Insurance Status and Race Represent Independent Predictors of Undergoing Laparoscopic Surgery for Appendicitis: Secondary Data Analysis of 145,546 Patients Ulrich Guller, MD, MHS, Nitin Jain, MBBS, MSPH, Lesley H Curtis, PhD, Daniel Oertli, MD, FACS, Michael Heberer, MD, MBA, FACS, Ricardo Pietrobon, MD, PhD BACKGROUND: Studies have shown that racial and socioeconomic differences lead to inequality in access to health care. It is unknown whether insurance status and race affect the choice of surgical treatment for patients presenting with appendicitis. STUDY DESIGN: Patients with primary ICD-9 procedure codes for laparoscopic and open appendectomy were selected from the 1998, 1999, and 2000 Nationwide (US) Inpatient Samples. The primary predictor variables were insurance status (private, Medicare, Medicaid, other) and race (Cau- casian, African American, Hispanic, other). Multiple logistic regression models were used to assess whether insurance status and race are associated with the choice of surgical procedure for patients presenting with appendicitis. RESULTS: Discharge abstracts of 145,546 patients were used for our analyses. There were 32,407 patients (22.3%) who underwent laparoscopic appendectomy and 113,139 patients (77.7%) who had open appendectomy. Although 24.2% of privately insured patients underwent laparoscopic appendec- tomy, only 16.9% of Medicare patients, 17.4% of Medicaid patients, and 19.6% of patients in the “other” insurance category were treated using the laparoscopic procedure (p  0.001). Caucasian patients underwent laparoscopic surgery in 24.8%, African Americans in 18.6%, Hispanics in 19.6%, and other ethnicities in 18.8% of patients (p  0.001). Compared with the Medicaid subset, and after adjusting for potential confounders such as age, gender, race, patient comorbidity, median ZIP code income, hospital location and teaching status, and presence of abscess or perforation, privately insured patients (odds ratio [OR] = 1.26, 95% [CI [1.20, 1.33], p  0.001) and Medicare patients (OR = 1.17, 95% CI [1.05, 1.30], p = 0.004) were significantly more likely to undergo laparoscopic surgery. Caucasian patients (OR = 1.42, 95% CI [1.33, 1.51], p  0.001) and Hispanics (OR = 1.12, 95% CI [1.04, 1.20], p = 0.002) were significantly more likely to have laparoscopic appendectomy, compared with African Americans, even after adjusting for the previ- ously mentioned confounders and insurance status. CONCLUSIONS: Even after adjusting for potential confounders, insurance status and race are marked indepen- dent predictors of having laparoscopic surgery in patients treated for appendicitis in this sample. (J Am Coll Surg 2004;199:567–577. © 2004 by the American College of Surgeons) Appendicitis represents one of the most common intra- abdominal conditions requiring emergency operation, with approximately 250,000 cases per year in the US. 1-5 The lifetime risks of appendicitis for women and men are estimated to be 6.7% and 8.6%, respectively. 3 Al- though open appendectomy (OA) was the gold standard for treatment of appendicitis for more than a century, the advent of endoscopic surgery led to the idea of per- forming laparoscopic appendectomy (LA). Although the benefits of LA remain a matter of debate, prospective randomized clinical trials and retrospective chart reviews have provided increasing evidence that LA is advanta- No competing interests declared. The results of this investigation were presented at the American College of Surgeons 89th Clinical Congress, Chicago, IL, October 2003. Dr Guller’s research fellowship at the Duke University Medical Center was supported by the Swiss National Foundation, Bern, Switzerland; Krebsliga beider Basel, Basel, Switzerland; Freiwillige Akademische Gesellschaft, Basel, Switzerland; and Fondazione Gustav e Ruth Jacob, Aranno, Switzerland. Received October 22, 2003; Revised June 18, 2004; Accepted June 23, 2004. From the Department of Surgery, Divisions of General Surgery and Surgical Research, University of Basel/Switzerland (Guller, Oertli, Heberer), and the De- partment of Surgery (Guller), Center for Excellence in Surgical Outcomes (Guller, Jain, Pietrobon), Division of Orthopedic Surgery (Jain, Pietrobon), and Duke Clinical Research Institute (Curtis), Duke University Medical Center, Durham, NC. Correspondence address: Ulrich Guller, MD, MHS, University of Basel, De- partment of Surgery, Divisions of General Surgery and Surgical Research, Spitalstrasse 21, CH-4031 Basel, Switzerland. 567 © 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00 Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2004.06.023