Evaluation of disparity in care for perforated appendicitis in a universal healthcare system

  • Laura M. Fluke
  • Christian S. McEvoy
  • Anne H. Peruski
  • Christina A. Shibley
  • Brian T. Adams
  • Samuel E. Stinnette
  • Robert L. RiccaEmail author
Original Article



Racial and socioeconomic disparities have been reported in the management of appendicitis. Perforated appendicitis (PA) is used as an index for barriers to care due to delays in treatment. This study evaluates the effect of racial and socioeconomic differences on the likelihood of PA in a universally insured national healthcare system.


A retrospective review of pediatric patients enrolled in TRICARE who underwent appendectomy during a 5-year period was performed. Logistic regression was used to examine the association between ethnicity, age, gender, parent, or guardian marital status and deployment status of the active duty parent, type of facility, and type of admission with the odds of perforated appendicitis.


A total of 3124 children met inclusion criteria. One-third of children carried the diagnosis of PA. Increased odds of PA was associated with younger age of patient among children of military personnel with enlisted ranks and senior officer ranks.


In a universal healthcare system, no disparities across race with regard to presentation of appendicitis were identified. Increased odds of perforated appendicitis were observed in younger patients, but this was demonstrated in families of both high and low socioeconomic status. Universal coverage does appear to eliminate some barriers to healthcare.


Pediatric appendicitis Socioeconomic disparity Access to care Universal healthcare coverage 


Author contributions

Primary author LMF contributed to literature search, IRB protocol writing, data interpretation, and writing. AHP, CAS, BTA, CSM, and SES contributed to study design and data collection and analysis. CSM and RLR, as the senior author, contributed with study design, data interpretation, and critical review.


This study required no specific funding.

Compliance with ethical standards

Conflict of interest

Laura Fluke declares that she has no conflict of interest. Christian McEvoy declares that he has no conflict of interest. Anne Peruski declares that she has no conflict of interest. Christina Shibley declares that she has no conflict of interest. Brian Adams declares that he has no conflict of interest. Samuel Stinnette declares that he has no conflict of interest. Robert Ricca declares that he has no conflict of interest.

Ethical approval

This study is a retrospective review and does not contain any procedures or studies with human participants performed by any of the authors.

Informed consent

This was a retrospective database review. Informed consent was not required.


The authors of this study have no financial disclosures to report. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, The United States Navy, United States Air Force, or the United States Government. Research data derived from an approved Naval Medical Center, Portsmouth, VA IRB protocol. I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • Laura M. Fluke
    • 1
    • 2
  • Christian S. McEvoy
    • 1
    • 2
    • 3
  • Anne H. Peruski
    • 3
  • Christina A. Shibley
    • 3
  • Brian T. Adams
    • 3
  • Samuel E. Stinnette
    • 3
  • Robert L. Ricca
    • 1
    • 2
    Email author
  1. 1.Department of Pediatric SurgeryNaval Medical Center PortsmouthPortsmouthUSA
  2. 2.Uniformed Services University of the Health SciencesBethesdaUSA
  3. 3.Health Analysis DepartmentNavy and Marine Corps Public Health CenterPortsmouthUSA

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