Factors influencing delayed hospital presentation in patients with appendicitis: the APPE survey

Background Among patients with acute appendicitis (AA), perforation is thought to be associated with symptom duration before treatment. Perforation rates vary between hospitals raising the possibility that some perforations are preventable. The factors that compel patients to present earlier or later are unknown but are critical in developing quality improvement interventions aimed at reducing perforation rates. Materials and methods The Appendicitis Patient Pre-Hospital Experience (APPE) Survey is a prospective study of adults and parents of children with AA in six hospitals participating in Washington State's Comparative Effectiveness Research Translation Network (CERTAIN). The APPE survey includes questions about symptom duration before presentation (late defined as >24 h), predisposing characteristics, enabling factors, and need. Results Among 80 patients, perforation occurred more frequently in late presenters (44% versus 11%, P < 0.01). Late presenters more frequently drove themselves to the hospital (64% versus 52%, P = 0.05) as opposed to relying on friends/family members and described their health behavior as “waiting it out” when something is wrong (71% versus 46%, P = 0.03). We found similar sociodemographics, clinical characteristics, health care utilization, optimism, health care trust, and risk taking between the two cohorts. Conclusions Late presenters described reduced social support and a tendency to “wait it out” and had higher rates of perforation than early presenters. These characteristics have not been well-studied conditions but are important to understand to identify patients at high risk for delayed presentation. Future interventions might target those with low social support or those who are reluctant to seek care early to decrease rates of perforation.