Secondary Effects of the COVID 19 Pandemic –did Delayed Acute Appendicitis Diagnosis and Treatment Occur? - An Accountable Care Organization Pediatric Population Study

Background: The effect of the COVID 19 pandemic and public shutdowns remains to be fully elucidated, particularly in the pediatric population. Clinically, and in the literature, urgent and emergent disease processes that typically have a stable yearly incidence, were thought to have declined during the height of the pandemic. One such disease, acute appendicitis, has been studied both in the US and abroad with varying results. There appears to be a trend toward higher rates of complicated appendicitis and overall decrease of acute appendicitis presentations to healthcare centers during the pandemic. We set out to determine if these trends hold true in a large pediatric population.

Methods: The Partners For Kids database, an accountable care organization database that comprises approximately 325,000 unique children annually, was queried for cases of acute appendicitis, including complicated, uncomplicated, and unspecified from April 1st – August 31st 2017-2020. The overall monthly rate/100,000 covered lives in the PFK database from April-August was calculated each year and compared for overall acute appendicitis diagnosis. The rate of complicated and uncomplicated appendicitis/100 cases of appendicitis were calculated from April-August for each year and compared as well. P-values < 0.05 were considered significant.

Results: The overall monthly rate of acute appendicitis/100,000 covered lives in the PFK database was significantly lower in 2020 compared to 2017 and 2018, but not compared to 2019 (2.0% in 2020 vs 3.2% 2017 and 2018, 2.8% 2019, p <0.01, Figure 1). The rate of complicated appendicitis cases showed a decline over the study time period, with both 2019 and 2020 significantly lower than 2018 and 2017 (55.8% 2017, 53.7% 2018, 23.9% 2019, 20.6% 2020, p <0.01). The rate of uncomplicated appendicitis was significantly higher in 2020 compared to 2017, but otherwise the rates between years were not significant (46.3% 2017 and 2018, 71.4% 2019, 79.4% 2020, p = 0.02). See Figure 2.

Conclusion: The results of this study using an accountable care organization database indicate that 2020 was not an outlier with regard to overall presentation of acute appendicitis, nor delayed presentation as indicated by complicated appendicitis rates in the pediatric population. Looking beyond the immediately preceding year to the pandemic demonstrates that overall rates of appendicitis had been declining and reached significance in 2020 compared to two and three years prior to the pandemic but not 2019. Rates of complicated appendicitis underwent a large decline one year prior to 2020 and remained low during the pandemic. Uncomplicated rates of appendicitis have followed a reciprocal pattern. While many secondary effects of the COVID 19 pandemic remain to be seen, acute appendicitis appears to have maintained its prior trajectory, contrary to smaller studies and those comparing 2020 to only the immediately preceding 1 or 2 years.