title: Use and accuracy of diagnostic imaging by hospital type in pediatric appendicitis.
abstract: OBJECTIVE
  Accurate, timely diagnosis of pediatric appendicitis minimizes unnecessary operations and treatment delays. Preoperative abdominal-pelvic computed tomography (CT) scan is sensitive and specific for appendicitis; however, concerns regarding radiation exposure in children obligate scrutiny of CT use. Here, we characterize recent preoperative imaging use and accuracy among pediatric appendectomy subjects.
  
  
  METHODS
  We retrospectively reviewed children who underwent operations for presumed appendicitis at a single tertiary-care children's hospital and examined preoperative CT and ultrasound use with subject characteristics. Preoperative imaging accuracy was compared with postoperative and histologic diagnosis as the reference standard.
  
  
  RESULTS
  Most children (395/423, 93.4%) who underwent an operation for appendicitis during 2009-2010 had preoperative imaging. Final diagnoses included normal appendix (7.3%) and perforated appendicitis (23.6%). In multivariable analysis, initial evaluation at a community hospital versus the children's hospital was associated with 4.4-fold higher odds of obtaining a preoperative CT scan (P = .002), whereas preoperative ultrasound was less likely (odds ratio 0.20; P = .003). Ultrasound and CT sensitivities for appendicitis were diminished for studies performed at community hospitals compared with the children's hospital. Girls were 4.5-fold more likely to undergo both ultrasound and CT scans and were associated with lower ultrasound sensitivity for appendicitis.
  
  
  CONCLUSIONS
  Widespread preoperative imaging did not eliminate unnecessary pediatric appendectomies. Controlling for factors potentially associated with referral bias, a CT scan was more likely to be performed in children initially evaluated at community hospitals compared with the children's hospital. Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are urgently needed.
authors.affiliation: Division of Pediatric Surgery, Washington University, One Children's Pl, Suite 5S40, St Louis, MO 63110 63110, USA. saitoj@wudosis.wustl.edu
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Saito
authors.forename: Yan
authors.initials: Y
authors.lastname: Yan
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Evashwick
authors.forename: Brad W
authors.initials: BW
authors.lastname: Warner
authors.forename: Phillip I
authors.initials: PI
authors.lastname: Tarr
mesh_terms: D000293:Adolescent; D001064:Appendicitis / Q000000981:diagnostic imaging*; D002648:Child; D015331:Cohort Studies; D003952:Diagnostic Imaging / Q000592:standards* / Q000706:statistics & numerical data*; D005260:Female; D006764:Hospitals, Community / Q000592:standards*; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000592:standards / Q000706:statistics & numerical data; D014463:Ultrasonography