Given the current focus on insurance reimbursement, some authors have noted with concern a trend to transfer uninsured patients with appendicitis to county hospitals for subsequent appendectomy.33 In a disease process where delayed care has implications for increased morbidity, such a transfer has ramifications for patients' health. Although the Consolidated Omnibus Reconciliation Act (COBRA) restricts transfer of unstable patients, decisions regarding patients' care are increasingly made on the basis of financial concerns. Although no study has yet documented a negative outcome for patients transferred under these conditions, uninsured patients with appendicitis generally have been found to be at increased risk for complications, 34 and the future impact of this practice is not clear.
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