Sociodemographic Inequities and Risk Factors for Radiation Exposure and Suboptimal Imaging in Suspected Pediatric Appendicitis

Abstract

Background Inequity in health care access leads to inequities in outcome. In recent years, health outcome disparities have been documented in children with appendicitis, but inequities in accessing optimal diagnostic imaging have not been adequately assessed, particularly with respect to imaging-related ionizing radiation exposure. Objective The purpose of our study is to assess sociodemographic and racial/ethnic inequities in accessing optimal diagnostic imaging for children with suspected appendicitis. Our hypothesis is that sociodemographic inequities exist in accessing optimal imaging modalities and in ionizing radiation exposure. Material and Methods Our nation-wide retrospective cohort study examined emergency room encounters for suspected appendicitis between January 2018 and September 2023. Primary exposures included neighborhood-level sociodemographic metrics as measured by Child Opportunity Index (COI), race/ethnicity, and insurance status. Outcomes included access to diagnostic imaging, suboptimal imaging, imaging with ionizing radiation, and imaging without radiation exposure. Mixed effects multivariable logistic regression analyses assessed factors associated with suboptimal imaging. A mixed effects multivariable ordered logistic regression analysis was performed using a three-tiered hierarchal imaging variable (no imaging, imaging with ionizing radiation, imaging without radiation). Results 105,392 patient encounters were examined (mean patient age 11.2 years +/- 3.9; 62,001 females). 85.2% were imaged. Children from lower COI neighborhoods were less frequently imaged (83.8%), and more often imaged suboptimally (aOR 1.10 [95% CI 0.95–1.14]) or with ionizing radiation (aOR 1.07 [95%CI 1.03–1.31]). Black children were less frequently imaged (80.5%) and more often imaged suboptimally (aOR 1.35 [95% CI 1.28–1.42]) or with ionizing radiation (aOR 1.16 [95% CI 1.12–1.21]). Children with public insurance were less frequently imaged (83.8%) and more often imaged suboptimally (aOR 1.25 [95% CI 1.20–1.30]) or with ionizing radiation (aOR 1.16 [95% CI 1.12–1.19]). Conclusion Children from lower COI neighborhoods, Black children, and children with public insurance are less often imaged in the setting of suspected appendicitis; and when they were imaged, it was more likely to be suboptimal or utilize ionizing radiation.