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Progress in the Diagnosis and Management of Appendicitis in High-Risk Patients: A Report from SCOAP
The SCOAP Collaborative*1, Frederick Thurston Drake*2, Steve Kwon*2, Zeila Schmidt*3, Michael Florence*4, Richard C. Thirlby5, Gregory J. Jurkovich2, Morris G. Johnson*6, David R. Flum2
1Washington State, Seattle, WA;2University of Washington Department of Surgery, Seattle, WA;3University of Washington Surgical Outcomes Research Center (SORCE), Seattle, WA;4Swedish Medical Center, Seattle, WA;5Virginia Mason Medical Center, Seattle, WA;6Skagit Valley Hospital, Mount Vernon, WA

For the SCOAP Collaborative.

OBJECTIVE(S): Appendectomy is the most common non-elective abdominal procedure performed in the United States. Our objective was to assess whether advanced diagnostic imaging and laparoscopy have impacted diagnosis and outcomes, especially in those at higher risk for misdiagnosis.
METHODS: SCOAP is a Washington State performance monitoring and benchmarking QI program focusing on process of care and outcomes. From 2006-2011 SCOAP focused on increasing the accuracy and use of diagnostic imaging (CT/US) for women of reproductive age (18-50 yrs). We evaluated rates of negative appendectomy (NA) and infectious complications (reoperation/antibiotics).
RESULTS: 16,117 underwent non-elective appendectomies (52% men [age 39.1±16.0], 34% women 18-50). Among women 18-50 yrs: In 2011 the rate of NA was 5.1% compared to 13.5% in 2006. From 2006-2011, the use of laparoscopy increased from 73.3% to 90.4% and the use of CT/US increased from 83.9% to 95.3%. NA was 7.0% for those having CT/US vs. 25.2% for those without imaging (p<0.001). Concordance between imaging and pathology was greater for CT with oral contrast (92.1%) compared to without (78.8%) contrast (p=0.01). Perforation and NA were not associated. Among all patients the rate of infectious complications was 2.2% and significantly lower among patients having laparoscopy compared to open procedures (1.9 vs. 3.7% p value<0.001) [AOR 0.67 95% 0.47-0.96].
CONCLUSIONS: Advances in the diagnosis and management of appendicitis have reduced misdiagnosis and complications. CT with oral contrast was associated with improved test performance characteristics. Benchmarking is an effective approach to reducing practice variation, morbidity and unnecessary surgery.

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