To the best of our knowledge, this study is the first to evaluate the emergency department management, in-hospital outcomes, and in-hospital expenditure experiencedby acute appendicitis patients with or without severe mental illness. This real-world database study found no significant difference in appendiceal perforation rate between the SMI and non-SMI patients with acute appendicitis. ED management, in-hospital outcome, and in-hospital expenditure also showed no significant differences between these two groups.
Previous studies have found a higher appendiceal perforation rateamongvulnerable groups, including elderly, racial minority, immigrant, poor socioeconomic, and insurance statuspopulations, in comparison to the other groups (14, 22-24). This correlation was also demonstrated in the case of psychiatric patients andconsidered to be an instance of medical disparity. Using the Taiwan national insurance health data of1997 to 2001,Tsay et al. published an article in 2007 provingthat SMI patientshave a 2.83 times higher risk of appendiceal perforation than non-SMI patients with acute appendicitis(13, 25, 26). However, we found no significant difference in appendiceal perforationrate between the SMI and non-SMI groups in this study. The evolution of medical treatment may explain this improvement. The increased utility of diagnostic modalities, including CT scans of acute appendicitis in the past few years, eliminates the medical gap in SMI patients (27, 28). Besides, the national health insurance in Taiwan has shown a positive influence in narrowing down the financial gap and improving the outcomesprovided to vulnerable groups (29). The advantage ofa near 100%population coverage rate with comprehensive expenditure coverage may alleviate the obstacles ofmedical accessibility faced by patients with SMI (30, 31).
Previous studies adopted analgesic prescription rate as an indicator to evaluate treatment disparity and proved the existence of a lower prescription rate amongfemale and racial minoritiesduring acute pain management (32-34).We found no obvious differences in analgesic prescription ratesbetweenthe SMI and non-SMI groups.However,a trend of lower opioid analgesics prescription ratewas noticedamong SMI patients.Several randomized trials have demonstrated that opioid analgesic is safe and efficient in treating acute appendicitis patients (35, 36). Further, a previous study found a lower opioid prescription rate also among black paediatric children with acute appendicitis in the United States and considered this phenomenon asthat of treatment inequity(37). Although our study found no statistical significance amongthe two groups, the trend of lower opioid administration in SMI patients still needs further investigation. The waiting time for medical evaluation and treatment is also important to evaluate the potential disparities in ED. Previous studies have foundthat patients with mental illness experience a longer waiting time to see a physician in ED(38). To understand the medical management in ED more comprehensively, we analysedtime from triage to first order, time from triage to first antibioticsadministration, time from triage to receiving CT scan, and time from triage to surgical consultation in ED. None of the above variables showed differences between the SMI and non-SMI groups.
Our study aligns with the prior research that proved SMI patients to have a higher prevalence of several physical comorbidities, including cardiovascular disease, cerebrovascular disease, pulmonary disease, liver disease, DM, and renal disease(39). Although SMI patients with acute appendicitis have a higher prevalence of comorbidities than the general population, we found no obvious differences in admission day, ICU admission, in-hospital mortality, and in-hospital expenditure between the two groups.This may be because acute appendicitis is a relatively benign disease with extremely low postoperative major adverse effects and mortality rate. Even in patients with multiple comorbidities, the current management can treat effectively without excessive cost (40).
We founda higher rate of unscheduled 72-hour ED revisits prior to the diagnosis of acute appendicitis in the SMI group. This may be because of the following reasons. First, SMI patients have a higher emergency medical resource usage in the case of psychiatric or physical illness (41). Second, the higher unscheduled 72-hour ED revisits rate may associate with misdiagnosis for prior ED visits. The possible risk factors include lower pain perception,poorer communication of SMI patients, and diagnostic overshadowingof health providers (42). Diagnostic overshadowing, the misattribution of physical symptoms to mental illness, was proved toexist among ED health providers(43). Thesuperimposition of thisstigmatizing attitude by the cognitive impairment and excess negative symptoms of SMI patients may make it difficultto have a timely diagnosis (44). ED health providers have to be more cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints, and multidisciplinary evaluation may benefit these vulnerablegroups (45).