Quantifying the disparity in outcome between urban and rural patients with acute appendicitis in South Africa

Abstract

Background. Acute appendicitis in South Africa is associated with higher morbidity than in the developed world. 

Objective. To compare outcomes of urban and rural patients in KwaZulu-Natal and to determine whether there are disparities in outcome.

Methods. We conducted a prospective study from September 2010 to September 2012 at Edendale Hospital in Pietermaritzburg, South Africa. All patients who presented with acute appendicitis were included. The operative and clinical course of urban and rural patients was compared.

Results. A total of 500 patients were included, with 200 patients in the rural group and 300 in the urban group. Those from the rural group had a significantly longer duration of symptoms prior to presentation. All septic parameters were significantly worse in the rural group. Significantly more patients from the rural group required a laparotomy (77% v. 51% urban; p<0.001). Inflamed, non-perforated appendicitis was more commonly seen in the urban group (52.3% v. 21% rural; p<0.001), while perforated appendicitis was much more common in the rural group (79% v. 47.7% urban; p<0.001). Perforation associated with generalised, four-quadrant intra-abdominal contamination was significantly higher in the rural group than the urban group (60.5% v. 21%, respectively; p<0.05). Significantly more patients from the rural group required an open abdomen (46% v. 12% urban; p<0.001) and ≥1 re-laparotomies to control severe intra-abdominal sepsis (60.5% v. 23.3% urban; p<0.001). 

Conclusion. We have identified rural origin as an independent indicator of poor outcome. Possible reasons may include difficulty in accessing the health system or delay in transfer to a regional hospital. These need to be investigated further.