This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (16) Citing Articles via Google Scholar Google Scholar Articles by Smink, D. S. Articles by Fishman, S. J. Search for Related Content PubMed PubMed Citation Articles by Smink, D. S. Articles by Fishman, S. J. Related Collections Surgery Social Bookmarking                         What's this?

PEDIATRICS Vol. 113 No. 1 January 2004, pp. 18-23

The Effect of Hospital Volume of Pediatric Appendectomies on the Misdiagnosis of Appendicitis in Children

Douglas S. Smink, MD, MPH^*,,,||, Jonathan A. Finkelstein, MD, MPH^||,¶, Ken Kleinman, ScD^|| and Steven J. Fishman, MD

^* Harvard Pediatric Health Services Research Fellowship
Department of Surgery
^¶ Division of General Pediatrics, Children’s Hospital Boston, Boston, Massachusetts
Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
^|| Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts

Background. Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children.

Methods. The Kids’ Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (<1 per month), low (1 per month but <1 per week), medium (1–2 per week), high (2–3 per week), and highest (3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status.

Results. In the database, 37 109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24 655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0–2.2) and low- (OR: 1.6; 95% CI: 1.1–2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0–2.2) and high- (OR: 1.4; 95% CI: 0.9–2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals.

Conclusions. Almost two thirds of pediatric appendectomies are performed at hospitals performing <1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.

---

Key Words: appendicitis • misdiagnosis • volume • outcome

Abbreviations: KID, Kids’ Inpatient Database • ICD-9, International Classification of Diseases, Ninth Revision • OR, odds ratio • CI, confidence interval

---

Received for publication Feb 4, 2003; Accepted May 20, 2003.

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				J. A. Sosa, C. T. Tuggle, T. S. Wang, D. C. Thomas, L. Boudourakis, S. Rivkees, and S. A. Roman Clinical and Economic Outcomes of Thyroid and Parathyroid Surgery in Children J. Clin. Endocrinol. Metab., August 1, 2008; 93(8): 3058 - 3065. [Abstract] [Full Text] [PDF]

				M. J. Vermeulen and M. J. Schull Missed Diagnosis of Subarachnoid Hemorrhage in the Emergency Department Stroke, April 1, 2007; 38(4): 1216 - 1221. [Abstract] [Full Text] [PDF]

				J. G. Berry, T. A. Lieu, P. W. Forbes, and D. A. Goldmann Hospital Volumes for Common Pediatric Specialty Operations Arch Pediatr Adolesc Med, January 1, 2007; 161(1): 38 - 43. [Abstract] [Full Text] [PDF]

				J. Todd, C. Armon, A. Griggs, S. Poole, and S. Berman Increased Rates of Morbidity, Mortality, and Charges for Hospitalized Children With Public or No Health Insurance as Compared With Children With Private Insurance in Colorado and the United States Pediatrics, August 1, 2006; 118(2): 577 - 585. [Abstract] [Full Text] [PDF]

				L. J. Levine, D. F. Schwarz, J. Argon, D. S. Mandell, and C. Feudtner Discharge Disposition of Adolescents Admitted to Medical Hospitals After Attempting Suicide Arch Pediatr Adolesc Med, September 1, 2005; 159(9): 860 - 866. [Abstract] [Full Text] [PDF]

				D. Merenstein, B. Egleston, and M. Diener-West Lengths of Stay and Costs Associated With Children's Hospitals Pediatrics, April 1, 2005; 115(4): 839 - 844. [Abstract] [Full Text] [PDF]

				D. S. Smink, S. J. Fishman, K. Kleinman, and J. A. Finkelstein Effects of Race, Insurance Status, and Hospital Volume on Perforated Appendicitis in Children Pediatrics, April 1, 2005; 115(4): 920 - 925. [Abstract] [Full Text] [PDF]

				D. G. Bundy, D. S. Smink, and S. J. Fishman Diagnostic Accuracy in Pediatric Appendicitis Pediatrics, August 1, 2004; 114(2): 514 - 515. [Full Text] [PDF]