A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

Abstract

Introduction: Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up

“…However, this comes at an increased cost, with a 22% longer ED stay than reported in this study. 10 Previous studies with similar appendicitis rates and CT utilization to this study reported higher hospitalization rates, 51% 2 compared with 36% in this study, highlighting the admission reduction achieved when offering a next-day surgery clinic follow-up option. Hospital admission is sometimes necessary but costly and inconvenient solution to diagnostic uncertainty.…”

“…7 Others have described using a limited right lower quadrant MRI to reduce ionizing radiation exposure. 8,9 However, these gains in reduction of CT use resulted in increased utilization of MRI, longer ED length of stay (over 5 hours), 10 increased in-ED surgical consultation (70%), 11 and high rates of admission (above 50%). 2 These authors and others 13 have recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons.…”

“…These studies emphasize the selective use of US, resulting in reduced CT utilization. 2,[10][11][12][13] Recent studies have successfully reduced CT rates in children evaluated for suspected appendicitis with diagnostic protocols within single institutions 10,11 and in regional care systems of community hospitals. 12…”

Paediatric negative appendicectomy rates at a regional Western Australian Centre: a five‐year cohort study

“…A combination of PAS and selective ultrasound (USS) has been observed to decrease rates of NA 1 . Unnecessary imaging in cases of low suspicion of appendicitis increases healthcare costs for minimal benefit 17 …”

“…1 Unnecessary imaging in cases of low suspicion of appendicitis increases healthcare costs for minimal benefit. 17 Several studies have demonstrated higher NA rates in nonpaediatric compared to paediatric surgical services. 18,19 This is particularly relevant as appendicectomy is the most common surgical operation performed by general surgeons on children.…”