Diagnostic Accuracy in Pediatric Appendicitis
David G. Bundy, MD, MPHDivision of General Pediatrics and Adolescent Medicine
Department of Pediatrics
University of North Carolina
Chapel Hill, NC 27599-7105
To the Editor.—
Smink et al1 analyzed the Kids’ Inpatient Database and found that pediatric appendicitis misdiagnosis rates were lower in hospitals with higher annual appendectomy volumes. They suggested that successful practices from highest-volume hospitals could be disseminated to "improve the diagnosis of appendicitis throughout the pediatric population." An accompanying editorial concluded that "experienced clinicians and institutions produce optimal patient outcomes."2
These conclusions rest heavily on the assumption that lowering the negative appendectomy rate (the measure of "misdiagnosis" in this study) does not result in a corresponding increase in the appendiceal perforation rate through delayed diagnoses. Smink et al make precisely this assertion in their introduction. However, they presented no data on perforation rates despite the fact that their choice of International Classification of Diseases, Ninth Revision codes suggests that this might have been possible. If perforation rates are similar across hospitals of varying appendectomy volume, the conclusions of Smink et al and Ziegler are strengthened. If, however, higher-volume hospitals achieved lower negative appendectomy rates simply by raising their threshold for appendectomy (and thus increasing their rates of perforation through delayed diagnoses in equivocal cases), then the findings in the present study would be tempered.
Although I do not dispute the findings of Smink et al, I feel that their conclusions would have been strengthened with the inclusion of perforation data in their analyses, which would reassure readers that high-volume hospitals are not simply maximizing their diagnostic specificity at the expense of sensitivity.
REFERENCES
1. Smink DS, Finkelstein JA, Kleinman K, Fishman SJ. The effect of hospital volume of pediatric appendectomies on the misdiagnosis of appendicitis in children.
Pediatrics.2004; 113
:18
–23
2. Ziegler MM. The diagnosis of appendicitis: an evolving paradigm [commentary].
Pediatrics.2004; 113
:130
–132
Douglas S. Smink, MD, MPH
Steven J. Fishman, MD
Department of Surgery
Children’s Hospital Boston
Boston, MA 02115
In Reply.—
We agree with Bundy that both misdiagnosis and perforation are important outcomes in pediatric appendicitis. Although initial reports suggested that the 2 outcomes are inversely related,1 recent research questions this belief.2 We therefore decided to focus initially on misdiagnosis in our analysis. In addition, we suspected that the predictors of misdiagnosis and perforation (ie, patient and hospital characteristics) would differ, making a combined analysis inappropriate. Nonetheless, we concur that in order to completely understand the relationship between hospital volume and the diagnosis of pediatric appendicitis, the relationship between hospital volume and perforation should be analyzed also. We are currently in the process of performing this investigation.
REFERENCES
1. Velanovich V, Satava R. Balancing the normal appendectomy rate with the perforated appendicitis rate: implications for quality assurance. Am Surg.1992; 58 :264 –269[Web of Science][Medline]
2. Hale DA, Jaques DP, Molloy M, Pearl RH, Schutt DC, d’Avis JC. Appendectomy. Improving care through quality improvement.
Arch Surg.1997; 132
:153
–157
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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