title: Progress in the diagnosis of appendicitis: a report from Washington State's Surgical Care and Outcomes Assessment Program.
abstract: OBJECTIVE
  Studies suggest that computed tomography and ultrasonography can effectively diagnose and rule out appendicitis, safely reducing negative appendectomies (NAs); however, some within the surgical community remain reluctant to add imaging to clinical evaluation of patients with suspected appendicitis. The Surgical Care and Outcomes Assessment Program (SCOAP) is a physician-led quality initiative that monitors performance by benchmarking processes of care and outcomes. Since 2006, accurate diagnosis of appendicitis has been a priority for SCOAP. The objective of this study was to evaluate the association between imaging and NA in the general community.
  
  
  METHODS
  Data were collected prospectively for consecutive appendectomy patients (age > 15 years) at nearly 60 hospitals. SCOAP data are obtained directly from clinical records, including radiological, operative, and pathological reports. Multivariate logistic regression models were used to examine the association between imaging and NA. Tests for trends over time were also conducted.
  
  
  RESULTS
  Among 19,327 patients (47.9% female) who underwent appendectomy, 5.4% had NA. Among patients who were imaged, frequency of NA was 4.5%, whereas among those who were not imaged, it was 15.4% (P < 0.001). This association was consistent for men (3% vs 10%, P < 0.001) and for women of reproductive age (6.9% vs 24.7%, P < 0.001). In a multivariate model adjusted for age, sex, and white blood cell count, odds of NA for patients not imaged were 3.7 times the odds for those who received imaging (95% CI: 3.0-4.4). Among SCOAP hospitals, use of imaging increased and NA decreased significantly over time; frequency of perforation was unchanged.
  
  
  CONCLUSIONS
  Patients who were not imaged during workup for suspected appendicitis had more than 3 times the odds of NA as those who were imaged. Routine imaging in the evaluation of patients suspected to have appendicitis can safely reduce unnecessary operations. Programs such as SCOAP improve care through peer-led, benchmarked practice change.
authors.affiliation: Department of Surgery, University of Washington, 1859 NE Pacific Street, Box 356410, Seattle, WA 98195, USA. ftdrake@u.washington.edu
authors.forename: Frederick Thurston
authors.initials: FT
authors.lastname: Drake
authors.forename: Michael G
authors.initials: MG
authors.lastname: Florence
authors.forename: Morris G
authors.initials: MG
authors.lastname: Johnson
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.forename: Steve
authors.initials: S
authors.lastname: Kwon
authors.forename: Zeila
authors.initials: Z
authors.lastname: Schmidt
authors.forename: Richard C
authors.initials: RC
authors.lastname: Thirlby
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001062:Appendectomy / Q000706:statistics & numerical data*; D001064:Appendicitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000601:surgery; D019985:Benchmarking; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014463:Ultrasonography / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D014861:Washington; D055815:Young Adult