CHICAGO – Use of a diagnostic algorithm for pediatric appendicitis significantly decreases computed tomography utilization without compromising high sensitivity and specificity, according to findings from a study of emergency cases.
Of 840 patients seen in an academic children’s hospital emergency department from Aug. 1, 2014 to July 31, 2015, after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. CT utilization was 27.3% overall, and 24.2% in patients with appendicitis, compared with 75.4% among 557 patients with appendicitis seen from Jan. 1, 2011 to February 28, 2014, before implementation, Dr. Sohail R. Shah of Baylor College of Medicine/Texas Children’s Hospital, Houston reported at the annual meeting of the American Surgical Association
Courtesy Dr. Shah
Dr. Sohail R. Shah
The work was completed at his prior position at Children’s Mercy Hospital Kansas City.
“Additionally, utilization of ultrasound prior to CT went from 24% up to 95%, surgical consultation prior to CT increased from 14.7% to 76.1% after implementation, and operative intervention without any imaging went from just under 2% to almost 10% after implementation of the diagnostic algorithm,” Dr. Shah said, adding that the pre- and postimplementation patient groups were similar with respect to demographics.
The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%, he said.
Appendicitis is the most common abdominal condition leading to the hospitalization of children, and it accounts for about 70,000 children hospitalized annually in the United States, with an average related healthcare cost of $675 million each year, he said.
The diagnosis in children can be difficult, thus many centers rely heavily on CT scans. However, increasing use of CT in children could lead to an increased lifetime risk of radiation-induced malignancy.
“In fact, the American College of Radiology currently recommends that a CT scan not be done for the diagnosis of appendicitis until after ultrasound has been considered as an option. Our objective with this work was to decrease CT utilization for the diagnosis of appendicitis in children at our academic free-standing children’s hospital emergency department through the introduction of a diagnostic algorithm,” he said.
A multidisciplinary team at Children’s Mercy Hospital worked to develop an algorithm, which promoted earlier surgical consultation and prioritized ultrasound imaging over CT scans. The algorithm involved the use of the 10-point Pediatric Appendicitis Score for risk stratification. For a score of 1-3, with low probability of appendicitis, the patient was discharged home or received further work-up for an alternative diagnosis. For a score of 4-6, with intermediate probability of appendicitis, an ultrasound was ordered. If the ultrasound was negative, the patient was discharged home or received further work-up for an alternative diagnosis; if the ultrasound was positive, surgery was consulted; if the ultrasound was indeterminate, surgery was consulted prior to consideration of CT scan. For a score of 7-10, surgery was immediately consulted for further management.
“If this algorithm is followed appropriately for all patients, then no patient should have a CT scan without first having an ultrasound and surgical consultation,” Dr. Shah said.
He reported having no disclosures.
The complete manuscript of this presentation is anticipated to be published in the Annals of Surgery pending editorial review.