title: The optimal initial management of children with suspected appendicitis: a decision analysis.
abstract: OBJECTIVE
  As abdominal imaging has improved, the use of computed tomography (CT) and ultrasonography (US) for evaluating children with suspected appendicitis has increased. The purpose of this study was to determine the optimal management strategy for evaluating children with suspected appendicitis given the current accuracy of abdominal imaging.
  
  
  METHODS
  Decision analysis was used to evaluate 5 management strategies: discharge, observation, CT, US, and appendectomy. Probabilities and time variables were obtained from publications and a chart review. Each approach was evaluated for its impact on length of stay, hospital charges, cost effectiveness and its capacity to minimize perforation and avoid negative appendectomy (risk-benefit).
  
  
  RESULTS
  Discharge was preferred when the probability of appendicitis was low (<0.09 to <0.47), imaging when in an intermediate range and surgery when high (>0.61 to >0.91). A role for observation was found only when the anticipated time of inpatient observation was brief (<9 hours). Although CT was more expensive than US, CT was more cost effective for preventing negative appendectomy and perforation and achieved a better risk-benefit.
  
  
  CONCLUSIONS
  CT has an important role in the management of suspected appendicitis. Among children with a low or high likelihood of appendicitis, the cost of imaging tests required to prevent the complications of appendicitis is high.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA.
authors.forename: Benjamin A
authors.initials: BA
authors.lastname: Hagendorf
authors.forename: John R
authors.initials: JR
authors.lastname: Clarke
authors.forename: Randall S
authors.initials: RS
authors.lastname: Burd
mesh_terms: D015746:Abdominal Pain / Q000175:diagnosis / Q000209:etiology; D000293:Adolescent; D001062:Appendectomy / Q000191:economics; D001064:Appendicitis / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000191:economics / Q000601:surgery / Q000628:therapy*; D019090:Case Management / Q000191:economics; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007223:Infant; D007902:Length of Stay; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D010351:Patient Discharge; D012189:Retrospective Studies; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed / Q000191:economics; D014463:Ultrasonography