.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19,897 (46.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,846 (4.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,037 (4.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,809 (4.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac Risk factors:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e526 (0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e354 (0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e328 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (0.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e229 (0.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (0.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,377 (2.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e428 (1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e949 (2.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClean/contaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,144 (15.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,287 (14.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,857 (16.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37,042 (56.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12,868 (54.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24,174 (56.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirty/infected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17,413 (26.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,879 (29.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,534 (24.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30,664 (46.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,482 (40.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21,182 (49.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21,257 (32.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,039 (34.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13,218 (31.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,002 (21.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,916 (25.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,086 (19.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic shock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase type:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,750 (10.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,168 (9.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,582 (10.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24,878 (37.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8,345 (35.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,533 (38.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34,348 (52.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12,949 (55.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21,399 (50.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplicated Appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18,144 (27.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,450 (31.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,694 (25.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62,512 (94.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22,070 (94.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40,442 (95.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eASA American Society of Anesthesiologists; SD Standard deviation; SIRS Systemic inflammatory response syndrome\u003c/p\u003e \u003cp\u003eP-values in bold indicate statistical significance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications in Hispanic and non-Hispanic white patients are demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Hispanics were more likely to experience serious complications compared to whites (4.06% vs 3.55%, P\u0026thinsp;=\u0026thinsp;0.001), however, there was no difference in rates of overall complications between them (5.37% for Hispanics vs 5.09% for whites, P\u0026thinsp;=\u0026thinsp;0.12). Of the 14 postoperative complications included in our analysis, Hispanics had a significantly higher incidence for 3 (organ/space surgical site infection, Clostridium difficile infection and rate of reoperation) while whites only had a higher incidence of pneumonia. In addition, the rate of postoperative emergency department (ED) visits related to the appendectomy was higher in Hispanics compared to whites (8.78% vs 6.82%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). However, in the setting of complicated appendicitis, non-Hispanic whites were more likely to experience overall postoperative complications than Hispanics (13.03% for white vs 11.81% for Hispanics, P\u0026thinsp;=\u0026thinsp;0.016) but not serious complications (P\u0026thinsp;=\u0026thinsp;0.15). Furthermore, no difference in postoperative complications, whether serious (P\u0026thinsp;=\u0026thinsp;0.45) or overall (P\u0026thinsp;=\u0026thinsp;0.79), was found between the 2 groups in the setting of uncomplicated appendicitis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e30-day postoperative outcomes after appendectomy by patient ethnicity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;65,976 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHispanic,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;23,462 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Hispanic white,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42,514 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,422 (5.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,260 (5.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,162 (5.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSerious complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,463 (3.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e952 (4.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,511 (3.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuperficial SSI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e683 (1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e232 (0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e451 (1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDeep incisional SSI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOrgan/space SSI*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,932 (2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e744 (3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,188 (2.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWound disruption*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePneumonia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u0026nbsp;(0.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrinary tract infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u0026nbsp;(0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnplanned intubation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026nbsp;(0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeizure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBleeding*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026nbsp;(0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSepsis*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e196 (0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u0026nbsp;(0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117 (0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSeptic shock*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026nbsp;(0.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClostridioides difficile\u003c/b\u003e \u003cb\u003einfection*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e216 (0.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u0026nbsp;(0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e160\u0026nbsp;(0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRate of reoperation*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e621 (0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e245\u0026nbsp;(1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e376 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSSI\u003c/b\u003e surgical site infection\u003c/p\u003e \u003cp\u003e* These complications were considered serious complications\u003c/p\u003e \u003cp\u003eP-values in bold indicate statistical significance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition, Hispanic patients experienced longer postoperative length of stay (for Hispanics vs Whites: mean 1.56 vs 1.02 days; median 1 vs 1 day; interquartile range [IQR] 0\u0026ndash;2 vs 0\u0026ndash;1; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and underwent more postoperative interventions including percutaneous drainage placement (3.65% vs 3.12%, P\u0026thinsp;=\u0026thinsp;.0002), PICC placement (2.57% vs 2.28%, P\u0026thinsp;=\u0026thinsp;0.02), postoperative imaging with computed tomography (CT) (5.32% vs 4.67%, P\u0026thinsp;=\u0026thinsp;0.0002) or ultrasound ( 4.84% vs 4.25%, P\u0026thinsp;=\u0026thinsp;0.0005). Hispanic children were also more likely to develop postoperative fever (2.65% vs 1.81%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and to be discharged on oral antibiotics (25.60% vs 20.29%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative length of stay and interventions after pediatric appendectomy by patient ethnicity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;65,976 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHispanic,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;23,462 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-Hispanic white,\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;42,514 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-op length of stay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplicated appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUncomplicated appendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-operative pathologic finding\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal appendix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e980 (1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e267\u0026nbsp;(1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e713 (1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppendicitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63126 (95.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22,609 (96.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40,517 (95.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther appendiceal disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1799 (2.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e562\u0026nbsp;(2.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1237 (2.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-operative imaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2,943 (4.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,135\u0026nbsp;(4.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,808 (4.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,232 (4.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,248\u0026nbsp;(5.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,984 (4.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68\u0026nbsp;(0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131 (0.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFever\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,390 (2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e621\u0026nbsp;(2.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e769 (1.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePercutaneous drainage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2183 (3.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e857\u0026nbsp;(3.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,326 (3.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePICC placement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,574 (2.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e604\u0026nbsp;(2.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e970 (2.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParenteral nutrition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,136 (1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e427\u0026nbsp;(1.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e709 (1.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOral antibiotics at discharge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,631 (22.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,006 (25.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,625 (20.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParenteral antibiotics at discharge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e707 (1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e550 (1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRate of readmission\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,840 (2.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e667\u0026nbsp;(2.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,173 (2.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRate of ED visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,959 (7.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,059\u0026nbsp;(8.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,900 (6.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCT\u003c/b\u003e computerized tomography; \u003cb\u003eED\u003c/b\u003e Emergency department; \u003cb\u003eMRI\u003c/b\u003e Magnetic Resonance Imaging; \u003cb\u003ePICC\u003c/b\u003e Peripherally inserted central catheter; \u003cb\u003eUS\u003c/b\u003e Ultrasound\u003c/p\u003e \u003cp\u003eP-values in bold indicate statistical significance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter accounting for potential confounding factors on multivariate analysis (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) including age, preoperative sepsis, presentation with a complicated appendicitis, and surgical approach, the association of Hispanic ethnicity with increased incidence of serious complications lost its significance (adjusted odds ratio [OR] 0.93, 95% confidence interval [CI] 0.85\u0026ndash;1.01, P\u0026thinsp;=\u0026thinsp;0.088) while its association with increased postoperative LOS maintained it (OR 1.09; IQR 1.04\u0026ndash;1.14; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In addition, Hispanic ethnicity was associated with a decreased incidence of overall complications (OR 0.88; 95% CI 0.81\u0026ndash;0.96; P\u0026thinsp;\u0026lt;\u0026thinsp;0.004) when accounting for how patients present. Among the various factors studied, complicated appendicitis emerged as the primary cause of postoperative serious complications (OR 6.54; 95% CI 5.77\u0026ndash;7.41; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), overall complications (OR 5.55; 95% CI 4.95\u0026ndash;6.23; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and an extended length of stay (OR 10.74, 95% CI 10.08\u0026ndash;11.43; P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate analysis of predictors of serious and overall complications and post-operative length of stay in children undergoing appendectomy for acute appendicitis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSerious complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost-operative length of stay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHispanic ethnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93 [0.85\u0026ndash;1.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.88 [0.81\u0026ndash;0.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.09 [1.04\u0026ndash;1.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (in years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0.99\u0026ndash;1.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e[0.99\u0026ndash;1.01]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97 [0.97\u0026ndash;0.98]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIRS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.94 [0.81\u0026ndash;1.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95 [0.83\u0026ndash;1.08]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.97 [0.93\u0026ndash;1.02]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSepsis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.43 [2.17\u0026ndash;2.73]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.35 [2.11\u0026ndash;2.62]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.24 [3.03\u0026ndash;3.48]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplicated appendicitis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.54 [5.77\u0026ndash;7.41]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.55 [4.95\u0026ndash;6.23]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.74 [10.08\u0026ndash;11.43]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaparoscopic approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.65 [0.56\u0026ndash;0.76]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68 [0.59\u0026ndash;0.79]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.67 [0.61\u0026ndash;0.74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSIRS\u003c/b\u003e Systemic inflammatory response syndrome\u003c/p\u003e \u003cp\u003eValues are presented as odds ratio [95% confidence intervals]\u003c/p\u003e \u003cp\u003eP-values in bold indicate statistical significance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study aims to better understand ethnic disparities in perioperative outcomes of children undergoing appendectomy. We found that disparities exist in both preoperative appendicitis presentation and postoperative outcomes. We found that Hispanic children were more likely to present with complicated appendicitis than non-Hispanic white children, and this led to an increased overall rate of complications for all acute appendicitis in this population. However, after adjusting for multiple factors including the presence of complicated appendicitis, we found there was no increased risk of serious complications in the Hispanic population, and even findings of decreased overall complications. This suggests that there is not a disparity in the care received once they present to the hospital, and that the disparity is mainly driven by delayed presentation and hence complicated appendicitis.\u003c/p\u003e \u003cp\u003eCompared to non-Hispanic white children, Hispanic children had more surgical drains placed, indicating that they had developed an appendiceal abscess, which supports our finding that they present with more complicated appendicitis. In addition, they had more open surgeries, developed more postoperative fevers, received more postoperative imaging including CT scans and ultrasounds, and had a longer length of stay. They also had a higher rate of postoperative ED visits. These findings are consistent with the higher incidence of complicated appendicitis at presentation.\u003c/p\u003e \u003cp\u003eA presentation with a high rate of complicated appendicitis and appendiceal perforation have been documented previously in people of Hispanic ethnicity and limited English proficiency [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These studies suggest that Hispanic patients present with a more severe form of appendicitis, which is then associated with worse outcomes and the further perpetuation of disparity. This difference could be reflective of the social determinants of health, which includes factors such as economic stability, neighborhood and physical environment, education, community and social context, and the health care system. Barriers to care in Hispanic patients such as limited English language proficiency, lower health insurance rates and lack of transportation in conjunction with lower health literacy are factors that may contribute to the delay of care and more complex presentation of appendicitis [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Studies have also shown that rates of pediatric appendiceal perforation are higher in Medicaid and uninsured patients, as parents of these children are likely delaying care due to financial factors and failure to recognize symptoms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, a significant amount of disparity in appendicitis outcomes is attributable to the fact that more Hispanic patients present with complicated appendicitis than non-Hispanic white patients. Extended post-operative stay, higher revisit rates, and rate of surgical site infections have been found to be associated with complicated appendicitis across many studies [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our data indicates that inpatient care is similar for Hispanic and non-Hispanic, as indicated by our multivariate analysis. Therefore, the higher rate of postoperative complications in Hispanics can be rather attributed to pre-hospital care deficiencies.\u003c/p\u003e \u003cp\u003eEducation is another social determinant of health and is strongly associated with health outcomes. Studies have found that Hispanics in the US have lower levels of health literacy compared to other populations [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In the context of appendicitis, parental knowledge of the symptoms can influence the timing of care that children receive and adherence to discharge instructions. Providing parents with comprehensive education on monitoring for negative symptoms and the urgency of seeking medical will likely improve outcomes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Parental health literacy is a strong predictor of childhood health and thus it is critical to deliver quality health education to parents and caregivers to aid in early intervention and improve postoperative outcomes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are also many language barriers that Spanish-speaking patients face when seeking care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Limitations in English proficiency have been found to be associated with longer postoperative length of stay, decreased patient satisfaction, and higher rates of adverse events [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Language barriers are also associated with decreased discharge instruction comprehension and increased preventable emergency department visits [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This might be a reason for the higher rate of ED visits observed among Hispanics. Interventions to reduce the language barrier and improve caregiver-physician communication are imperative in improving pediatric appendicitis outcomes.\u003c/p\u003e \u003cp\u003eOur study is not without limitations. First, it is a retrospective analysis. Second, detailed demographic data and social determinants of health variables, including socioeconomic status, insurance status, and language preference were not recorded in the database. As previously discussed, these factors might help in understanding the origin of the described disparities. In addition, we were unable to adjust for hospital-level factors, including location and academic status of the hospital, that may influence patient outcomes after appendectomy. Nevertheless, our large sample size provides a clear picture of macroscopic issues that can then be further investigated through more focused research.\u003c/p\u003e \u003cp\u003eIn conclusion, Hispanic children were more likely to experience postoperative complications and an increased length of stay compared to non-Hispanic white children. This is due to their higher rate of complicated appendicitis at presentation and not to their inpatient management. Therefore, the main issue lies before hospital presentations and efforts should be made to understand what factors, including social determinants of health, access to care, language barrier and hospital level factors, aggravate this situation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican College of Surgeons\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAkaike Information Criterion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eC. diff\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eClostridioides difficile\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCurrent Procedural Terminology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eemergency department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Classification of Diseases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elength of stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSQIP-P\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Surgical Quality Improvement Program- Pediatric\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePICC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eperipherally inserted central catheter\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esystemic inflammatory response syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthical Approval:\u0026nbsp;\u003c/u\u003eThis study was deemed exempted by the Johns Hopkins Internal Review Boards\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e: All of the authors declare that they have no competing interests, whether financial or personal, related to this research.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' contributions:\u0026nbsp;\u003c/u\u003eDr. Alejandro Garcia and Dr. Daniel Rhee conceived and designed the study. Dr. Charbel Chidiac and Dr. Daniel Rhee conducted the analysis and interpreted the data. Dr. Charbel Chidiac prepared the tables and figures. The manuscript was drafted by Ms. Olivia Liu, Mr. Rahul Gorijavolu., and Dr. Charbel Chidiac. Dr. Alejandro Garcia and Dr. Daniel Rhee provided critical revisions to the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding:\u003c/u\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials:\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe American College of Surgeons National Surgical Quality Improvement Program- Pediatrics (NSQIP-P) database can be accessed by requesting the database from the American College of Surgeons. The link to the participant use request form is the following:\u003c/p\u003e\n\u003cp\u003ehttps://www.facs.org/quality-programs/data-and-registries/acs-nsqip/participant-use-data-file/participant-use-request-form/\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDavenport M. Acute abdominal pain in children. BMJ 1996;312:498\u0026ndash;501. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.312.7029.498\u003c/span\u003e\u003cspan address=\"10.1136/bmj.312.7029.498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. 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Ann Otol Rhinol Laryngol 2021;130:833\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0003489420980176\u003c/span\u003e\u003cspan address=\"10.1177/0003489420980176\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarliner LS, Auerbach A, N\u0026aacute;poles A, Schillinger D, Nickleach D, P\u0026eacute;rez-Stable EJ. Language barriers and understanding of hospital discharge instructions. Med Care 2012;50:283\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/MLR.0b013e318249c949\u003c/span\u003e\u003cspan address=\"10.1097/MLR.0b013e318249c949\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Appendectomy, Acute Appendicitis, Ethnic Disparities, Hispanic, Pediatric surgery","lastPublishedDoi":"10.21203/rs.3.rs-3353222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3353222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eOur study assesses if Hispanic children with acute appendicitis experience a more complicated hospital course than non-Hispanic children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a retrospective analysis of pediatric patients undergoing appendectomy for acute appendicitis from 2015-2020 using the National Surgical Quality Improvement Program-Pediatric database. Hispanic were compared to non-Hispanic white patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e65,976 patients were included, of which 23,462 (35.56%) were Hispanic and 42,514 (64.44 %) non-Hispanic white. Hispanic children were more likely to present to the hospital with complicated appendicitis (31.75% vs 25.15%,P\u0026lt;0.0001) and sepsis (25.22% vs 19.02%,\u003cem\u003eP\u003c/em\u003e \u0026lt;0.0001) compared to non-Hispanic white. Hispanics had higher rates of serious complications (4.06% vs 3.55%,\u003cem\u003eP\u003c/em\u003e=0.001) but not overall complications (5.37% vs 5.09%,\u003cem\u003eP\u003c/em\u003e=0.12). However, after multivariate analysis, Hispanic ethnicity was not associated with an increased rate of serious postoperative complications (OR 0.93, CI 0.85-1.01,P=0.088); it was associated with less overall complications (OR 0.88, CI 0.81-0.96,\u003cem\u003eP\u003c/em\u003e=0.003) but a longer postoperative length of stay (OR 1.09, CI 1.04-1.14,\u003cem\u003eP\u003c/em\u003e\u0026lt;0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eHispanic children are more likely to present with complicated appendicitis. This leads to increased postoperative complications in Hispanic children. After adjusting for complicated appendicitis, outcomes may be favorable for Hispanic ethnicity. This emphasizes the need to understand delays in presentation to improve outcomes in the Hispanic population.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eLevel of evidence:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e III\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Ethnic disparities in children with acute appendicitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-09-25 13:59:23","doi":"10.21203/rs.3.rs-3353222/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-10-29T15:07:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-09-18T20:50:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2ab707ca-d0c5-4f52-96b0-66a106c30a89","date":"2023-09-18T20:05:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-09-18T19:12:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-09-18T01:34:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-09-18T01:34:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2023-09-13T20:19:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"21b350c4-ddb9-4567-9ca0-db528bc42f70","owner":[],"postedDate":"September 25th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-02-26T15:13:02+00:00","versionOfRecord":{"articleIdentity":"rs-3353222","link":"https://doi.org/10.1007/s00384-024-04598-8","journal":{"identity":"international-journal-of-colorectal-disease","isVorOnly":false,"title":"International Journal of Colorectal Disease"},"publishedOn":"2024-02-22 15:01:43","publishedOnDateReadable":"February 22nd, 2024"},"versionCreatedAt":"2023-09-25 13:59:23","video":"","vorDoi":"10.1007/s00384-024-04598-8","vorDoiUrl":"https://doi.org/10.1007/s00384-024-04598-8","workflowStages":[]},"version":"v1","identity":"rs-3353222","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3353222","identity":"rs-3353222","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}