Disparities in Care: An Investigation of Children with Autism Spectrum Disorder and Appendicitis

Background: Children with Autism Spectrum Disorders (ASD) display a range of language abilities and behaviors to reflect symptoms from illness or injury that challenge interpretation in the health care environment that, in turn, impact evaluations and appropriate treatment, possibly leaving these individuals a vulnerable population within health care systems. The overwhelming nature of the emergency department (ED) environment as point of entry for diagnosis and treatment of abdominal pain may also contribute to the challenging assessment of the child with ASD. In addition, many providers of emergency medical services are largely unprepared to accommodate and adapt communication and practices to identify and meet the needs of individuals with social communicative differences. Importantly, delay in diagnosis for acute appendicitis may lead to increased morbidity, adding to length of stay, cost, and resource utilization.

Objectives: 1) To evaluate differences in the administration of analgesia between neurotypical (NT) individuals and children with ASD diagnosed with appendicitis in the ED and 2) to compare rates of complicated appendicitis (perforated or with peri-appendiceal abscess) among NT individuals and those with ASD at the time of diagnosis in the ED using the Pediatric Health Information System (PHIS), a comparative national database.

Methods: Retrospective case-control study of children 6-18 years of age with an ED visit for appendicitis between 2005 and 2015. Coarsened exact matching was used to match ASD children to NT controls within each hospital based on age, sex, race, ethnicity, ICD-9 diagnosis, and year of hospitalization. Logistic regression was used to investigate the association between ASD status and medication receipt. Outcomes included receipt of opioid or non-opioid analgesic within the first 48 hours of an ED visit. Comparison of the rates of complicated versus simple appendicitis in ASD and NT children was conducted before matching. Results of weighted logistic regression and truncated negative binomial regression models are reported.

Results: 126,412 children with appendicitis were identified in PHIS. The matched sample consisted of 889 children with ASD (>88% male, 60% 7-18 years of age, 77% white) and 35,672 NT controls. Receipt of opioids or non-opioid analgesics was not found to be statistically different between the two groups. Compared to NT controls, children with ASD with appendicitis had no significant difference regarding: receipt of no medication [0.67% vs. 0.97%; OR= 0.694 (0.309, 1.559), p= 0.38] and receipt of any pain medication [54.22% vs. 54.96%; OR=0.971 (0.848-1.109), p=0.66]. A significant difference (<0.0001) was found between children with ASD and NT controls for complicated appendicitis (N, ASD=355, 37.1% vs. N, NT=37,520, 29.9%).

Conclusions: Children with ASD have increased rates of complex appendicitis compared to those without ASD suggesting limited access to care, caregiver difficulty in assessing pain and others relevant symptoms in their child with ASD or provider difficulty in evaluating this population. However, receipt of analgesia in the ED for appendicitis did not differ significantly between populations of children with ASD and NT peers.