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Diercks DB, Adkins EJ, Harrison N, Sokolove PE, Kwok H, Wolf SJ, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis: Approved by ACEP Board of Directors February 1, 2023. Ann Emerg Med 2023; 81:e115-e152. [PMID: 37210169 DOI: 10.1016/j.annemergmed.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Reduced Computed Tomography for Appendicitis in Children after Implementation of Next-day Surgery Clinic Follow-up. Pediatr Qual Saf 2023; 8:e641. [PMID: 36926215 PMCID: PMC10013624 DOI: 10.1097/pq9.0000000000000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/27/2023] [Indexed: 03/15/2023] Open
Abstract
The use of computed tomography (CT) in the emergency department (ED) evaluation of pediatric patients for suspected appendicitis can be safely reduced. However, published examples of reduced CT use also report increased MRI utilization, ED length of stay, hospitalization rates, and in-ED surgical consultation. In addition, previous studies recommended follow-up for undifferentiated abdominal pain, yet none with pediatric surgeons. Therefore, we implemented a diagnostic algorithm that includes an option for next-day surgery clinic follow-up in cases where uncertainty remains after appendix ultrasound (US) to reduce CT utilization without increasing hospital-based resources. Methods We implemented a diagnostic algorithm in January 2014. We retrospectively identified 4,577 patients who underwent an evaluation for suspected appendicitis from January 2012 to September 2015. CT utilization was compared before and after implementation using Statistical Process Control. In addition, we evaluated secondary outcomes, including US utilization, hospital admission, surgery clinic follow-up, ED surgery consultation, ED return visits within 7 days, and ED length of stay. Results Following the implementation of the algorithm, CT utilization decreased significantly from 13.8% to 6%. Forty-eight patients were evaluated the next day in the optional pediatric surgery clinic for 21 months after implementation. There was no significant change in US utilization, hospital admission, ED surgery consultation, ED return visits within 7 days, or ED length of stay. Conclusion We achieved decreased CT utilization without an increase in the utilization of other hospital-based resources after implementing a pediatric appendicitis evaluation algorithm that includes the option for next-day pediatric surgery clinic follow-up.
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Lentz B, Fong T, Rhyne R, Risko N. A systematic review of the cost-effectiveness of ultrasound in emergency care settings. Ultrasound J 2021; 13:16. [PMID: 33687607 PMCID: PMC7943664 DOI: 10.1186/s13089-021-00216-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/19/2021] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Brian Lentz
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, 1411 E. 31st Street, QIC 22123, Oakland, CA, 94602, USA
| | - Tiffany Fong
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Randall Rhyne
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD, 21287, USA.
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Mushtaq R, Desoky SM, Morello F, Gilbertson-Dahdal D, Gopalakrishnan G, Leetch A, Vedantham S, Kalb B, Martin DR, Udayasankar UK. First-Line Diagnostic Evaluation with MRI of Children Suspected of Having Acute Appendicitis. Radiology 2019; 291:170-177. [PMID: 30747595 DOI: 10.1148/radiol.2019181959] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Advances in abdominal MRI have enabled rapid, free-breathing imaging without the need for intravenous or oral contrast material. The use of MRI as the primary imaging modality for suspected appendicitis has not been previously studied. Purpose To determine the diagnostic performance of MRI as the initial imaging modality in children suspected of having acute appendicitis. Materials and Methods The study included consecutive patients 18 years of age and younger presenting with acute abdominal pain at a tertiary care institution from January 2013 through June 2016 who subsequently underwent an unenhanced MRI examination as the primary diagnostic imaging modality. Electronic medical records and radiology reports were retrospectively evaluated for the feasibility and diagnostic performance of MRI, with surgical pathology and follow-up electronic records as reference standards. Statistical analyses were performed by using simple binomial proportions to quantify sensitivity, specificity, and accuracy, and exact 95% confidence intervals (CIs) were obtained. Results After exclusions, 402 patients (median age: 13 years; interquartile range [IQR], 9-15 years; 235 female patients; 167 male patients) were included. Sedation for MRI was required in 13 of 402 patients (3.2%; 95% CI: 1.7%, 5.5%). The appendix was visualized in 349 of 402 patients (86.8%; 95% CI: 83.1%, 90%); for the remaining patients, a diagnosis was provided on the basis of secondary signs of appendicitis. The sensitivity, specificity, and accuracy of MRI as the primary diagnostic imaging modality for the evaluation of acute appendicitis were 97.9% (95 of 97; 95% CI: 92.8%, 99.8%), 99% (302 of 305; 95% CI: 97.2%, 99.8%), and 98.8% (397 of 402; 97.1%, 99.6%), respectively. Among patients with negative findings for appendicitis at MRI, an alternate diagnosis was provided in 113 of 304 patients (37.2%; 95% CI: 31.7%, 42.9%). Conclusion When performed as the initial imaging modality in children suspected of having acute appendicitis, MRI examinations had high diagnostic performance for the diagnosis of acute appendicitis and in providing alternative diagnoses. © RSNA, 2019 See also the editorial by Dillman and Trout in this issue.
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Affiliation(s)
- Raza Mushtaq
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Sarah M Desoky
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Frank Morello
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Dorothy Gilbertson-Dahdal
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Geetha Gopalakrishnan
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Aaron Leetch
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Srinivasan Vedantham
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Bobby Kalb
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Diego R Martin
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
| | - Unni K Udayasankar
- From the Departments of Medical Imaging (R.M., S.M.D., F.M., D.G., S.V., B.K., D.R.M., U.K.U.), Pediatrics (G.G.), and Pediatric Emergency Medicine (A.L.), University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724
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