Comparison of pediatric emergency physicians' and surgeons' evaluation and diagnosis of appendicitis.
OBJECTIVE
To compare the interexaminer reliability and ability to predict appendicitis between pediatric emergency physicians (EPs) and senior surgical residents.


METHODS
The authors conducted a prospective cohort study of children aged 3 to 18 years of age with signs and symptoms suspicious for appendicitis. Patients were initially examined by a pediatric EP attending and then by a consulting senior surgical resident. Physicians reported the presence or absence of specific historical and physical exam findings and predicted the likelihood the patient had appendicitis. Interexaminer reliability of historical and physical exam findings was compared (kappa statistic). Distributions and median probabilities of appendicitis were calculated for pediatric EP and surgeon predictions.


RESULTS
The authors evaluated 350 patients with acute abdominal pain. Historical questions revealed slight to very good agreement (kappa statistic range 0.33-0.82) between physician types, whereas physical examination findings exhibited poor to fair agreement (range 0.14-0.48). Physicians predicted similar median probabilities of appendicitis for patients who were ultimately diagnosed with appendicitis (75% vs. 70%; p = 0.73) and patients without appendicitis (25% vs. 30%; p = 0.59). For a subset of patients given a > or = 90% predicted probability of appendicitis, pediatric EPs and senior surgical residents had similar accuracy (80% vs. 79%; p = 0.92). Similarly, among patients with < or = 10% predicted probability, pediatric EPs were correct in 95% and senior surgical residents correct in 94% of patients (p = 0.63).


CONCLUSIONS
Pediatric EPs and senior surgical residents elicit historical findings from patients with suspected appendicitis with a greater degree of similarity than physical examination findings, which exhibit a wide degree of variability. Pediatric EPs and senior surgical residents do not differ in their ability to clinically predict appendicitis. These findings may be helpful in developing institutional management protocols.
Kharbanda
Anupam B
AB
Division of Emergency Medicine, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA. ak493@columbia.edu
Fishman
Steven J
SJ
Bachur
Richard G
RG
D000293:Adolescent; D001064:Appendicitis / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence; D004635:Emergency Medicine; D013502:General Surgery; D006801:Humans; D008487:Medical History Taking; D015588:Observer Variation; D010808:Physical Examination; D011446:Prospective Studies