Skip to main content
Download PDF

Does medical disparity exist while treating severe mental illness patients with acute appendicitis in emergency departments? A real-world database study

BMC Psychiatry volume 22, Article number: 488 (2022) Cite this article

Abstract

Background

Patients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group. As the causes for this mortality gap are complex, clarification regarding the contributing factors is crucial to improving the health care of SMI patients. Acute appendicitis is one of the most common indications for emergency surgery worldwide. A higher perforation rate has been found among psychiatric patients. This study aims to evaluate the differences in appendiceal perforation rate, emergency department (ED) management, in-hospital outcomes, and in-hospital expenditure among acute appendicitis patients with or without SMI via the use of a multi-centre database.

Methods

Relying on Chang Gung Research Database (CGRD) for data, we selectively used its data from January 1st, 2007 to December 31st, 2017. The diagnoses of acute appendicitis and SMI were confirmed by combining ICD codes with relevant medical records. A non-SMI patient group was matched at the ratio of 1:3 by using the Greedy algorithm. The outcomes were appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure.

Results

A total of 25,766 patients from seven hospitals over a span of 11 years were recruited; among them, 11,513 were excluded by criteria, with 14,253 patients left for analysis. SMI group was older (50.5 vs. 44.4 years, p < 0.01) and had a higher percentage of females (56.5 vs. 44.4%, p = 0.01) and Charlson Comorbidity Index. An analysis of the matched group has revealed that the SMI group has a higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). There was no significant difference in appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure.

Conclusions

Our study demonstrated no obvious differences in appendiceal perforation rate, ED management, in-hospital outcomes, and in-hospital expenditure among SMI and non-SMI patients with acute appendicitis. A higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group was found. ED health providers need to be cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints.

Peer Review reports

Background

Patients with severe mental illness (SMI) have a shorter life expectancy and have been considered by the World Health Organization (WHO) as a vulnerable group [1, 2]. This mortality gap is estimated to shorten by 13 to 30 years among SMI patients, and 60% of this excess mortality is attributed to physical illness [3, 4]. Even in countries with high-quality health care systems, the gap still exists and has, in fact, widened in recent decades [5]. The causes for this mortality gap are complex and multifactorial. The patient-level factors include higher rates of suicide, accidental and violent death, poorer self-care, and higher occurrence of physical diseases; the socioeconomic-level factors include lower economic support, social stigma, and structural discrimination; and the health service-level factors include the iatrogenic adverse effect of some psychiatric medications, inequalities in physical comorbidity, and poorer access to emergent healthcare resources [6,7,8]. To clarify the contributing factors, it is crucial to improve the health care of SMI patients and further narrow down the disparity gap.

Acute appendicitis is one of the most common indications for emergency surgery worldwide, having an estimated 7–8% lifetime risk [9]. Although the specific pathophysiology of acute appendicitis is still unknown, inflammation secondary to direct luminal obstruction caused by a fecalith, lymphoid hyperplasia, or impacted stool is considered a major trigger. Given the variable presentations of acute appendicitis, the diagnostic values of clinical symptoms and signs are low. The most commonly used image modality in adult patients is the Computed Tomography (CT) scan. Surgical intervention is the cornerstone of treatment, and delay in management is associated with increased perforation rates [10]. Due to the high incidence of acute appendicitis and the effectiveness of surgical interventions, appendectomy is considered the essential surgical service for basic human rights and is an indicator to evaluate health disparities [11, 12].

Earlier literature found a higher appendiceal perforation rate among vulnerable groups and considered the phenomenon as a disparity [13, 14]. It is unclear whether the disparity still exists within the SMI patient population and what potential factors contribute to this phenomenon. This study aims to evaluate the differences in appendiceal perforation rate, emergency department (ED) management, in-hospital outcomes, and in-hospital expenditure experienced by acute appendicitis patients with or without SMI via the use of a multi-centre database.

Methods

Data source

We obtained our data from the Chang Gung Research Database (CGRD), the largest multi-institutional electronic medical records (EMR) collection in Taiwan. CGRD collects data from seven Chang Gung Memorial Hospitals (CGMH), including two tertiary medical centres, two regional hospitals, and three district hospitals. CGMH has a 10,050 beds capacity and admits more than a million patients each year [15]. According to government statistics, there were over 500,000 ED visits to CGMH in 2015 and CGMH annually receives 11.5% of the National Health Insurance budget in Taiwan [16]. The basic architecture for CGRD includes clinical, epidemiological, laboratory, nursing, and disease categories, and cancer registry data for inpatient, outpatient, and emergency patients. The CGRD has been collecting de-identified data on the current and previous health conditions of patients by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes before 2016 and using ICD-10-CM codes afterwards [17].

Study population

The study subjects were selected based on the CGRD data from January 1st, 2007 to December 31st, 2017. The diagnoses of acute appendicitis were confirmed by the ICD codes in discharge medical records combined with the national health insurance declarations data. Relevant diagnostic ICD codes identified the diagnoses of SMI for schizophrenia, bipolar disorder, or major depressive disorder by the psychiatrist at least once before the diagnosis of acute appendicitis. The exclusion criteria were below 18 years of age, transferred from other health facilities and incomplete medical records. The relevant ICD codes for acute appendicitis and SMI are listed in Table 1.

Table 1 ICD codes for inclusion criteria
Full size table

Study outcomes and covariates

Patients in the CGRD who were hospitalized through ED under the diagnosis of acute appendicitis were identified. The outcomes were appendiceal perforation rate, ED treatment, in-hospital outcome, and in-hospital expenditure. ED treatment consisted of analgesics usage, opioid analgesics, and non-opioid analgesics usage, and time from triage to first order, time from triage to first antibiotics administration, time from triage to receive CT scan, and time from triage to surgical consultation. The in-hospital outcome consisted of admission day, ICU admission, and in-hospital mortality. Appendiceal perforation has been identified as ICD-9-CM codes 540.0 and 540.1 or ICD-10-CM codes K35.2 and K35.3. In-hospital mortality has been defined as mortality during the hospitalization by any etiology. The in-hospital expenditure was extracted from national health insurance declarations data. The covariates include demographic data, triage data, vital signs during ED stay, laboratory data, Charlson Comorbidity Index (CCI), operative methods, and unscheduled 72-hour revisit before the diagnosis of acute appendicitis. CCI is calculated based on the sum of weighted diagnoses, including several comorbidities [18]. We determined the CCI score of patients based on there being two or more OPD visits with the same diagnosis in 1 year. CCI scores were categorized into three grades: mild, with CCI scores of 1–2; moderate, with CCI scores of 3–4; and severe, with CCI scores ≧ 5 [19]. The covariates include acute psychiatric ward admission in the past 1 year, length of stay in acute psychiatric ward in the past 1 year, medications include antipsychotics, antidepressant, benzodiazepine and mood stabilizer were identified in SMI group.

Statistical analysis

The continuous variables are presented as mean (SD), and the categorical variables are presented as count (%). Given the large gap in the numbers of patients between the two groups, we utilized a matched case-control study design. A non-SMI patient group was matched at a ratio of 1:3 by using the Greedy algorithm [20]. The variables included in the matching process were age (±5 years) and gender. We compared the continuous variables between the two independent groups by using the Student’s t-test and compared the categorical variables between the two independent groups by using the Chi-square test. The statistical analysis is done using SAS version 9.4. A p-value of less than 0.05 is considered statistically significant. The work has been reported in line with the Strengthening The Reporting of Observational Studies in Epidemiology (STROBE) criteria [21].

Ethical approval

This study was approved by the Chang Gung Medical Foundation Institutional Review Board (IRB: 202001785B0), waiving the need for obtaining the informed consent of the study participants.

Results

Patient characteristics

A total of 25,766 patients from seven hospitals over a span of 11 years were recruited; of these, 11,513 were excluded by criteria, with 14,253 patients left for analysis. The recruitment flowchart is summarized in Fig. 1. The mean age of the participants is 44.5 Â± 17.5 (years). Of all the participants, 47.0% were female. In the SMI group, 64.1% of the patients had depression, 27.7% had schizophrenia, and 8.2% had bipolar disorder. When the patient demographics and medical history of both the groups were compared, we found the SMI group to be older (50.5 vs. 44.4 years, p < 0.01) and have a higher percentage of females (56.5 vs. 44.4%, p = 0.01). Comorbidities including cardiovascular disease (21.2 vs. 7.1%, p < 0.01), cerebrovascular disease (22.8 vs. 8.6%, p < 0.01), pulmonary disease (33.7 vs. 14.6%, p < 0.01), liver disease (43.5 vs. 19.1%, p < 0.01), diabetes mellitus (32.6 vs. 11.7%, p < 0.01), renal disease (16.9 vs. 7.4%, p < 0.01), and malignancy (13.0 vs. 8.3%, p = 0.03) had a higher prevalence in the SMI group. SMI group also had a higher percentage of patients placed in moderate to severe CCI stages (p < 0.01). After matching with age and gender, comorbidities including cardiovascular disease (21.2 vs. 9.3%, p < 0.01), cerebrovascular disease (22.8 vs. 11.1%, p = 0.01), pulmonary disease (33.7 vs. 16.8%, p < 0.01), liver disease (43.5 vs. 23.3%, p < 0.01), diabetes mellitus (32.6 vs. 14.3%, p < 0.01), and renal disease (16.9 vs. 8.4%, p < 0.01) still showed a higher prevalence in the SMI group with a higher percentage of patients placed in moderate to severe CCI stages (p < 0.01). The above results were summarized in Table 2.

Fig. 1
figure 1

Flow chart of participants in cohort study. a CGRD, Chang Gung Research Database. b SMI, severe mental illness

Full size image
Table 2 Patient characteristics for overall, non-matched and matched groups
Full size table

Further analysis of the matched group revealed SMI group to have a higher triage pulse rate (94.1 vs. 90.0 times/min, p = 0.01), lower sodium level (136.8 vs. 137.7 mEq/L, p = 0.03) and higher unscheduled 72-hour revisit to ED (17.9 vs. 10.4%, p = 0.01). ED management, including opioid and non-opioid analgesics prescription, time to first order, time to the first antibiotics treatment, time to receive CT scan, and time to surgical consultation, for the two groups had no significant difference. In-hospital expenditure and in-hospital outcomes, including admission day, ICU admission rate, and appendiceal perforation rate, for the two groups also had no significant difference. The above results were summarized in Table 3.

Table 3 Vital signs, laboratory test, operative methods, ED treatment and hospital outcomes for matched group
Full size table

For SMI group, we further analyzed the psychiatric disease status, medication for SMI, ED treatment and in-hospital outcome according to SMI subgroup and there were no significant differences in psychiatric disease status, ED treatment and in-hospital outcomes. The results were summarized in Supplementary 1.

Discussion

To the best of our knowledge, this study is the first to evaluate the emergency department management, in-hospital outcomes, and in-hospital expenditure experienced by acute appendicitis patients with or without severe mental illness. This real-world database study found no significant difference in appendiceal perforation rate between the SMI and non-SMI patients with acute appendicitis. ED management, in-hospital outcome, and in-hospital expenditure also showed no significant differences between these two groups.

Previous studies have found a higher appendiceal perforation rate among vulnerable groups, including elderly, racial minority, immigrant, poor socioeconomic, and insurance status populations, in comparison to the other groups [14, 22,23,24]. This correlation was also demonstrated in the case of psychiatric patients and considered to be an instance of medical disparity. Using the Taiwan national insurance health data of 1997 to 2001, Tsay et al. published an article in 2007 proving that SMI patients have a 2.83 times higher risk of appendiceal perforation than non-SMI patients with acute appendicitis [13, 25, 26]. However, we found no significant difference in appendiceal perforation rate between the SMI and non-SMI groups in this study. The evolution of medical treatment may explain this improvement. The increased utility of diagnostic modalities, including CT scans of acute appendicitis in the past few years, eliminates the medical gap in SMI patients [27, 28]. Besides, the national health insurance in Taiwan has shown a positive influence in narrowing down the financial gap and improving the outcomes provided to vulnerable groups [29]. The advantage of a near 100% population coverage rate with comprehensive expenditure coverage may alleviate the obstacles of medical accessibility faced by patients with SMI [30, 31].

Previous studies adopted analgesic prescription rate as an indicator to evaluate treatment disparity and proved the existence of a lower prescription rate among female and racial minorities during acute pain management [32,33,34]. We found no obvious differences in analgesic prescription rates between the SMI and non-SMI groups. However, a trend of lower opioid analgesics prescription rate was noticed among SMI patients. Several randomized trials have demonstrated that opioid analgesic is safe and efficient in treating acute appendicitis patients [35, 36]. Further, a previous study found a lower opioid prescription rate also among black paediatric children with acute appendicitis in the United States and considered this phenomenon as that of treatment inequity [37]. Although our study found no statistical significance among the two groups, the trend of lower opioid administration in SMI patients still needs further investigation. The waiting time for medical evaluation and treatment is also important to evaluate the potential disparities in ED. Previous studies have found that patients with mental illness experience a longer waiting time to see a physician in ED [38]. To understand the medical management in ED more comprehensively, we analysed time from triage to first order, time from triage to first antibiotics administration, time from triage to receiving CT scan, and time from triage to surgical consultation in ED. None of the above variables showed differences between the SMI and non-SMI groups.

Our study aligns with the prior research that proved SMI patients to have a higher prevalence of several physical comorbidities, including cardiovascular disease, cerebrovascular disease, pulmonary disease, liver disease, DM, and renal disease [39]. Although SMI patients with acute appendicitis have a higher prevalence of comorbidities than the general population, we found no obvious differences in admission day, ICU admission, in-hospital mortality, and in-hospital expenditure between the two groups. This may be because acute appendicitis is a relatively benign disease with extremely low postoperative major adverse effects and mortality rate. Even in patients with multiple comorbidities, the current management can treat effectively without excessive cost [40].

We found a higher rate of unscheduled 72-hour ED revisits prior to the diagnosis of acute appendicitis in the SMI group. This may be because of the following reasons. First, SMI patients have a higher emergency medical resource usage in the case of psychiatric or physical illness [41]. Second, the higher unscheduled 72-hour ED revisits rate may associate with misdiagnosis for prior ED visits. The possible risk factors include lower pain perception, poorer communication of SMI patients, and diagnostic overshadowing of health providers [42]. Diagnostic overshadowing, the misattribution of physical symptoms to mental illness, was proved to exist among ED health providers [43]. The superimposition of this stigmatizing attitude by the cognitive impairment and excess negative symptoms of SMI patients may make it difficult to have a timely diagnosis [44]. ED health providers have to be more cautious when it comes to SMI patients with vague symptoms or unspecified abdominal complaints, and multidisciplinary evaluation may benefit these vulnerable groups [45].

Limitations

There are remaining limitations of this study. First, due to the nature of the database study, some crucial clinical details, including individual symptoms, mental status of SMI patients, physical examinations, and bedside ultrasonography results, were not included in the pre-designed data format. This hampered further analysis owing to the potential reasons of higher unscheduled 72-hr ED revisit, which may be a result of multi-factors. Second, although CGRD is one of the largest databases in Taiwan, we still missed the patients with SMI diagnoses or those who received appendectomies in other medical facilities. Third, there are many components of disparities in the medical field. Although we demonstrated the cardinal management and timeline in ED without there being any obvious difference among the SMI patients, further investigations on the overshadowing or stigmatizing attitudes of health providers are still needed.

Conclusion

Our study demonstrated no obvious differences in appendiceal perforation rate, ED management, in-hospital outcomes, and in-hospital expenditure between the SMI and non-SMI patients with acute appendicitis. It found a higher unscheduled 72-hour ED revisit rate prior to the diagnosis of acute appendicitis in the SMI group. ED health providers need to be cautious of SMI patients with vague symptoms or unspecified abdominal complaints. There is a need for further investigation on the other components of medical disparities, including the overshadowing effect.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Chang CK, Hayes RD, Perera G, Broadbent MT, Fernandes AC, Lee WE, et al. Life expectancy at birth for people with serious mental illness and other major disorders from a secondary mental health care case register in London. PLoS One. 2011;6(5):e19590.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  2. Funk M, Drew N, Freeman M, Faydi E, World Health O. Mental health and development : targeting people with mental health conditions as a vulnerable group / Michelle funk ... [et al]. Geneva: World Health Organization; 2010.

    Google Scholar 

  3. Vreeland B. Bridging the gap between mental and physical health: a multidisciplinary approach. J Clin Psychiatry. 2007;68(Suppl 4):26–33.

    PubMed  Google Scholar 

  4. Tiihonen J, Lönnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet. 2009;374(9690):620–7.

    Article  PubMed  Google Scholar 

  5. Osby U, Correia N, Brandt L, Ekbom A, Sparén P. Time trends in schizophrenia mortality in Stockholm county, Sweden: cohort study. BMJ. 2000;321(7259):483–4.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  6. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry. 2011;199(6):441–2.

    Article  PubMed  Google Scholar 

  7. Reilly S, Olier I, Planner C, Doran T, Reeves D, Ashcroft DM, et al. Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK. BMJ Open. 2015;5(12):e009010.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Hayes JF, Marston L, Walters K, King MB, Osborn DPJ. Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014. Br J Psychiatry. 2017;211(3):175–81.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg. 2014;101(1):e9–22.

    Article  PubMed  CAS  Google Scholar 

  10. Papandria D, Goldstein SD, Rhee D, Salazar JH, Arlikar J, Gorgy A, et al. Risk of perforation increases with delay in recognition and surgery for acute appendicitis. J Surg Res. 2013;184(2):723–9.

    Article  PubMed  Google Scholar 

  11. McQueen KA, Ozgediz D, Riviello R, Hsia RY, Jayaraman S, Sullivan SR, et al. Essential surgery: integral to the right to health. Health Hum Rights. 2010;12(1):137–52.

    PubMed  Google Scholar 

  12. Ingram ME, Calabro K, Polites S, McCracken C, Aspelund G, Rich BS, et al. Systematic review of disparities in care and outcomes in pediatric appendectomy. J Surg Res. 2020;249:42–9.

    Article  PubMed  Google Scholar 

  13. Tsay JH, Lee CH, Hsu YJ, Wang PJ, Bai YM, Chou YJ, et al. Disparities in appendicitis rupture rate among mentally ill patients. BMC Public Health. 2007;7:331.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ponsky TA, Huang ZJ, Kittle K, Eichelberger MR, Gilbert JC, Brody F, et al. Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children. JAMA. 2004;292(16):1977–82.

    Article  PubMed  CAS  Google Scholar 

  15. Chang Gung Memorial Hospital International Medical Center- Overview 2022 [updated January 6, 2022. Available from: http://www.chang-gung.com/en/about.aspx?id=11&bid=1.

  16. Tsai MS, Lin MH, Lee CP, Yang YH, Chen WC, Chang GH, et al. Chang gung research database: a multi-institutional database consisting of original medical records. Biom J. 2017;40(5):263–9.

    Google Scholar 

  17. Shao SC, Lai EC, Huang TH, Hung MJ, Tsai MS, Yang YH, et al. The Chang gung research database: multi-institutional real-world data source for traditional Chinese medicine in Taiwan. Pharmacoepidemiol Drug Saf. 2021;30(5):652–60.

    Article  PubMed  Google Scholar 

  18. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  PubMed  CAS  Google Scholar 

  19. Huang YQ, Gou R, Diao YS, Yin QH, Fan WX, Liang YP, et al. Charlson comorbidity index helps predict the risk of mortality for patients with type 2 diabetic nephropathy. J Zhejiang Univ Sci B. 2014;15(1):58–66.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  20. Kosanke J, Bergstralh E. Match one or more controls to cases using the GREEDY algorithm. Rochester: Mayo Clinic College of Medicine; 2004.

    Google Scholar 

  21. Skrivankova VW, Richmond RC, Woolf BAR, Yarmolinsky J, Davies NM, Swanson SA, et al. Strengthening the reporting of observational studies in epidemiology using Mendelian randomization: the STROBE-MR statement. JAMA. 2021;326(16):1614–21.

    Article  PubMed  Google Scholar 

  22. Hui TT, Major KM, Avital I, Hiatt JR, Margulies DR. Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy. Arch Surg. 2002;137(9):995–8 discussion 9-1000.

    Article  PubMed  Google Scholar 

  23. Lin KB, Chan CL, Yang NP, Lai RK, Liu YH, Zhu SZ, et al. Epidemiology of appendicitis and appendectomy for the low-income population in Taiwan, 2003-2011. BMC Gastroenterol. 2015;15:18.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med. 1994;331(7):444–9.

    Article  PubMed  CAS  Google Scholar 

  25. Nishihira Y, McGill RL, Kinjo M. Perforated appendicitis in patients with schizophrenia: a retrospective cohort study. BMJ Open. 2017;7(9):e017150.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Lin HR, Wang HC, Wang JH, Lu HH. Increased risk of perforated appendicitis in patients with schizophrenia and dementia: a population-based case-control study. Medicine (Baltimore). 2020;99(5):e18919.

    Article  Google Scholar 

  27. Wagner M, Tubre DJ, Asensio JA. Evolution and current trends in the Management of Acute Appendicitis. Surg Clin North Am. 2018;98(5):1005–23.

    Article  PubMed  Google Scholar 

  28. Raptopoulos V, Katsou G, Rosen MP, Siewert B, Goldberg SN, Kruskal JB. Acute appendicitis: effect of increased use of CT on selecting patients earlier. Radiology. 2003;226(2):521–6.

    Article  PubMed  Google Scholar 

  29. Lin KB, Lai KR, Yang NP, Wu KS, Ting HW, Pan RH, et al. Trends and outcomes in the utilization of laparoscopic appendectomies in a low-income population in Taiwan from 2003 to 2011. Int J Equity Health. 2015;14:100.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Wu TY, Majeed A, Kuo KN. An overview of the healthcare system in Taiwan. London J Prim Care (Abingdon). 2010;3(2):115–9.

    Article  Google Scholar 

  31. Wang SI, Yaung CL. Vertical equity of healthcare in Taiwan: health services were distributed according to need. Int J Equity Health. 2013;12:12.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Guedj R, Marini M, Kossowsky J, Berde CB, Kimia AA, Fleegler EW. Racial and ethnic disparities in pain Management of Children with Limb Fractures or suspected appendicitis: a retrospective cross-sectional study. Front Pediatr. 2021;9:652854.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Wilson TT, Chou SC, Becker S, Schuur JD, Beaudoin F. Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006-2015. Am J Emerg Med. 2021;50:597–601.

    Article  PubMed  Google Scholar 

  34. Morden NE, Chyn D, Wood A, Meara E. Racial inequality in prescription opioid receipt - role of individual health systems. N Engl J Med. 2021;385(4):342–51.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Amoli HA, Golozar A, Keshavarzi S, Tavakoli H, Yaghoobi A. Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial. Emerg Med J. 2008;25(9):586–9.

    Article  PubMed  CAS  Google Scholar 

  36. Yuan Y, Chen JY, Guo H, Zhang Y, Liang DM, Zhou D, et al. Relief of abdominal pain by morphine without altering physical signs in acute appendicitis. Chin Med J. 2010;123(2):142–5.

    PubMed  CAS  Google Scholar 

  37. Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial disparities in pain Management of Children with Appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996–1002.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Opoku ST, Apenteng BA, Akowuah EA, Bhuyan S. Disparities in emergency department wait time among patients with mental health and substance-related disorders. J Behav Health Serv Res. 2018;45(2):204–18.

    PubMed  Google Scholar 

  39. De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52–77.

    Article  Google Scholar 

  40. Sartelli M, Baiocchi GL, Di Saverio S, Ferrara F, Labricciosa FM, Ansaloni L, et al. Prospective observational study on acute appendicitis worldwide (POSAW). World J Emerg Surg. 2018;13:19.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Niedzwiecki MJ, Sharma PJ, Kanzaria HK, McConville S, Hsia RY. Factors associated with emergency department use by patients with and without mental health diagnoses. JAMA Netw Open. 2018;1(6):e183528.

    Article  PubMed  PubMed Central  Google Scholar 

  42. De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138–51.

    Article  PubMed  Google Scholar 

  43. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms--a qualitative study. PLoS One. 2014;9(11):e111682.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  44. Sølvhøj IN, Kusier AO, Pedersen PV, Nielsen MBD. Somatic health care professionals' stigmatization of patients with mental disorder: a scoping review. BMC Psychiatry. 2021;21(1):443.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Navanandan N, Schmidt SK, Cabrera N, Topoz I, DiStefano MC, Mistry RD. Seventy-two-hour return initiative: improving emergency department discharge to decrease returns. Pediatr Qual Saf. 2020;5(5):e342.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This research was supported by Chang-Gung Memorial Hospital. We are thankful to our colleagues who provided their expertise, which greatly assisted the research, although they may not agree with all the interpretations provided in this paper.

Prior presentations

This research has not been presented previously.

Funding

There is no funding to disclose.

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan

    Shang-Kai Hung, Shou-Yen Chen, Chih-Huang Li, Shi-Ying Gao, Chiao-Hsuan Hsieh & Chung-Hsien Chaou

  2. Department of Surgery, Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan

    Hao-Wei Kou & Chao-Wei Lee

  3. Department of Emergency Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi County, 613, Taiwan

    Kai-Hsiang Wu & Po-Han Wu

  4. Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi County, 613, Taiwan

    Kai-Hsiang Wu

  5. Graduate Institute of Clinical Medical Sciences, Division of Medical Education, College of Medicine, Chang Gung University, Taoyuan City, 333, Taiwan

    Shou-Yen Chen & Chao-Wei Lee

  6. Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, 333, Taiwan

    Chih-Huang Li

  7. College of Medicine, Chang Gung University, Guishan, Taoyuan City, 333, Taiwan

    Chao-Wei Lee & Chung-Hsien Chaou

  8. Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung City, 813, Taiwan

    Yu-Yung Hung

  9. Chang-Gung Medical Education Research Centre, Chang-Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan City, 333, Taiwan

    Chung-Hsien Chaou

Authors
  1. Shang-Kai Hung
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hao-Wei Kou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kai-Hsiang Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shou-Yen Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Chih-Huang Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chao-Wei Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yu-Yung Hung
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shi-Ying Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Po-Han Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Chiao-Hsuan Hsieh
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Chung-Hsien Chaou
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: SKH, HWK, YYH; Data Curation: SKH, PHW, CHH; Formal analysis: SYG, CHC; Methodology: SYC, CHL; Investigation: SKH, SYC, KHW; Resources: CHL, CWL; Supervision: CHC; Writing: SKH, HWK, CHC. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Chung-Hsien Chaou.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Chang Gung Medical Foundation Institutional Review Board (IRB: 202001785B0C601), waiving the need for obtaining the informed consent of the study participants. All methods were carried out in accordance with relevant regulations.

Consent for publication

Not applicable.

Competing interests

The corresponding author confirms on behalf of all authors that there have been no involvements that might raise the question of bias in the work reported or in the conclusions, implications, or opinions stated.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

12888_2022_4141_MOESM1_ESM.docx

Additional file 1.

Additional file 2: Supplementary 1.

Psychiatric disease status and clinical outcomes for SMI subgroup.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hung, SK., Kou, HW., Wu, KH. et al. Does medical disparity exist while treating severe mental illness patients with acute appendicitis in emergency departments? A real-world database study. BMC Psychiatry 22, 488 (2022). https://doi.org/10.1186/s12888-022-04141-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12888-022-04141-5

Keywords

  • Severe mental illness
  • Acute appendicitis
  • Health disparity
  • Emergency department

BMC Psychiatry

ISSN: 1471-244X

Contact us