Abstract
Importance
Safety-net hospitals serve vulnerable populations with limited resources. Although complex, elective operations performed at safety-net hospitals have been associated with inferior outcomes and higher costs, it is unclear whether a similar association has been seen with common emergency general surgery performed at safety-net hospitals.
Objective
To evaluate the association of safety-net burden with the outcomes of appendectomy.
Design, Setting, and Participants
A retrospective review was conducted of all nonfederally funded hospitals in the California state inpatient database that performed appendectomies from January 1, 2005, to December 31, 2011. A total of 349 hospitals performing 274 405 nonincidental appendectomies were stratified based on safety-net burden; low-burden hospitals had the lowest quartile of patients who either had Medicaid or were uninsured (0%-14%), medium-burden hospitals had the middle 2 quartiles (15%-41%), and high-burden hospitals had the highest quartile (>42%). Data analysis was performed from August 27 to September 8, 2016.
Main Outcomes and Measures
Rates of laparoscopy, perforation, negative appendectomy, morbidity, length of stay, and cost.
Results
Among the 349 hospitals in the study, high-burden hospitals treated a larger proportion of black patients than did medium- and low-burden hospitals (4.5% vs 2.4% vs 2.9%; P = .01), as well as Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and patients with perforated appendicitis (27.6% vs 23.6% vs 23.6%; P = .005). High-burden hospitals were less likely than medium- or low-burden hospitals to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). There were no differences in morbidity, length of stay, or cost. Multivariable regression analysis confirmed that high-burden hospitals were more likely than low-burden hospitals to treat perforated appendicitis (log %, 0.07; 95% CI, 0.03-0.12; P = .04) and less likely to use laparoscopy (–16.9% difference; 95% CI, –26.1% to –7.6%; P < .001), while achieving similar complication rates. Multivariable analysis also confirmed that high-burden hospitals have similar costs, despite being associated with longer length of stay (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001).
Conclusions and Relevance
Safety-net hospitals treat a disproportionate number of patients with advanced appendicitis while falling behind in the use of laparoscopy. Nonetheless, safety-net hospitals treat this common surgical emergency with morbidity and cost similar to that seen at other hospitals. Additional research is needed to evaluate how these outcomes are achieved to improve all surgical outcomes at underresourced hospitals.
This database review evaluates the association of safety-net hospital burden with the outcomes of appendectomy.
Key Points
Question
Do safety-net hospitals have poorer outcomes and higher costs associated with common, urgent general surgical procedures such as appendectomy?
Findings
In this database review, safety-net hospitals had lower rates of laparoscopy vs non–safety-net hospitals. Safety-net hospitals had higher rates of perforated appendicitis, yet maintained similar rates of negative appendectomy and postoperative morbidity; safety-net hospitals also had longer lengths of stay, but no difference in overall cost.
Meaning
Safety-net hospitals may be well equipped to perform common, urgent general surgical procedures such as appendectomy.
Introduction
Disparities in health have been linked to various social factors including age, sex, race/ethnicity, geography, and wealth. According to the most recent CDC Health Disparities and Inequalities Report in 2013, significant gaps persist as people of “low socioeconomic status were more likely to be affected by diabetes, hypertension, and human immunodeficiency virus (HIV) infection”(p184) and were “less likely to be screened for colorectal cancer and vaccinated against influenza.”(p184) Safety-net hospitals care for a disproportionate share of this disadvantaged population including minorities, the impoverished, and the uninsured, a demographic that is an unreliable payment source. At the same time, safety-net hospitals are often tasked by their state and local governments with providing unprofitable health care services. These factors contribute to financial limitations that affect the care they provide, raising questions about quality and patient outcomes at safety-net hospitals.
Safety-net hospitals have been associated with poor outcomes and increased costs and consistently score poorly on patient-centered service measures such as timeliness and patient satisfaction. Some studies have suggested that safety-net hospitals have higher readmission rates and mortality following admission for myocardial infarction, heart failure, and pneumonia. Recent studies examining the association of safety-net burden with surgical outcomes have been mixed. Safety-net hospitals had similar mortality rates with vascular operations for carotid stenosis and abdominal aortic aneurysm repair, but safety-net burden had no association with morbidity and mortality following ablative procedures for oropharyngeal neoplasms. Other studies have suggested the opposite. Safety-net burden was associated with increased morbidity and mortality following certain abdominal, urologic, and orthopedic procedures. In addition to these safety concerns, multiple studies found that safety-net hospitals incur higher costs with surgery when compared with non–safety-net hospitals.
There is growing evidence regarding inferior surgical outcomes at safety-net hospitals, especially with complicated, elective operations. The findings of Go et al highlight the inferior outcomes and higher costs by evaluating pancreaticoduodenectomy performed at safety-net hospitals. However, there are very little data regarding the outcomes of common, urgent general surgical procedures. Therefore, it was our aim to evaluate the association of safety-net burden with outcomes and costs of appendectomy. Our hypothesis was that patients undergoing appendectomy at safety-net hospitals present with advanced disease, have limited access to advanced technology, have inferior outcomes, and incur higher costs.
Methods
Data Source
We used the California state inpatient database from the Healthcare Cost and Utilization Project, which includes all inpatient discharges from nongovernmental hospitals in the state. It provides discharge data such as patient demographics, insurance status, discharge diagnoses, procedures performed, length of stay (LOS), and total charges. Cost was adjusted for inflation to 2010 dollars using the cost to charge ratio files provided by the Healthcare Cost and Utilization Project and the published medical consumer price index. The California hospital annual utilization data were used to determine hospital characteristics, such as teaching hospital status and ownership type (public or private). This study was exempted from institutional review board approval at Los Angeles Biomedical Institute at Harbor–University of California Los Angeles; therefore, patient consent was not required.
Population
We identified all inpatient discharges in the California state inpatient database from January 1, 2005, to December 31, 2011, with a nonincidental appendectomy listed as the primary procedure, using International Classification of Diseases, Ninth Revision (ICD-9) codes 47.0 (appendectomy), 47.01 (laparoscopic appendectomy), and 47.09 (other appendectomy). We excluded patients older than 70 years owing to concerns that age-related confounders may affect cost and comorbidity rates. All hospitals that performed an appendectomy were then stratified based on their safety-net burden. A hospital’s safety-net burden was defined as the percentage of patients treated who were either uninsured or had Medicaid. These hospitals were then grouped into 3 different cohorts, with low-burden hospitals (LBHs) having cared for the lowest quartile of patients who had Medicaid or were uninsured (<14%), medium-burden hospitals (MBHs) having cared for the middle 2 quartiles of such patients (15%-41%), and high-burden hospitals (HBHs) having cared for the highest quartile of such patients (>42%).
Outcomes
Primary outcomes included diagnosis or type of nonincidental appendectomy, use of laparoscopy, complications, LOS, and cost. Every nonincidental appendectomy was categorized into 1 of the following 3 types: negative appendectomy, appendectomy performed for nonperforated appendicitis, and appendectomy performed for perforated appendicitis. A negative appendectomy was defined as a nonincidental appendectomy without a diagnosis of appendicitis. Appendectomies in which a diagnosis of appendicitis was not among the first 3 diagnoses were also considered negative appendectomies given the possibility that suspected appendicitis at presentation is coded as a nonprimary appendicitis even without eventual confirmation of the diagnosis. Nonperforated appendicitis was identified with ICD-9 codes 540.9 (acute appendicitis without mention of peritonitis), 541 (appendicitis, unqualified), and 542 (other appendicitis). Perforated appendicitis was identified with ICD-9 code 540.0 (acute appendicitis with generalized peritonitis) or 540.1 (acute appendicitis with peritoneal abscess). We also investigated common complications associated with appendectomy including infectious complications, intestinal complications, and other miscellaneous complications using appropriate ICD-9 codes. Other miscellaneous complications included renal failure, postoperative respiratory complications (ie, atelectasis, pneumonia, pneumothorax, or acute respiratory insufficiency), and postoperative cardiovascular complications (ie, deep vein thrombosis, pulmonary embolus, postoperative stroke, or cardiac arrest).
Statistical Analysis
Statistical analysis was performed from August 27 to September 8, 2016. Bivariate and multivariate analyses were performed on the 3 cohorts of hospitals stratified by safety-net burden. Negative binomial regression was performed on LOS to account for overdispersion present in the data. To account for the significant right skew, rates of negative appendectomy, nonperforated appendicitis, and perforated appendicitis were log transformed, giving the data a more normal distribution. Total mean cost was also log transformed for the same reason. The distribution of laparoscopy rates appeared normally distributed, so they were not transformed for regression analysis. All multivariate analyses were clustered by each hospital’s respective Federal Information Processing Standard county code. Covariates included in the study were age, sex, race/ethnicity, insurance type, hospital ownership (public or private), teaching hospital status, and hospital volume (number of appendectomies performed per year). All data analysis was conducted using Stata, version 14.1, software (StataCorp). P < .05 was considered significant.
Results
We identified 274 405 nonincidental appendectomies performed at 349 hospitals (73 LBHs, 178 MBHs, and 98 HBHs).
As seen in Table 1, HBHs by design had higher rates of patients with Medicaid than did MBHs and LBHs (42.2% vs 21.1% vs 5.5%; P < .001) and uninsured patients (14.0% vs 10.7% vs 5.6%; P < .001), as well as the lowest rate of patients with private insurance (28.7% vs 56.5% vs 80.9%; P < .001). High-burden hospitals were more likely than MBHs and LBHs to have Hispanic patients (64.8% vs 27.0% vs 22.0%; P < .001) and black patients (4.5% vs 2.4% vs 2.9%; P = .01). High-burden hospitals had the lowest percentage of female patients compared with MBHs and LBHs (35.0% vs 37.5% vs 39.7%; P = .02) and were less likely to use laparoscopy (51.6% vs 60.7% vs 71.9%; P < .001). High-burden hospitals had the highest rate of perforated appendicitis compared with MBHs and LBHs (27.6% vs 23.6% vs 23.6%; P = .005). However, there was no difference in morbidity rates or in rates of negative appendectomy. High-burden hospitals also had similar LOS and overall costs compared with MBHs and LBHs. High-burden hospitals were more likely to be teaching hospitals 14.3% of HBHs were teaching hospitals, compared with 5.1% of MBHs and 2.7% of LBHs (P = .004).
Table 1. Descriptive Characteristics and Outcomes.
| Characteristic | Patients, Mean % (SD) | P Value | ||
|---|---|---|---|---|
| Low-Burden Hospitals (n = 73) |
Medium-Burden Hospitals (n = 178) |
High-Burden Hospitals (n = 98) |
||
| Patients | ||||
| Age, y | ||||
| 0-4 | 0.5 (0.9) | 0.8 (1.6) | 2.0 (3.0) | <.001 |
| 5-9 | 6.0 (5.2) | 9.1 (8.5) | 13.0 (10.0) | <.001 |
| 10-19 | 11.9 (8.5) | 16.2 (9.7) | 22.3 (11.2) | <.001 |
| 20-29 | 20.8 (12.1) | 24.0 (9.9) | 24.5 (9.9) | .045 |
| 30-39 | 17.9 (11.6) | 15.8 (6.4) | 15.6 (7.6) | .13 |
| 40-49 | 18.4 (8.4) | 16.2 (7.1) | 11.9 (6.7) | <.001 |
| 50-59 | 14.3 (12.0) | 11.1 (5.6) | 6.8 (5.2) | <.001 |
| 60-69 | 10.1 (15.6) | 6.7 (4.0) | 3.8 (3.8) | <.001 |
| Race/ethnicity | ||||
| White | 65.8 (26.6) | 64.5 (26.3) | 25.4 (25.7) | <.001 |
| Black | 2.9 (26.6) | 2.4 (4.0) | 4.5 (8.3) | .01 |
| Hispanic | 22.0 (21.8) | 27.0 (22.6) | 64.8 (25.9) | <.001 |
| Other | 2.8 (4.9) | 6.9 (9.2) | 11.9 (14.1) | <.001 |
| Female sex | 39.7 (15.2) | 37.5 (9.2) | 35.0 (7.1) | .02 |
| Insurance | ||||
| Medicaid | 5.5 (5.8) | 21.1 (10.8) | 42.2 (15.7) | <.001 |
| Uninsured | 5.6 (5.2) | 10.7 (7.0) | 14.0 (10.1) | <.001 |
| Private | 80.9 (16.4) | 56.5 (15.9) | 28.7 (16.0) | <.001 |
| Laparoscopy | 71.9 (24.6) | 60.7 (27.6) | 51.6 (30.1) | <.001 |
| Nonperforated appendicitis, acute | 72.9 (16.0) | 72.1 (10.7) | 68.4 (10.4) | .048 |
| Perforated appendicitis | 23.6 (16.2) | 23.6 (9.5) | 27.6 (8.6] | .005 |
| Negative appendectomy | 3.6 (4.1) | 4.3 (6.2) | 4.0 (10.3) | .77 |
| Complications | 5.7 (11.5) | 5.0 (3.9) | 4.5 (3.1) | .44 |
| Infectious | 3.9 (11.5) | 3.2 (3.2) | 2.7 (2.5) | .39 |
| Gastrointestinal | 1.1 (1.1) | 1.0 (1.4) | 1.2 (1.1) | .42 |
| Other | 1.1 (1.2) | 1.2 (1.0) | 1.0 (1.2) | .51 |
| Length of stay, mean (SD), d | 3.3 (6.5) | 2.6 (1.0) | 2.9 (0.8) | .21 |
| Cost, mean (SD), $ | 12 205 (9933) | 11 077 (5466) | 12 786 (27 287) | .69 |
| Hospital | ||||
| Teaching hospital, % | 2.7 | 5.1 | 14.3 | .004 |
Multivariate analysis (Table 2) confirmed that HBHs were the least likely to use laparoscopy compared with LBHs (–16.9% difference; 95% CI, –26.1% to –7.6%; P < .001). It also confirmed that HBHs have higher rates of perforated appendectomies (log %, 0.07; 95% CI, 0.03-0.12; P = .04), with no difference in rates of negative appendectomy and postoperative morbidity. Multivariate analysis did show that HBHs have longer LOS (relative risk, 1.17; 95% CI, 1.09-1.26; P < .001) but no difference in overall cost.
Table 2. Multivariate Regression Analysis of Safety-Net Burden on Outcomes.
| Patient Characteristics | Laparoscopy, % Difference (95% CI) |
Complications, Log % (95% CI) |
Negative Appendectomy, Log % (95% CI) |
Perforated Appendicitis, Log % (95% CI) |
LOS, Relative Risk (95% CI) |
Cost, Log $ (95% CI) |
|---|---|---|---|---|---|---|
| Safety-net burden | ||||||
| Low-burden | 1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
| Medium-burden | −10.2 (−16.9 to −3.5)a |
−0.06 (−0.21 to 0.09) |
0.08 (−0.06 to 0.22) |
0.04 (−0.00 to 0.08) |
1.12 (1.07 to 1.18)a |
0.05 (−0.03 to 0.13) |
| High-burden | −16.9 (−26.1 to −7.6)a |
−0.19 (−0.38 to 0.01) |
−0.01 (−0.19 to 0.16) |
0.07 (0.03 to 0.12)b |
1.17 (1.09 to 1.26)a |
−0.02 (−0.11 to 0.07) |
| NPNA | −0.55 (−50.2 to 49.1) |
−0.76 (−1.85 to 0.32) |
−5.71 (−6.54 to −4.87)b |
−2.23 (−2.38 to −2.09)b | 0.16 (0.09 to 0.28)b |
−1.40 (−1.87 to −0.92)b |
| Log negative appendectomy | 6.6 (1.3 to 11.9)b |
0.05 (−0.06 to 0.16) |
NA | −0.15 (−0.18 to −0.13)b |
0.93 (0.90 to 0.96)b |
−0.05 (−0.11 to −0.01)b |
| Log perforation | 0.8 (−18.9 to 20.5) |
0.30 (−0.12 to 0.73) |
−2.10 (−2.43 to −1.77)b |
NA | 0.69 (0.56 to 0.84)b |
−0.31 (−0.50 to −0.12) |
| Log complication | −2.4 (−7.5 to 2.7) |
NA | 0.06 (−0.05 to 0.16) |
0.02 (−0.01 to 0.05) |
1.09 (1.04 to 1.13)b |
0.12 (0.07 to 0.17)b |
| % Teaching hospital | 9.7 (−0.6 to 19.9) |
0.04 (−0.18 to 0.26) |
−0.06 (−0.27 to 0.16) |
0.03 (−0.03 to 0.08) |
1.08 (1.03 to 1.14)b |
0.09 (−0.01 to 0.19) |
| % Laparoscopic | 0.2 (−0.3 to 0.8) |
.001 (−0.004 to 0.001) |
0.003 (0.001 to 0.005)b |
0.00 (−0.00 to 0.00) |
0.998 (0.997 to 0.999)b |
0.002 (0.001 to 0.002)b |
| % Female | 0.25 (−0.27 to 0.76) |
0.70 (−0.43 to 1.80) |
1.4 (0.38 to 2.52)b |
−0.6 (−1.00 to −0.40)b |
NA | NA |
| % White | 0.07 (−0.05 to 0.19) |
0.00 (−0.002 to 0.002) |
0.22 (−0.02 to 0.46) |
−0.00 (−0.01 to 0.00) |
NA | NA |
| Hospital Characteristics | ||||||
| Annual appendectomy volume, No. | ||||||
| 1-230 | 1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
| 231-573 | 3.3 (−4.7 to 11.2) |
−0.16 (−0.33 to 0.01) |
0.04 (−0.12 to 0.21) |
0.03 (−0.01 to 0.07) |
1.03 (0.97 to 1.10) |
−0.07 (−0.15 to 0.01) |
| 574-1217 | 8.5 (−0.2 to 17.1) |
−0.25 (−0.43 to −0.07)b |
0.04 (−0.13 to 0.21) |
0.04 (−0.01 to 0.09) |
1.01 (0.93 to 1.10) |
−0.11 (−0.19 to −0.03)b |
| >1217 | 11.1 (1.7 to 20.5)b |
−0.33 (−0.52 to −0.13)b |
0.12 (−0.06 to 0.30) |
0.06 (0.01 to 0.11)b |
1.04 (0.99 to 1.10) |
−0.11 (−0.19 to −0.02)b |
| Hospital type | ||||||
| Private nonprofit | 1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
1 [Reference] |
| Public | −0.59 (−8.1 to 6.9) |
−0.01 (−0.17 to 0.14) |
−0.07 (−0.22 to 0.09) |
−0.04 (−0.08 to −0.00)b |
0.98 (0.91 to 1.06) |
0.06 (−0.02 to 0.12) |
| Private for-profit | −3.5 (−10.5 to 3.5) |
−0.22 (−0.37 to −0.08)b |
−0.01 (−0.16 to 0.13) |
0.01 (−0.02 to 0.05) |
1.04 (0.97 to 1.11) |
0.05 (−0.02 to 0.11) |
Abbreviations: LOS, length of stay; NA, not applicable; NPNA, normal, nonperforated appendectomy. aP < .01. bP < .05.
Discussion
High-burden hospitals exceeded expectations and performed favorably in treating patients with appendicitis. Although they cared for a sicker patient population with higher rates of perforated appendicitis, HBHs did not have higher morbidity. High-burden hospitals also had similar rates of misdiagnosis and negative appendectomy as MHBs and LBHs, despite prior reports that negative appendectomy is more common in minorities and the publicly insured, who comprise a large segment of the HBH patient population. High-burden hospitals did have a longer mean LOS but were able to maintain similar costs. The results of our study indicate that safety-net hospitals performing appendectomy treat more patients with advanced disease but achieve similar outcomes without incurring higher costs.
High-burden hospitals had the largest share of teaching hospitals, at 14.3% vs 5.1% in MBHs and 2.7% in LBHs. Given the responsibility of training future surgeons, teaching hospitals had higher rates of laparoscopy compared with nonteaching hospitals (68.0% vs 59.9%). However, teaching hospitals were a relative minority among HBHs. The low rate of laparoscopy at nonteaching HBHs is indicative of the limited resources and financial constraints faced by most safety-net hospitals. They brought down overall rates of laparoscopy within HBHs, leading to a wide distribution of laparoscopy rates among HBHs. In our multivariate model (Table 2), we showed that safety-net burden and hospital annual appendectomy volume were associated with rates of laparoscopy, while rates of perforated appendicitis and postoperative complications were not. Even though HBHs had a longer mean LOS, they were likely able to maintain similar costs owing to their lower rates of laparoscopy.
Our findings contradict those of Go et al, who found that pancreaticoduodenectomy performed at safety-net hospitals is associated with increased morbidity, mortality, and cost. The discrepancy is likely due to the difference in the complexity of the operations. Although an appendectomy is a short, simple procedure removing a small appendage off the colon, pancreaticoduodenectomy is a very long, complicated operation requiring multiple anastomoses with numerous potential complications, often requiring prolonged hospitalizations. Another study that examined 9 different elective thoracic, orthopedic, and abdominal operations found that safety-net hospitals had higher mortality rates, with 3 of the 9 procedures examined (ventral hernia repair, colectomy, and pancreaticoduodenectomy), while incurring higher costs with 7 of the 9 operations (ventral hernia repair, colectomy, pancreaticoduodenectomy, esophagectomy, hip replacement, knee replacement, and pulmonary lobectomy). Other studies found that patients undergoing knee and hip arthroplasties at safety-net hospitals had higher early morbidity, while those undergoing nephrectomy and transurethral resection of the prostate had higher mortality. Most operations that resulted in inferior outcomes at safety-net hospitals were more technically challenging elective procedures requiring subspecialty-trained surgeons. Moreover, procedures such as esophagectomy, pancreaticoduodenectomy, and pulmonary lobectomy require prolonged hospitalizations with multidisciplinary postoperative management by surgeons, intensivists, physical therapists, and nutritionists. This type of complex surgical care may be better suited for hospitals without the limitations of a safety-net hospital.
Shahan et al examined the outcomes of urgent, general surgical procedures performed at safety-net hospitals. They included appendectomies as well as cholecystectomy and herniorrhaphy, and their criteria for a safety-net hospital was more exclusive than ours, including only 10% of hospitals treating the highest percentage of uninsured patients. They found that these hospitals had higher complication rates with appendectomy, cholecystectomy, and herniorrhaphy. This discrepancy in complication rates may be owing to the more exclusive classification of a safety-net hospital including only those within the top decile of safety-net burden as opposed to the top quarter. It may also be explained by the inclusion of 2 procedures (cholecystectomy and herniorrhaphy) that have a broader range of severity with many more possible outcomes and complications. However, similar to our findings, they found that safety-net hospitals had similar rates of mortality and failure to rescue without increased costs.
Limitations
The main limitation of our study was that we relied primarily on secondary claims data for the analyses. The accuracy and completeness of each diagnosis (ie, nonperforated appendicitis, perforated appendicitis, or negative appendectomy) and complication were based solely on the billing codes entered in the appropriate fields of the database. We did not have access to ancillary data including laboratory values and imaging results to confirm diagnosis. Given the fact that wait times prior to surgery have been shown to be longer for uninsured, publicly insured, and minority patients, we were also interested in comparing time to surgery at safety-net hospitals. We were able to see that approximately 98% of patients at LBHs (57930 of 58718 [98.7%]), MBHs (126537 of 128615 [98.4%]), and HBHs (77802 of 79547 [97.8%]) had surgery on the day of admission or the day after admission. However, because the database does not provide time to surgery in a more precise unit of measure, we were not able to comment on this likely disparity at safety-net hospitals.
Safety-net hospitals are providers of health care of last resort, and they play a vital role in the nation’s health care system by serving low-income, uninsured, and socially disadvantaged patients. Safety-net hospitals also face increasing financial challenges and have fewer resources to provide care for this medically vulnerable population. Because of the poor outcomes with highly complex surgical procedures, Go et al suggested redistributing these cases to hospitals with a low safety-net burden to improve clinical outcomes. This option may be feasible for patients with pancreatic cancer. However, it would be impossible to redistribute patients with a surgical problem as ubiquitous as appendicitis. Our results suggest that this solution may be unnecessary for simple, common, urgent surgical procedures such as appendectomy because safety-net hospitals can safely perform this procedure without incurring higher costs. Although safety-net hospitals may not have the resources to manage highly complex, elective surgical procedures such as pancreaticoduodenectomy, transplants, and joint replacements, they appear to be well equipped to manage common, urgent surgical procedures. The next step will be to understand how safety-net hospitals are able to achieve these outcomes so that these lessons can be applied to other surgical procedures.
Conclusions
Our data show that safety-net hospitals achieved good patient outcomes after appendectomy without incurring higher costs. Although safety-net hospitals may have higher morbidity, mortality, and costs with complex, elective surgical procedures, they may be well equipped to perform common, general surgical procedures such as appendectomy. Redistributing patients with complex surgical problems to mitigate costs may not be necessary for patients with common, urgent, general surgical conditions such as appendicitis.
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