Insurance-related differences in the risk of ruptured appendix.

BACKGROUND: We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage. METHODS: In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989. RESULTS: After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]). CONCLUSIONS: Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.

The limited value of symptoms and signs in the diagnosis of vaginal infections.

The etiology of vaginitis can be difficult to prove. To determine the relationship between clinical criteria (symptoms and signs) and three causes of vaginitis, we prospectively evaluated 22 criteria in 123 unselected symptomatic patients. Diagnoses of Candida albicans and Trichomonas vaginalis infection were based on culture. Bacterial vaginosis was defined by the presence of 3 of 4 clinical criteria. Only 49% of our patients received diagnoses, and itching was the only symptom more frequently noted among those with diagnoses. Symptoms did not differ among the three infections, and lack of vaginal odor in yeast infection was the only significantly different physical sign. Yeast and trichomonads were seen on microscopy in 63% and 75% of culture-positive specimens. Bacterial vaginosis had no significant clinical criteria beyond those that defined the diagnosis. We conclude that presenting symptoms and signs in vaginitis evaluation have limited value, and that half of the women with vaginitis may lack a microbiologic diagnosis.