Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy

Russell, W. Scott; Schuh, A.; Hill, Jeanne G.; Hebra, André; Cina, Robert A.; Smith, Charles D.; Streck, Christian J.

doi:10.1097/pec.0b013e31828e5718

Cited by 79 publications

(59 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…26 However, one-third of the children with suspected appendicitis currently undergo CT scans, with considerable practice variation between hospitals. Although a guideline encouraging US and early surgical consultation in suspected appendicitis may decrease the CT rate significantly, 55 as may a staged US-CT protocol, 36 our approach would avoid the majority of the currently recommended CTs. A CT was required in only 3% of the equivocal USs.…”

Section: Discussionmentioning

confidence: 99%

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Schuh

Langer

Kulik

et al. 2015

Academic Emergency Medicine

View full text Add to dashboard Cite

Objectives: The primary objective was to determine the diagnostic accuracy of a serial ultrasound (US) clinical diagnostic pathway to detect appendicitis in children presenting to the emergency department (ED). The secondary objective was to examine the diagnostic performance of the initial and interval US and to compare the accuracy of the pathway to that of the initial US.Methods: This was a prospective cohort study of 294 previously healthy children 4 to 17 years old with suspected appendicitis and baseline pediatric appendicitis scores of ≥2, who were managed with the serial US clinical diagnostic pathway. This pathway consisted of an initial US followed by a clinical reassessment in each patient and an interval US and surgical consultation in patients with equivocal initial US and persistent concern about appendicitis. The USs were interpreted by published criteria as positive, negative, or equivocal for appendicitis. Children in whom this pathway did not rule in or rule out appendicitis underwent computed tomography (CT). Cases with missed appendicitis, negative operations, and CTs after the pathway were considered inaccurate. The primary outcome was the diagnostic accuracy of the serial US clinical diagnostic pathway. The secondary outcomes included the test performance of the initial and interval US imaging studies.Results: Of the 294 study children, 111 (38%) had appendicitis. Using the serial US clinical diagnostic pathway, 274 of 294 children (93%, 95% confidence interval [CI] = 90% to 96%) had diagnostically accurate results: 108 of the 111 (97%) appendicitis cases were successfully identified by the pathway without CT scans (two missed and one CT), and 166 of the 183 (91%) negative cases were ruled out without CT scans (14 negative operations and three CTs). The sensitivity of this pathway was 108 of 111 (97%, 95% CI = 94% to 100%), specificity 166 of 183 (91%, 95% CI = 87% to 95%), positive predictive value 108 of 125 (86%; 95% CI = 79% to 92%), and negative predictive value 166 of 169 (98%, 95% CI = 96% to 100%). The diagnostic accuracy of the pathway was higher than that of the initial US alone (274 of 294 vs. 160 of 294; p < 0.0001). Of 123 patients with equivocal initial US, concern about appendicitis subsided on clinical reassessment in 73 (no surgery and no missed appendicitis). Of 50 children with persistent symptoms, 40 underwent interval US and 10 had surgical consultation alone. The interval US confirmed or ruled out appendicitis in 22 of 40 children (55.0%) with equivocal initial US, with one false-positive interval US. Conclusions:The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans.

show abstract

Section: Discussionmentioning

confidence: 99%

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Schuh

Langer

Kulik

et al. 2015

Academic Emergency Medicine

View full text Add to dashboard Cite

show abstract

“…16,17,19,22 The methods for assigning risk for appendicitis differed across these studies. For example, Santillanes et al 17 based their guideline on the work of Garcia Pena et al, 31 Fleischman et al 22 developed a CPG based on the work of Samuels 29 and Kharbanda et al, 20 whereas Russell et al 21 developed a CPG that emphasized early surgical consultation and the use of ultrasound. Regardless, these studies have shown a reduction in CT use, with effect sizes of around 50%.…”

Section: Discussionmentioning

confidence: 99%

“…Regardless, these studies have shown a reduction in CT use, with effect sizes of around 50%. 21,22 Most previous studies have had limited follow-up periods, and the long-term effectiveness of these CPGs is not known. In addition, despite the demonstrated effectiveness of CPGs in these previous studies, barriers to e6…”

Section: Discussionmentioning

confidence: 99%

“…[16][17][18][19][20] Previous studies have demonstrated that it is possible, within a single academic ED, to safely limit the use of advanced diagnostic imaging in patients with suspected appendicitis. 21,22 To impact care over the long term, a CPG must be well integrated into the clinical workflow and provide information appropriate to the clinical scenario. 23,24 Clinical decision support (CDS) delivered through the electronic health record (EHR) provides a potentially innovative and scalable method for integrating CPGs into routine care within large health systems.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Implementation of Electronic Clinical Decision Support for Pediatric Appendicitis

Kharbanda¹,

Madhok²,

Krause³

et al. 2016

Pediatrics

View full text Add to dashboard Cite

BACKGROUND AND OBJECTIVE: Computed tomography (CT) and ultrasound (US) are commonly used in patients with acute abdominal pain. We sought to standardize care and reduce CT use while maintaining patient safety through implementation of a multicomponent electronic clinical decision support tool for pediatric patients with possible appendicitis. METHODS: We conducted a quasi-experimental study of children 3 to 18 years old who presented with possible appendicitis to the pediatric emergency department (ED) between January 2011 and December 2013. Outcomes were use of CT and US. Balancing measures included missed appendicitis, ED revisits within 30 days, appendiceal perforation, and ED length of stay. RESULTS: Of 2803 patients with acute abdominal pain over the 3-year study period, 794 (28%) had appendicitis and 207 (26.1% of those with appendicitis) had a perforation. CT use during the 10-month preimplementation period was 38.8% and declined to 17.7% by the end of the study (54% relative decrease). For CT, segmented regression analysis revealed that there was a significant change in trend from the preimplementation period to implementation (monthly decrease –3.5%; 95% confidence interval: –5.9% to –0.9%; P = .007). US use was 45.7% preimplementation and 59.7% during implementation. However, there was no significant change in US or total imaging trends. There were also no statistically significant differences in rates of missed appendicitis, ED revisits within 30 days, appendiceal perforation, or ED length of stay between time periods. CONCLUSIONS: Our electronic clinical decision support tool was associated with a decrease in CT use while maintaining safety and high quality care for patients with possible appendicitis.

show abstract

“…[11][12][13][14] These tests are limited by suboptimal accuracy, limited availability, or potential for adverse effects 15 in the pediatric population, compelling health care providers to seek better diagnostic strategies for children presenting to the emergency department (ED) with suspected appendicitis. Recent evidence demonstrates that combining these strategies into clinical pathways may be an effective way to improve diagnostic accuracy; [16][17][18][19] however, the extent to which this knowledge has been translated into practice in EDs is not known.…”

mentioning

confidence: 99%

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

et al. 2015

View full text Add to dashboard Cite

Objectives: The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.Methods: Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with afterhours surgery were determined using generalized estimating equations logistic regression.Results: Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).Conclusions: Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.ACADEMIC EMERGENCY MEDICINE 2015;22:811-822 © 2015 by the Society for Academic Emergency Medicine A ppendicitis is the most common nontraumatic surgical emergency in children, 1,2 yet it continues to present diagnostic and management uncertainty.3 Current strategies for diagnosing appendicitis include the use of clinical scoring systems, 4-7 laboratory markers of infection and inflammation, [8][9][10] and

show abstract

Clinical Practice Guidelines for Pediatric Appendicitis Evaluation Can Decrease Computed Tomography Utilization While Maintaining Diagnostic Accuracy

Cited by 79 publications

References 18 publications

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Properties of Serial Ultrasound Clinical Diagnostic Pathway in Suspected Appendicitis and Related Computed Tomography Use

Implementation of Electronic Clinical Decision Support for Pediatric Appendicitis

Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals

Contact Info

Product

Resources

About