Living in an area with few general surgeons may make people with appendicitis more likely to turn into ruptured appendix cases by the time they get to surgery, according to new research.

“The study shows that access to surgical care, especially general surgical care, is important and low access can have real impacts that affect peoples’ health,” coauthor Thomas Ricketts of the University of North Carolina at Chapel Hill told Reuters Health by email.

The Affordable Care Act includes a provision for incentive payments to increase the supply of doctors in areas with shortages, but those bonuses only apply in places with too few primary care doctors.

General surgeon and primary care shortage areas don’t always line up, Ricketts said, and even when they do, general surgeons can’t move to areas that don’t already have primary care physicians to serve the community and refer patients back to them.

Almost 30,000 patients with appendicitis – a quarter of whom suffered a burst appendix – were discharged from hospitals in North Carolina between 2007 and 2009, according to data from hospitals and surgery centers in the state analyzed by the researchers.

There are 95,000 burst appendices per year in the U.S. according to the Agency for Healthcare Research and Quality. A 2008 study found that an appendectomy can cost between $10,000 and $18,000 more when the appendix has burst.

With surgery before a rupture, typically about 20 hours or less after abdominal pain begins, patients usually recover quickly. If the appendix has burst (roughly 40 hours after symptoms begin), that could mean repeat operations and longer recovery time, according to the Merck Manual.

To see whether a surgeon shortage was linked to more burst appendices in an area, the researchers compared the number of cases of appendicitis, and specifically burst appendices, with the number of general surgeons in “surgical service areas” of the state that roughly align with zip codes.

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