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PEDIATRICS Vol. 106 No. 4 October 2000, pp. 672-676
,
From the * Department of Medicine, Division of Emergency
Medicine, and the Departments of Radiology and § Surgery,
Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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ABSTRACT |
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Abstract
Methods
Results
Discussion
References
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Background. A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children.
Objective. To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children.
Design, Setting, and Subjects. Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998.
Protocol. Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC.
Main Outcome Measures. Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital's cost database and by ratios of costs to charges.
Results. Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient.
Conclusion. A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis. Key words: appendicitis, ultrasonography, computed tomography, cost analysis.
The diagnosis of acute appendicitis in children continues
to be a challenge because the initial presentation of the disease is
often obscure and closely imitated by other common childhood diseases.1-7 Many children with suspected appendicitis
are often admitted to the hospital for an observation period before the
diagnosis is made.8-11 However, morbidity and mortality
from appendicitis are most often caused by complications associated
with delayed diagnosis.12-18 Hence, prompt diagnosis and
management remain critical features when considering the diagnosis of
childhood appendicitis.
Recent advances in diagnostic imaging have given clinicians important
modalities to aid them in the diagnosis of childhood appendicitis.
Ultrasonography (US) is the most widely used technique in the pediatric
population because it is noninvasive and does not involve
radiation.19-23 However, US is highly operator-dependent
and only rarely is the normal appendix visualized
sonographically.24 Computed tomography (CT) is
increasingly being used as the primary imaging modality in adults with
signs and symptoms of acute appendicitis with high sensitivity and
specificity for the diagnosis.24-34 The highest accuracy
in adults has been found with CT using rectal contrast (CTRC) to
outline the appendix.24-30 This technique has been shown
to improve the diagnosis and management of acute appendicitis, while
also reducing the use of hospital resources.25,26
Recently, a protocol of CTRC after a negative or equivocal ultrasound examination has been evaluated in children with an overall accuracy of
94% for the diagnosis of acute appendicitis.35
The purpose of this investigation was to assess the beneficial and
detrimental changes in patient management following a protocol using US
and CTRC in children with suspected acute appendicitis and to evaluate
the use of hospital resources using the US-CTRC protocol.
Study Subjects
Children and adolescents between the ages of 3 and 21 years with
equivocal findings for suspected acute appendicitis who presented to
the emergency department (ED) of Children's Hospital, Boston, Massachusetts, from July 1998 to December 1998, were prospectively identified. Patients with equivocal findings were defined as those children with concerning, but not classic signs or symptoms for acute
appendicitis. Patients who were pregnant, who had previous appendectomy, or who had a contraindication to rectal contrast were
ineligible. The hospital's institutional review board approved the
study.
Study Protocol
Details of the study protocol have been described
previously.35 The consulting surgical senior resident, who
is in the fourth or fifth postgraduate year, under the supervision of
an attending pediatric surgeon, evaluated all patients with suspected
appendicitis in the ED. Children with equivocal presentations for
appendicitis comprised the study cohort and initially underwent pelvic
US. If the ultrasound was definitive for appendicitis, no further imaging was performed and the patient underwent appendectomy. If the
appendix was not visualized by ultrasound or if the sonogram was
equivocal, limited CTRC of the pelvis was performed. Results of both
the ultrasound and CTRC were immediately made known to the treating
physicians. Both studies were performed by 1 of 6 pediatric radiology
fellows between 5:00 PM and 8:00 AM or by an
attending pediatric radiologist between 8:00 AM and
5:00 PM.
Management Decisions
The consulting surgeons were asked their management plans before
imaging, after US, and after CTRC and were recorded by the radiologist
performing the studies. The 3 management plans included: discharge home
from the ED, admit to hospital for an observation period, or proceed to
operating room (OR) for appendectomy. Changes in management were
determined by the principal investigator by comparing the preimaging
disposition with that following the US-CTRC protocol. Correct changes
in management decisions were defined as those decisions that were
necessary and/or benefited the child (ie, a child with appendicitis who
would have been discharged from the hospital or admitted for inpatient
observation that went directly to the OR). Incorrect changes in
management were defined as those that were unnecessary and/or not
beneficial for the patient (ie, a child without appendicitis who was to
be discharged from the hospital or admitted for inpatient observation
who underwent appendectomy). Data regarding beneficial changes in
patient management using US and CTRC individually have been published
previously.35
Final Diagnosis and Patient Follow-Up
Final diagnoses were determined by pathologic examination of the
appendix for patients who underwent appendectomy and by clinical follow-up for those children managed nonoperatively. All children who
did not undergo appendectomy were followed up by telephone 2 weeks
after their ED visit. The Children's Hospital medical records of all
patients were reviewed 4 to 6 months after study completion.
Assumptions
Because 80% of children with appendicitis have appendiceal
perforation within 48 hours,12 we first assumed a
conservative rate of 50% appendiceal perforation in those children
with appendicitis who would have been discharged from the hospital from
the ED. We then assumed that no child with appendicitis who would have
been discharged from the hospital from the ED would have appendiceal
perforation (0% perforation rate). Second, we assumed that children
with appendicitis would eventually need appendectomy. Finally, the
costs of a negative laparotomy and positive laparotomy were assumed to
be the same.
Costs
The 1998 direct and indirect average costs for nonperforated
appendicitis, perforated appendicitis, and a hospital observation period for right lower quadrant abdominal pain were obtained from the
hospital cost database at Children's Hospital, Boston, Massachusetts. All costs are in 1998 US dollars. The cost of an inpatient
hospitalization day includes the daily room cost, intravenous fluids,
laboratory tests, and medications administered. The costs for a
nonperforated and perforated appendicitis do not include surgeons'
fees. ED costs were not included in the analysis. The costs of pelvic
US and CTRC were calculated from hospital charges with a cost-to-charge ratio of .47.36 US and CTRC costs include costs of
radiographic interpretation. The average number of inpatient
observation days for children with and without appendicitis were
calculated from the actual patient observation time of 351 children
between 1996 and 1997.
Costs were calculated for each child based on the change in management
following the US-CTRC protocol. Patients without appendicitis who were
to be observed before the imaging protocol and were subsequently discharged from the hospital after imaging as well as patients with
appendicitis who were to be observed initially and who subsequently went directly to the OR had inpatient observation hospitalization costs
subtracted. One half of those children with appendicitis who would have
been discharged from the hospital and who, after imaging, went directly
for appendectomy had perforation costs subtracted. Patients without
appendicitis who would have had appendectomy and were subsequently
discharged from the hospital or hospitalized for observation had
appendectomy costs subtracted. Children without appendicitis who would
have been observed and who, after imaging, went to the OR had
appendectomy costs added. Costs of US were added for the 139 children
and those of CTRC were added for the 108 children.
Cohort
The demographics and outcomes of the cohort have been previously
reported.35 One hundred thirty-nine children had equivocal
clinical presentations for appendicitis and were enrolled as the study
cohort. The mean (standard deviation) age of the cohort was 11.1 (4.25)
years (range: 3-20 years; median: 11 years). Two patients were >18
years of age. Seventy of the children (50.4%) were male. Fifty
children (36%) had pathologically proven appendicitis. Eleven of the
50 patients (22%) had perforated appendicitis and 3 (6%) had a
gangrenous appendix.
Thirty-one of the 139 children were imaged with US only. Of these, 19 children underwent appendectomy immediately after US and all had
pathologically proven appendicitis. One 5-year-old boy had an equivocal
US examination and was admitted for inpatient observation with
progression of symptoms. He underwent appendectomy 8 hours after
admission and pathologic examination revealed appendicitis. Eleven
children who had negative US examinations did not undergo CTRC due to
resolved symptoms (7/11), established alternative diagnoses (1/11),
visualization of a normal appendix (2/11), or patient inability to
retain the rectal contrast (1/11). The latter was an 11-year-old
developmentally delayed male with a negative US examination who was
hospitalized after failed CTRC and discharged within 24 hours after his
symptoms resolved. He returned 3 days later with perforated
appendicitis.
One hundred eight patients underwent CTRC imaging after a negative or
equivocal US. Thirty-one patients went immediately to the OR after
CTRC. Of these, 28 children (90.3%) had pathologically proven
appendicitis. Seven children (25%) had perforated appendicitis and 2 had a gangrenous appendix. Twenty-five patients were hospitalized for
observation; 24 (96%) did not have appendicitis. One patient had an
initial CTRC interpretation of terminal ileitis and was subsequently
diagnosed with a perforated appendicitis. He underwent percutaneous
drainage followed by interval appendectomy. Fifty-two children were
discharged from the hospital from the ED, none of whom had
appendicitis.
Changes in Management Decisions
The US-CTRC protocol resulted in a beneficial change in patient
management in 86/139 children (61.9%), no change in management in
50/139 children (36.0%), and an incorrect change in 3/139 children (2.1%). Of the 31 children who underwent US alone, a beneficial change
in management decision occurred in 12 children (38.7%), an incorrect
change in 1 (3.2%), and no change in management in 18 children
(58.1%; Tables 1 and
2). US followed by CTRC resulted in a
beneficial change in management in 74/108 children (68.5%), an
incorrect change in 2/108 (1.9%), and no change in management in
32/108 patients (29.6%; Tables 1 and 2).
TABLE 1 TABLE 2
METHODS
Top
Abstract
Methods
Results
Discussion
References
RESULTS
Top
Abstract
Methods
Results
Discussion
References
Changes in Management With US-CTRC Protocol
No Changes in Management With US-CTRC Protocol
Resources Saved
The average direct and indirect costs for each diagnosis and radiographic modality are shown in Table 3. From these values, the average amount saved or incurred by each patient in the protocol was calculated based on the change in management decisions before and after imaging (Table 4). Assuming a 50% perforation rate in those children with appendicitis who would have been discharged from the hospital from the ED before imaging, US alone in the 31 children who did not undergo CTRC saved $20 422.14 and US followed by CTRC saved $58 081.85 in the remaining 108 children. This resulted in total net savings of $78 503.99 or $564.78 per patient. Assuming a more conservative 0% perforation rate in these same children, US alone saved $4372.83, while US followed by CTRC saved $52 732.08 for total net savings of $57 104.91 or $410.83 per child.
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DISCUSSION |
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Abstract
Methods
Results
Discussion
References
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Advances in US and CT over the past decade have allowed for expedient ED diagnosis and management decisions in children with suspected appendicitis. Earlier diagnosis is essential in decreasing the perforation rate and its associated complications in those children with appendicitis. In addition, inpatient observation time and resultant costs can be reduced if a diagnosis is expediently made in the ED. A protocol of US followed by CTRC in those children with equivocal presentations for acute appendicitis has been shown to be accurate, highly sensitive, and specific.35
Previous studies have shown that in the adult population, routine use of CT lowers the cost and use of hospital resources in caring for patients with clinically suspected appendicitis.25,26 In addition, models using CT constructed from retrospective inpatient admissions for suspected appendicitis in children have also been shown to markedly reduce morbidity as well as the acute care costs associated with clinically suspected appendicitis.37
We have prospectively shown that a protocol of US followed by CTRC in a cohort of children with equivocal clinical findings for suspected appendicitis can reduce both morbidity and acute care costs as well as produce a net savings of $565 per child. Use of the protocol resulted in a correct change in management in 86/139 patients (61.9%), including preventing children with appendicitis from being discharged from the hospital or observed in the hospital as well as preventing children without appendicitis from undergoing unnecessary laparotomy.
Our study had a few limitations. First, several assumptions were made that may not be entirely valid. We assumed that 50% of patients with appendicitis who were discharged from the hospital would subsequently suffer appendiceal perforation. Although 80% of children with acute appendicitis will perforate within 48 hours,12 those children who were sent home may have been diagnosed before perforation. However, even if those patients were not treated as perforated appendicitis (0% perforation rate), the overall cost savings would be reduced from $78 503.99 to $57 104.91 or $411 per patient, which remains a substantial net savings. Second, the use of the cost-to-charge ratio for determining cost for the radiologic imaging studies is an estimate and may not reflect the accurate direct and indirect costs incurred by the hospital for these studies. In addition, our analysis only accounted for the short-term costs and morbidity associated with acute appendicitis. Additional costs, morbidity and even mortality may be incurred by the long-term complications of appendicitis, particularly perforated appendicitis.
When the imaging protocol was first implemented in our institution, many surgeons were initially reticent about discharging patients from the ED with negative CTRC scans because its accuracy in children had not yet been determined. Hence, many patients without appendicitis were admitted to the hospital for a period of inpatient observation. As the surgeons became more comfortable with the performance of CTRC, children were increasingly discharged from the hospital from the ED with appropriate follow-up. Thus, there would have been even greater cost savings than what we have reported in this study if all of the well-appearing children with negative CTRC scans were discharged from the hospital. In addition, the inconvenience of inpatient observation to the child as well as to the family would have been eliminated.
The protocol of US and CT was performed in those children with equivocal clinical findings for acute appendicitis, and thus, routine use of the protocol on all children with suspected appendicitis cannot be justifiably advocated. However, use of the US-CTRC protocol in those children with equivocal presentations for acute appendicitis has been shown to be highly accurate as well as to decrease morbidity and the acute care costs associated with the disease. Because we have shown both clinical benefit to patients as well as cost reduction, our data support the use of such a protocol in the management of children with equivocal presentations for acute appendicitis.
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ACKNOWLEDGMENTS |
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We thank John Howley in the Department of Finance for his help and patience; and Gary Fleisher, MD, and Constantino S. Peña, MD, for their continued support and encouragement.
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FOOTNOTES |
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Received for publication Oct 22, 1999; accepted Jan 11, 2000.
Reprint requests to (B.M.G.P.) Division of Emergency Medicine, Children's Hospital, 300 Longwood Ave, Boston, MA 02215. E-mail: pena_b{at}a1.tch.harvard.edu
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ABBREVIATIONS |
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US, ultrasonography; CT, computed tomography; CTRC, computed tomography with rectal contrast; ED, emergency department; OR, operating room.
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REFERENCES |
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Discussion
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This article has been cited by other articles:
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  A. B. Kharbanda, G. A. Taylor, S. J. Fishman, and R. G. Bachur A Clinical Decision Rule to Identify Children at Low Risk for Appendicitis Pediatrics, September 1, 2005; 116(3): 709 - 716. [Abstract] [Full Text] [PDF]
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 E. Cherniavsky, P. Crystal, and Y. Barki Sonography of Acute Appendicitis in a 9-Month-Old Infant J. Ultrasound Med., June 1, 2004; 23(6): 865 - 867. [Full Text] [PDF]
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 G. A. Taylor Suspected Appendicitis in Children: In Search of the Single Best Diagnostic Test Radiology, May 1, 2004; 231(2): 293 - 295. [Full Text] [PDF]
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B. M. Garcia Pena, E. F. Cook, and K. D. Mandl Selective Imaging Strategies for the Diagnosis of Appendicitis in Children Pediatrics, January 1, 2004; 113(1): 24 - 28. [Abstract] [Full Text] [PDF]
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A. M. Kosloske, C. L. Love, J. E. Rohrer, J. F. Goldthorn, and S. R. Lacey The Diagnosis of Appendicitis in Children: Outcomes of a Strategy Based on Pediatric Surgical Evaluation Pediatrics, January 1, 2004; 113(1): 29 - 34. [Abstract] [Full Text] [PDF]
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M. M. Ziegler The Diagnosis of Appendicitis: An Evolving Paradigm Pediatrics, January 1, 2004; 113(1): 130 - 132. [Full Text] [PDF]
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 Selections from Journal Watch Pediatrics and Adolescent Medicine Arch. Dis. Child., August 1, 2003; 88(8): 740 - 741. [Full Text] [PDF]
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B. M. G. Pena, G. A. Taylor, S. J. Fishman, and K. D. Mandl Effect of an Imaging Protocol on Clinical Outcomes Among Pediatric Patients With Appendicitis Pediatrics, December 1, 2002; 110(6): 1088 - 1093. [Abstract] [Full Text] [PDF]
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 B. K. Silverman Utility of Limited CT With Rectal Contrast for Diagnosing Appendicitis AAP Grand Rounds, February 1, 2001; 5(2): 17 - 17. [Full Text] [PDF]
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 Stepwise US and CT Reduce Morbidity and Costs of Childhood Appendicitis Journal Watch Emergency Medicine, December 6, 2000; 2000(1206): 2 - 2. [Full Text]
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 Ultrasound and CT Scan to Diagnose Appendicitis in Children Journal Watch (General), October 20, 2000; 2000(1020): 6 - 6. [Full Text]
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