Evaluating a Health Care Disparity Among Marine Recruits Treated for Acute Appendicitis

Abstract

Introduction: One of the most common emergent surgical diseases encountered within the active duty (AD) military population is acute appendicitis, yet the rate of perforation among military members is lower than agematched civilians in the USA. Among all demographics, a delay in presentation to surgical care has been associated with an increase in perforation rates and postoperative complications. A subset of the U.S. military population, the Marine Corps recruits (MCRs), are subjected to a unique and vigorous training environment which may result in delayed medical care. This retrospective study aims to evaluate if there is a delay in presentation and to investigate the surgical outcomes in MCR as compared with AD personnel and military health system beneficiaries with appendicitis. Materials and methods: A retrospective review was conducted on all MCRs, AD military personnel, and military health system beneficiaries between the ages of 17 and 25 who underwent surgical treatment of appendicitis between October 2006 and June 2013 at a single military hospital. Data collected included demographics, time from symptom onset to presentation, clinical and pathologic severity of appendicitis, postoperative complications, and length of stay. The primary outcome was the clinical severity of appendicitis. Secondary outcomes include length of stay and postoperative complications. An analysis of the data was performed using basic statistical methods, to include Fisher's exact, oneway ANOVA, and Kruskal-Wallis. Results: Of the 577 patients that were reviewed, there were 393 (68%) AD military and reserve members, 139 (24%) military health system beneficiaries, and 45 (8%) MCR. The population was 67% male and 68% Caucasian. The mean age was 21.6 years (SD 2.2). The rate of perforated appendicitis was significantly higher among MCR than among AD and beneficiaries (25% vs. 7% vs. 6%, respectively; p < 0.0001). MCR experienced significantly longer hospital lengths of stay (3.1 days vs. 1.7 days, p < 0.0001). Rates of readmission (20% vs. 6% vs. 4%; p = 0.002) and complications (40% vs. 8% vs. 9%; p < 0.0001) were higher among MCR. Among patients with perforated appendicitis (n = 47), MCR had longer delay to presentation for treatment than AD and beneficiaries, but this was not statistically significant (59.4 hours vs. 45.7 hours vs. 35 hours, respectively; p = 0.2). Conclusion: This retrospective review identifies that MCRs have a higher incidence of perforated appendicitis as compared with AD members and military health system beneficiaries. This distinguishes a unique health care disparity found within MCR which military health care providers must recognize. Identification of potential social factors, education of military health care providers, and earlier surgical evaluation may lead to improved outcomes.