The impact of delay and prehospital factors on acute appendicitis severity in New Zealand children: a national prospective cohort study

Background: Appendicitis is the most common reason children undergo acute general surgery but international, population-level disparities exist. This is hypothesised to be caused by preoperative delay and differential access to surgical care. The impact of prehospital factors on paediatric appendicitis severity in New Zealand is unknown. Methods: A prospective, multicentre cohort study with nested parental questionnaire was conducted by a national trainee-led collaborative group. Across 14 participating hospitals, 264 patients aged <= 16 years admitted between January and June 2020 with suspected appendicitis were screened. The primary outcome was the effect of prehospital factors on the American Association for the Surgery of Trauma (AAST) anatomical severity grade. Results: Overall, 182 children had confirmed appendicitis with a median age of 11.6. The rate of complicated appendicitis rate was 38.5% but was significantly higher in rural (44.1%) and M (a) over bar ori children (54.8%). Complicated appendicitis was associated with increased prehospital delay (47.8 h versus 20.1 h; P < 0.001), but not in-hospital delay (11.3 h versus 13.3 h; P = 0.96). Multivariate analysis revealed increased anatomical severity in rural (OR 4.33, 95% CI 1.78-7.25; P < 0.001), and M (a) over bar ori children (OR 2.39, 95% CI 1.24-5.75; P = 0.019), as well as in families relying on external travel sources or reporting unfamiliarity with appendicitis symptomology. Conclusion: Prehospital delay and differential access to prehospital determinants of health are associated with increased severity of paediatric appendicitis. This manifested as increased severity of appendicitis in rural and M (a) over bar ori children. Understanding the prehospital factors that influence the timing of presentation can better inform health-system improvements.