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CT Utilization for the Diagnosis of Pediatric Acute Appendicitis Decreases with a Diagnostic Algorithm
Sohail R Shah*1, Kelly Sinclair*2, Stephanie B. Theut*2, Kathy M. Johnson*2, George W. Holcomb, III2, Shawn D. St. Peter2
1Baylor College of Medicine / Texas Children's Hospital, Houston, TX;2Children's Mercy Hospital, Kansas City, MO

OBJECTIVE(S): The primary objective of this study was to decrease CT utilization for the diagnosis of appendicitis in an academic children’s hospital emergency department (ED) through a multidisciplinary quality improvement initiative.
METHODS: A retrospective review was conducted of patients diagnosed with appendicitis in our ED from 1/1/2011 - 2/28/2014 to establish a baseline cohort. From 8/1/2014 - 7/31/2015 a newly designed diagnostic algorithm was used in our ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. Additionally, any patient evaluated for appendicitis after implementation was analyzed based on algorithm adherence. Group differences were analyzed using ANOVA, Wilcoxon Rank Sum, Chi-square, and Fisher’s Exact tests.
RESULTS: Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation CT utilization decreased from 75.4% to 24.2% (p<0.0001) in patients with appendicitis (Table1). CT utilization was 27.3% after implementation, regardless of ultimate diagnosis or algorithm adherence (Table2). The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.
CONCLUSIONS: Implementation of a diagnostic algorithm for pediatric appendicitis significantly decreases CT utilization, while maintaining a high sensitivity and specificity.
Table1 Comparison of Patients with Appendicitis Before and After Diagnostic Algorithm Implementation
Prior to Diagnostic Algorithm
(N = 557)
After Diagnostic Algorithm
(N = 267)
p value
Age (years)10.410.20.41
Gender (% female)40.2%37.5%0.45
CT ordered (%)75.4%24.2%<0.0001
Ultrasound prior to CT order (%)24.4%95.3%<0.0001
Surgical consult prior to CT order (%)14.7%76.1%<0.0001
Operative intervention without imaging (%)1.8%9.9%<0.0001
Negative appendectomy rate (%)5.6%8.7%0.09
Time spent in ED (hours)

Table2 Comparison of All Patients Evaluated for Appendicitis Based on Diagnostic Algorithm Adherence
Patients in whom the diagnostic algorithm was followed
(N = 421)
Patients not on the diagnostic algorithm or had significant variation from the algorithm
(N = 419)
All patients evaluated for appendicitis after implementation of the diagnostic algorithm
(N = 840)
p value
Age (years)
Gender (% female)54.9%51.8%53.3%0.37
Ultrasound ordered (%)85.5%96.4%91.0%<0.0001
CT ordered (%)28.4%26.3%27.3%0.51
Ultrasound prior to CT order (%)97.4%90.1%93.9%0.02
Operative intervention without any imaging (%)15.9%1.8%9.9%0.0001
Missed appendicitis rate (%)1.1%3.9%2.6%0.11
Time spent in ED (hours)

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