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Correspondence |

Proportion of Cases of Perforated Appendicitis: A Bad Measure of Quality of Care

Roland Erik Andersson, MD, PhD
Arch Surg. 2011;146(7):885-886. doi:10.1001/archsurg.2011.168.
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In their analysis of the quality of the health care system in US counties, Camp et al1 analyzed the proportion of cases of perforated appendicitis in children as a measure of the quality of surgical care and found that counties with the highest density of pediatricians had the lowest proportion of perforations. No association was found for other providers or health care facility factors.

Camp et al1 assume that a high proportion of perforations is an indication of the low quality of the health care system. However, this may be very misleading. The proportion of cases of perforated appendicitis is positively related to the number of perforations and inversely related to the number of cases of nonperforated appendicitis. There is now clear evidence that perforation can rarely be prevented and that spontaneous resolution of nonperforated appendicitis is common.2 Variations in the proportion of perforations is therefore mainly determined by variations in the incidence rate of nonperforated appendicitis, whereas the incidence rate of perforated appendicitis is stable over different health care systems.3 An increase in the use of health care and diagnostic techniques can explain the recent report of an increasing incidence rate of nonperforated appendicitis in the United States.4,5 A low proportion of perforations is therefore most probably an indication of a higher consumption of health care leading to more operations for mild appendicitis that would otherwise resolve. The proportion of perforations is therefore a bad measure of the quality of care. I would advice future investigators of this issue to use population-based data and analyze the results as incidence rates.

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July 1, 2011
Fizan Abdullah, MD, PhD; Dominic Papandria, MD; Melissa Camp, MD, MPH
Arch Surg. 2011;146(7):885-886. doi:10.1001/archsurg.2011.169.
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