Appendiceal Perforation as a Potential Indicator of Healthcare Disparities Between Thai and Non-Thai Populations: A Nationwide Study of Public Hospitals in Thailand

Abstract This study examines disparities in appendiceal perforation between Thai nationals and non-Thai populations treated at Ministry of Public Health (MOPH) hospitals in Thailand, using perforation rates as a potential proxy for delayed access to emergency surgical care. We conducted a nationwide, facility-based cross-sectional analysis of 365,581 patients treated for acute appendicitis at 943 hospitals in Thailand between 2018 and 2022. Multivariable logistic regression models were estimated and reported as Average Marginal Effects (AMEs) with Generalized Estimating Equations (GEE) used as a sensitivity analysis. Thai nationals comprised 96% of cases. Non-Thai groups, including Burmese, Cambodian, Laotian, and stateless people had a substantially higher rate of out-of-pocket (OOP) payment. The overall perforation rate was 8.9%, varying by nationality / legal status from 7.6% among Burmese patients to 12.1% among Laotian patients. In adjusted analyses, Laotian and stateless individuals had higher probabilities of perforation compared with Thai nationals (AME: 1.7%, 95% CI: 0.3%, 3.1% and 3.1%, 95% CI: 1.5%, 4.6%, respectively), whereas Burmese and Cambodian patients had lower or similar probabilities. Older age, male sex, comorbidities, OOP payment, and treatment at higher-level hospitals were also associated with higher perforation risk. Although a test of the nationality/legal status and payment status interaction was not statistically significant ( p = 0.225), exploratory stratified analyses revealed higher probabilities of perforation among OOP-paid Laotian (AME: 4.2%, 95% CI: 2.3%, 6.0%), Cambodian (AME: 2.0%, 95% CI: 0.3%, 3.6%), and stateless patients (AME: 2.2%, 95% CI: 0.4%, 4.0%). While Thailand’s health insurance framework promotes equity in emergency surgical care, outreach to specific vulnerable populations may help further reduce potential disparities in timely access.