Equal access; equal outcomes? The Impact of Rural Living and Prehospital Factors on the Severity and Outcomes of Paediatric Appendicitis in New Zealand.

Abstract

Aim: The aim of this project was to explore the outcomes and severity of paediatric appendicitis in New Zealand with a focus on prehospital and population-level factors. Methods: A 10-year retrospective study analysed paediatric appendicitis outcomes in Northland, New Zealand. Rural families in Northland were then invited to participate in a qualitative exploration of their experiences accessing acute surgical care for their child with appendicitis. An exploratory framework was created using grounded theory. Finally, a nationwide prospective cohort study was undertaken, implementing the prehospital factors identified by the preliminary work. A broad clinical dataset was supplemented by a parental prehospital questionnaire and a consultant surgeon survey. Findings: In Northland, multivariate analysis of 470 children with acute appendicitis demonstrated that increased AAST grade of anatomical severity was twice as likely in rural patients (OR 2.04; 95% CI 1.46–2.84; p<0.0001). Data from the semi-structured interviews of 11 rural Northland families suggested that prehospital delay was commonly a result of a protracted decision-making phase where families performed a dynamic assessment of the cost and benefits of accessing healthcare. Several notable healthcare barriers existed, such as poor cultural safety, maldistribution of services, and contradictory public health messages. Nationally, 182 children with confirmed appendicitis were prospectively recruited across 14 participating hospitals. The odds of rural and Māori children having an increased AAST grade of appendicitis was 4.33 (95% CI 2.04-9.21; p<0.0001) and 2.40 (95% CI 1.15-5.02; p=0.019) times that of urban and NZ European children respectively. Every hour of increased prehospital time was associated with 1.5% increased odds of a higher AAST grade. Māori families had a higher median prehospital delay, more commonly reported unfamiliarity with appendicitis and had a lower median annual household income. Rural children had higher rates of appendicolith and increased median inflammatory markers despite a lack of prehospital delay. The overall negative appendicectomy rate was 13%, and preoperative imaging was only utilised in 26% of cases. Surgeons reported inconsistent and lacking guidelines regarding the management of paediatric appendicitis. Conclusions: Inequities exist in the outcomes of paediatric appendicitis in New Zealand. Increased severity of paediatric appendicitis is independently associated with rural patient status and Māori ethnicity. Rural children may have a differing pathologic phenotype of appendicitis. However, in Māori, this is likely a result of differential access to key determinants of health. Despite a superficial focus on equity, accessing healthcare is frequently financially damaging and unpleasant for Māori. Finally, the management of paediatric appendicitis nationally is heterogeneous and standardised national guidelines are desperately needed.