Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis

Assessment of Alvarado criteria, ultrasound, CRP, and their combination in patients with suspected acute appendicitis: a single centre study

BACKGROUND

Acute appendicitis (AA) is one of the most common reasons for visiting the emergency room. The lack of proper diagnosis and rapid treatment of AA may lead to severe complications such as intestinal perforation and increased mortality. This study aimed to evaluate the diagnostic accuracy of the Alvarado criteria, ultrasound, and CRP criteria in comparison with their combined use in patients with suspected AA who presented to the emergency room.

METHODS

In this diagnostic accuracy study, 1411 patients with suspected AA who presented to the emergency department of Firoozabadi Hospital affiliated with Iran University of Medical Sciences and underwent appendectomy from October 2019 to October 2021 were examined. Nine hundred eighty-eight patients were enrolled. All patients were assessed using Alvarado, CRP, and ultrasound. The definitive diagnosis of AA was based on pathological findings and was considered the gold standard. Statistical analyses were performed with STATA VER 11.5. The diagnostic accuracy for each group was compared using the Pearson chi-square test. A value of p < 0.05 was considered statistically significant.

RESULTS

The mean age was 29.57 ± 13.66 years. The sensitivity and specificity of Alvarado in the diagnostic accuracy of appendicectomy were 75.2% and 61.3% (CI = 95%), respectively. The sensitivity of ultrasound and CRP for predicting appendicitis was significantly higher than the Alvarado criteria. The diagnostic accuracy for CRP was significantly higher than ultrasound (64.9% vs. 60.7%, P: 0.003). The diagnostic accuracy of the simultaneous use of Alvarado + CRP and CRP + Ultrasound was significantly higher than that of Alvarado + ultrasound. The sensitivity, specificity, and diagnostic accuracy of the simultaneous use of all three criteria together (Alvarado + Ultrasound + CRP) were estimated to be 94.9%, 25.8%, and 81.5% (CI = 95%), respectively, which were significantly higher than the use of other criteria.

CONCLUSION

This study showed that the Alvarado criteria had inadequate diagnostic sensitivity and accuracy for diagnosing acute appendicitis. The diagnostic accuracy of acute appendicitis increases to over 90% using the three Alvarado, ultrasound, and CRP criteria at the same time.

Clinical decision rules for appendicitis are not used by surgeons in training: A survey

BACKGROUNDS

We aimed to investigate surgeons in training knowledge of clinical decision rules (CDR) for diagnosing appendicitis and their attitudes toward implementing them.

METHODS

We included surgeons in training practicing in East Denmark who independently could decide to perform a diagnostic laparoscopy for suspected appendicitis. The survey was developed in Research Electronic Data Capture and face-validated before use. It consisted of three parts: (1) the characteristics of the surgeons, (2) their diagnostic approach, and (3) their knowledge and attitude toward introducing CDR in the clinic. Data were collected in January 2023.

RESULTS

We achieved 83 (90%) responses, and 52% of surgeons in training believed that appendicitis was difficult to diagnose. Their diagnostic approach mostly included symptoms and physical examinations for abdominal pain, and C-reactive protein. A total of 48% knew of at least one clinical decision rule, and 72% had never used a clinical decision rule. Regarding the necessity of CDR in clinical practice, surgeons in training options were divided into thirds: not needed, neither needed nor not needed, and needed. Surgeons in training indicated that CDR needed to be validated and easily applied before they would implement them.

CONCLUSION

Approximately 3/4 of surgeons in training had never utilized a clinical decision rule to diagnose appendicitis, and only half knew of their existence. The symptoms and findings incorporated in most CDR aligned with their diagnostic approach. They were conflicted if CDR needed to be implemented in clinical practice.

Diagnostic value of serum signal peptide-CUB-EGF-like domain-containing protein 1 levels in patients with acute appendicitis

OBJECTIVE

Acute appendicitis is one of the most common surgical causes of an acute abdomen among patients admitted to the emergency room due to abdominal pain. The clinical diagnosis of acute appendicitis is usually difficult and is made by evaluating the clinical, laboratory, and radiological findings together. The aim of this study was to investigate the diagnostic potential of signal peptide-CUB-EGF-like domain-containing protein 1 as a biomarker for acute appendicitis.

METHODS

A total of 67 adult patients without any comorbidities who presented to the emergency department with abdominal pain and were clinically diagnosed with acute appendicitis were included in the case group. The patients included in the study were classified into the negative appendectomy group and the acute appendicitis group according to their histopathological final diagnosis. In addition, 48 healthy volunteers without comorbidities were included in the control group. Signal peptide-CUB-EGF-like domain-containing protein 1 levels of patients and the control group were measured.

RESULTS

According to postoperative histopathological examinations of the patients, 7 (10.4%) patients were diagnosed with negative appendectomy, and 60 (89.6%) patients were diagnosed with acute appendicitis. Signal peptide-CUB-EGF-like domain-containing protein 1 levels were higher in the patients with acute appendicitis than in negative appendectomy patients (p=0.012). Signal peptide-CUB-EGF-like domain-containing protein 1 levels were also higher in the case group compared to the control group (p=0.001).

CONCLUSION

The admission signal peptide-CUB-EGF-like domain-containing protein 1 level was significantly higher in adults with acute appendicitis. The SCUBE1 level is a novel but promising biomarker that aids in the diagnosis of acute appendicitis.

Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

Barriers and facilitators of CT scan reduction in the workup of pediatric appendicitis: A pediatric surgical quality collaborative qualitative study

INTRODUCTION

Despite ongoing efforts to decrease ionizing radiation exposure from computed tomography (CT) use in pediatric appendicitis, high CT utilization rates are still observed across many hospitals. This study aims to identify factors influencing CT use and facilitators and barriers to quality improvement efforts.

METHODS

The Pediatric Surgery Quality Collaborative is a voluntary consortium of 42 children's hospitals participating in the National Surgical Quality Improvement Project - Pediatric. Hospitals were compared based on CT utilization from January 1, 2019, to December 31, 2019. Semi-structured interviews were conducted with surgeons, radiologists, emergency medicine physicians, and clinical data abstractors from 7 hospitals with low CT use rates (high performers) and 6 hospitals with high CT use rates (low performers). A mixed deductive and inductive coding approach for analysis of the interview transcripts was used to develop a codebook based on the Theoretical Domains Framework and subsequently identify prominent barriers and facilitators to CT reduction.

RESULTS

Thematic saturation was achieved after 13 interviews. We identified four factors that distinguish high-performing from low-performing hospitals: (1) consistent availability of resources such as ultrasound technicians, pediatric radiologists, and magnetic resonance imaging (MRI); (2) presence of and adherence to protocols guiding imaging modality decision making and imaging execution; (3) culture of inter-departmental collaboration; and (4) presence of a radiation reduction champion.

CONCLUSIONS

Significant barriers to reducing the use of CT in pediatric appendicitis exist. Our findings highlight that future quality improvement efforts should target resource availability, protocol adherence, collaborative culture, and radiation reduction champions.

LEVELS OF EVIDENCE

Level III.

Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center

OBJECTIVES

Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care. The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score.

METHODS

Prospective enrolled observational cohort single-center study of children aged 5-18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata. Total adjusted charges were determined for low-risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging.

RESULTS

Over the 13-month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient.

CONCLUSIONS

There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients.

Decline in Pediatric Emergency Department Behavioral Team Activations After Institution of an Agitation Protocol

OBJECTIVE

Aggressive behavior among pediatric patients with psychiatric complaints in emergency departments is a growing problem. An agitation protocol was instituted in 1 pediatric emergency department to provide scaled recommendations for differing levels of aggression. The study objective was to determine if the frequency of activation of an emergency behavioral response team changed after protocol initiation.

METHODS

A protocol for escalating management of agitation in pediatric patients was introduced in February 2016. The electronic medical record was queried for subsequent behavioral response team activations over the next 16 months. Patient demographics and specific features surrounding the activation were retrospectively recorded from the medical record, including length of stay, medications administered, and documented deescalation techniques. Frequency and features of behavioral team activations were compared with activations from a period before the planning and implementation of the protocol (May 2014 to May 2015).

RESULTS

Twenty-one patient visits were found to require behavioral response team activation over 16 months, compared with 31 for the 13-month preprotocol period. Attempts at verbal/ environmental redirection were seen in 77% and deescalation by medication administration before the activation occurred in 14% of patients. During the behavioral team activation, 81% of the patients were given psychiatric medications and 81% were placed in physical restraints.

CONCLUSIONS

A decrease from a baseline of 2.4 to 1.3 behavioral response team activations per month, or a 46% decline, was noted following the institution of a clinical protocol for pediatric agitation.

A systematic review of the cost-effectiveness of ultrasound in emergency care settings

BACKGROUND

The use of ultrasound (US) in emergency departments (ED) has become widespread. This includes both traditional US scans performed by radiology departments as well as point-of-care US (POCUS) performed by bedside clinicians. There has been significant interest in better understanding the appropriate use of imaging and where opportunities to enhance cost-effectiveness may exist. The purpose of this systematic review is to identify published evidence surrounding the cost-effectiveness of US in the ED and to grade the quality of that evidence.

METHODS

We performed a systematic review of the literature following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies were considered for inclusion if they were: (1) economic evaluations, (2) studied the clinical use of ultrasound, and (3) took place in an emergency care setting. Included studies were critically appraised using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

We identified 631 potentially relevant articles. Of these, 35 studies met all inclusion criteria and were eligible for data abstraction. In general, studies were supportive of the use of US. In particular, 11 studies formed a strong consensus that US enhanced cost-effectiveness in the investigation of pediatric appendicitis and 6 studies supported enhancements in the evaluation of abdominal trauma. Across the studies, weaknesses in methodology and reporting were common, such as lack of sensitivity analyses and inconsistent reporting of incremental cost-effectiveness ratios.

CONCLUSIONS

The body of existing evidence, though limited, generally demonstrates that the inclusion of US in emergency care settings allows for more cost-effective care. The most definitive evidence for improvements in cost-effectiveness surround the evaluation of pediatric appendicitis, followed by the evaluation of abdominal trauma. POCUS outside of trauma has had mixed results.

ACR Appropriateness Criteria® Suspected Appendicitis-Child

Acute appendicitis represents the most common abdominal surgical urgency/emergency in children. Imaging remains a central tool in the diagnosis of acute appendicitis and has been shown to facilitate management and decrease the rate of negative appendectomies. The initial consideration for imaging in a child with suspected acute appendicitis is based on clinical assessment, which can be facilitated with published scoring systems. The level of clinical risk (low, intermediate, high) and the clinical scenario (suspicion for complication) define the need for imaging and the optimal imaging modality. In some situations, no imaging is required, while in others ultrasound, CT, or MRI may be appropriate. This review frames the presentation of suspected acute appendicitis in terms of the clinical risk and also discusses the unique situations of the equivocal or nondiagnostic initial ultrasound examination and suspected appendicitis with suspicion for complication (eg, bowel obstruction). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Appendectomy or Not? An Update on the Evidence for Antibiotics Only Versus Surgery for the Treatment of Acute Appendicitis in Children

Appendicitis is a common diagnosis in children being evaluated in the emergency department. After diagnosis, standard treatment has been surgical appendectomy; however, in recent years there is a growing body of evidence evaluating the possibility of nonoperative management in both children and adults. This review will present the current state of the pediatric literature that suggests patients may be successfully treated with antibiotics alone (ie, without surgery), but that a proportion of these patients will have recurrent appendicitis. Given that the literature regarding the option of antibiotic-only management compared with surgery is not yet definitive, there are many factors for providers to discuss with families and patients when considering treatment for acute appendicitis.

The importance of visualization of appendix on abdominal ultrasound for the diagnosis of appendicitis in children: A quality assessment review

BACKGROUND

Ultrasound has the first line investigation role in the diagnosis of acute appendicitis in children. The purpose of this study was to perform a quality assessment review on the visualization rate of appendix on ultrasound in children in the community hospital setting.

METHODS

A retrospective chart review of the abdominal ultrasound findings for the visualization of the appendix was performed on paediatric patients ranging from 5 to 18 years. Data were collected from the two community hospitals of Toronto by using hospital electronic medical record for the ultrasound findings in patients presented with abdominal pain.

RESULTS

Data from two community hospitals indicated visualization rate of the appendix as 11.0% and 23.2% for site 1 and site 2 respectively. In cases where the ultrasound was repeated the visualization rate remains the same. A two-proportion z-test was performed to find whether the visualization of appendix increases the likelihood of diagnosing appendicitis. The results revealed that the visualization of an appendix (P=0.52), significantly improved the diagnosis of appendicitis (z=34, P<0.001).

CONCLUSION

Visualization of an appendix on ultrasound increases the likelihood of correctly diagnosing appendicitis. In our study, we found low visualization rate of appendix on ultrasound that could be the result of many factors that contribute towards the low visualization rate of an appendix on ultrasound. Hence, the challenges in identifying appendix should be minimized to improve the visualization and diagnosis of appendicitis on ultrasound.

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines

BACKGROUND AND AIMS

Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

METHODS

This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

CONCLUSIONS

The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

Cost-effectiveness of Imaging Protocols for Suspected Appendicitis

BACKGROUND

Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix.

METHODS

We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained).

RESULTS

The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients' risk of appendicitis but not the proportion of visualized appendices.

CONCLUSIONS

Tailored approaches to imaging based on patients' risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability <16% or >95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization.

Cost-Effectiveness Analysis in Pediatric Imaging: The Evidence (or Lack Thereof) Thus Far

OBJECTIVE

To systematically review all published cost-effectiveness analyses (CEAs) of imaging technologies in children.

METHODS

We identified all CEAs involving fetal and pediatric imaging included in a publicly available repository of CEAs published since 1976. Information on publication characteristics, methods, costs, quality of life weights, and incremental cost-effectiveness ratios (ICERs) was recorded for each article.

RESULTS

Of 480 diagnostic CEAs, only 10 focused on fetal and pediatric imaging. The 10 studies reported 43 quality of life weights based on previously published adult data (n = 20, 46.5%); pregnant women perspective (n = 11, 25.6%), and treating physician perspective (n = 12, 27.9%). None of the studies elicited quality of life weights from children nor took into consideration the postnatal impact of disease on family's quality of life. All studies used a health care payer perspective without incorporating patients' incurred cost such as loss wages or travel related cost. Of 37 ICERs, 7 (18.9%) were cost saving and 6 (16.2%) were more expensive and less effective. The remaining ICERs ranged from $1,400 per quality-adjusted life-year (MRI versus ultrasound in newborns with moderate risk of occult spinal dysraphism) to $10,000,000 per quality-adjusted life-year (CT versus no imaging in children at low risk for craniosynostosis).

CONCLUSION

There is a striking paucity of cost-effectiveness studies evaluating imaging technologies in children. Existing studies do not incorporate the patient and family perspectives regarding utilities (eg, impact of child's disease on families' quality of life) or cost (eg, loss wages, travel, time off). Future studies should elicit and incorporate the impact of disease on families to better reflect real-world scenarios.

Identifying Patients With Kawasaki Disease Safe for Early Discharge: Development of a Risk Prediction Model at a US Children's Hospital

OBJECTIVES

To develop a model to predict risk of intravenous immunoglobulin (IVIg) nonresponse in patients with Kawasaki disease (KD) to assist in early discharge decision-making.

METHODS

Retrospective cohort study of 430 patients 0 to 18 years old discharged from a US children's hospital January 1, 2010, through July 31, 2017 with a diagnosis of KD. IVIg nonresponse was defined as at least 1 of the following: temperature ≥38.0°C between 36 hours and 7 days after initial IVIg dose, receipt of a second IVIg dose after a temperature ≥38.0°C at least 20 hours after initial IVIg dose, or readmission within 7 days with administration of a second IVIg dose. Backward stepwise logistic regression was used to select a predictive model.

RESULTS

IVIg nonresponse occurred in 19% (81 of 430) of patients. We identified a multivariate model (which included white blood cell count, hemoglobin level, platelet count, aspartate aminotransferase level, sodium level, albumin level, temperature within 6 hours of first IVIg dose, and incomplete KD) with good predictive ability (optimism-adjusted concordance index: 0.700) for IVIg nonresponse. Stratifying into 2 groups by a predictive probability cutoff of 0.10, we identified 26% of patients at low risk for IVIg nonresponse, with a sensitivity and specificity of 90% and 30%, respectively, and a negative predictive value of 93%.

CONCLUSIONS

We developed a model with good predictive value for identifying risk of IVIg nonresponse in patients with KD at a US children's hospital. Patients at lower risk may be considered for early discharge by using shared decision-making. Our model may be used to inform implementation of electronic health record tools and future risk prediction research.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.

A simple algorithm to improve quality while reducing resource utilization in evaluation of suspected appendicitis in children

BACKGROUND

With similar effectiveness of ultrasonography, our institution replaced CT imaging with ultrasound for diagnosing appendicitis in children. An unexpected consequence was the overutilization of ultrasound. Our objective was to establish measures that could help prevent this overuse.

METHODS

A retrospective chart review of 327 consecutive pediatric patients evaluated for appendicitis between October 2014 and September 2015 at our institution was performed. Data on clinical, radiographic, and histopathologic findings were reviewed. Diagnostic accuracy of US and white blood cell (WBC) values was determined. An algorithm was created.

RESULTS

327 (100%) patients received an ultrasound for suspected appendicitis. WBC of 10,000/μl was determined to be the primary discriminant for management and ultrasound utilization. If a WBC ≥10,000/μL had been utilized as criteria for imaging, 49.5% fewer patients would have received an ultrasound.

CONCLUSIONS

Clinical exam, WBC count, and surgery consultation prior to ultrasonography can lessen then need for ultrasound utilization in children with suspected appendicitis.

Economic Analysis of Diagnostic Imaging in Pediatric Patients With Suspected Appendicitis

OBJECTIVE

The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals.

METHODS

This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration.

RESULTS

Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites.

CONCLUSIONS

Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.

Cost-effectiveness of rule-based immunoprophylaxis against respiratory syncytial virus infections in preterm infants

The objective of the paper is to assess the cost-effectiveness of targeted respiratory syncytial virus (RSV) prophylaxis based on a validated prediction rule with 1-year time horizon in moderately preterm infants compared to no prophylaxis. Data on health care consumption were derived from a randomised clinical trial on wheeze reduction following RSV prophylaxis and a large birth cohort study on risk prediction of RSV hospitalisation. We calculated the incremental cost-effectiveness ratio (ICER) of targeted RSV prophylaxis vs. no prophylaxis per quality-adjusted life year (QALYs) using a societal perspective, including medical and parental costs and effects. Costs and health outcomes were modelled in a decision tree analysis with sensitivity analyses. Targeted RSV prophylaxis in infants with a first-year RSV hospitalisation risk of > 10% resulted in a QALY gain of 0.02 (0.931 vs. 0.929) per patient against additional cost of €472 compared to no prophylaxis (ICER €214,748/QALY). The ICER falls below a threshold of €80,000 per QALY when RSV prophylaxis cost would be lowered from €928 (baseline) to €406 per unit. At a unit cost of €97, RSV prophylaxis would be cost saving.

CONCLUSIONS

Targeted RSV prophylaxis is not cost-effective in reducing RSV burden of disease in moderately preterm infants, but it can become cost-effective if lower priced biosimilar palivizumab or a vaccine would be available.

A prospective non-randomized controlled, multicenter trial comparing Appendectomy and Conservative Treatment for Patients with Uncomplicated Acute Appendicitis (the ACTUAA study)

PURPOSE

Acute appendicitis (AA) is among the most common causes of lower abdominal pain and admissions to the emergency department. Over the past 20 years, there has been a renewed interest in the conservative management of uncomplicated AA, and several studies demonstrated that an antibiotic-first strategy is a viable treatment option for uncomplicated AA. The aim of this prospective non-randomized controlled, multicenter trial is to compare antibiotic therapy and emergency appendectomy as treatment for patients with uncomplicated AA confirmed by US and/or CT or MRI scan.

METHODS

All adult patients in the age range 18 to 65 years with suspected AA, consecutively admitted to the Surgical Department of the 13 participating Italian Hospitals, will be invited to take part in the study. A multicenter prospective collected registry developed by surgeons, radiologists, and pathologists with expertise in the diagnosis and treatment of uncomplicated acute appendicitis represents the best research method to assess the long-term role of antibiotics in the management of the disease. Comparison will be made between surgical and antibiotic-first approaches to uncomplicated AA through the analysis of the primary outcome measure of complication-free treatment success rate based on 1-year follow-up. Quality of life, length of hospital stay, pain evaluation, and time to return to normal activity will be evaluated as secondary outcome measures.

TRIAL REGISTRATION

Clinicaltrials.gov ID: NCT03080103.

Defining the Rate of Negative Ureteroscopy in the General Population Treated for Upper Tract Urinary Stone Disease

INTRODUCTION

Ureteroscopy is increasingly used to treat upper tract urinary stone disease. A negative ureteroscopy is a ureteroscopy performed with the intent of removing a kidney or ureteral stone, but in which ultimately no stone is removed. Negative ureteroscopy may occur when the stone is found to have already passed, or the presumed stone is found to be outside of the collecting system. We sought to determine the rate of negative ureteroscopy in a large population-based sample as well as factors associated with its use.

PATIENTS AND METHODS

We examined nonpublic data from the Office of Statewide Health Planning and Development (OSHPD) Database for all patients in California undergoing outpatient surgery from 2010 to 2012. We identified all patients with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for upper tract urinary stone disease, who underwent a ureteroscopic procedure. After excluding patients undergoing second look procedures or who had diagnosis codes for separate urologic pathology, the negative ureteroscopy rate was defined as the proportion of those ureteroscopy cases coded as a diagnostic ureteroscopy. We fit logistic regression models to evaluate patient factors associated with negative ureteroscopy.

RESULTS

During the years 2010 to 2012, 20,236 eligible patients underwent ureteroscopic procedures for upper tract stone disease. Of these, 1287 patients underwent diagnostic ureteroscopy and 19,039 underwent ureteroscopy with stone removal accounting for a negative ureteroscopy rate of 6.3%. The odds of receipt of a negative ureteroscopy rate were higher in females compared to males (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25, 1.58) and lower in self-pay patients compared with insured patients (OR = 0.55, 95% CI 0.33, 0.91).

CONCLUSIONS

Negative ureteroscopy is common, occurring in nearly 1 in 16 procedures to treat urinary stone disease.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.