title: Implementing an ultrasound-based protocol for diagnosing appendicitis while maintaining diagnostic accuracy.
abstract: BACKGROUND
  The use of ultrasound to diagnose appendicitis in children is well-documented but not universally employed outside of pediatric academic centers, especially in the United States. Various obstacles make it difficult for institutions and radiologists to abandon a successful and accurate CT-based imaging protocol in favor of a US-based protocol.
  
  
  OBJECTIVE
  To describe how we overcame barriers to implementing a US-based appendicitis protocol among a large group of nonacademic private-practice pediatric radiologists while maintaining diagnostic accuracy and decreasing medical costs.
  
  
  METHODS
  A multidisciplinary team of physicians (pediatric surgery, pediatric emergency medicine and pediatric radiology) approved an imaging protocol using US as the primary modality to evaluate suspected appendicitis with CT for equivocal cases. The protocol addressed potential bias against US and accommodated for institutional limitations of radiologist and sonographer experience and availability. Radiologists coded US reports according to the probability of appendicitis. Radiology reports were compared with clinical outcomes to assess diagnostic accuracy. During the study period, physicians from each group were apprised of the interim US protocol accuracy results. Problematic cases were discussed openly.
  
  
  RESULTS
  A total of 512 children were enrolled and underwent US for evaluation of appendicitis over a 30-month period. Diagnostic accuracy was comparable to published results for combined US/CT protocols. Comparing the first 12 months to the last 12 months of the study period, the proportion of children achieving an unequivocal US result increased from 30% (51/169) to 53% (149/282) and the proportion of children undergoing surgery based solely on US findings increased from 55% (23/42) to 84% (92/109). Overall, 63% (325/512) of patients in the protocol did not require a CT. Total patient costs were reduced by $30,182 annually.
  
  
  CONCLUSIONS
  We overcame several barriers to implementing a US protocol. During the study period our ability to visualize the appendix with US increased and utilization of CT decreased. Our overall diagnostic accuracy with the US-based protocol was comparable to other published results and remained unchanged throughout the study.
authors.affiliation: University of Utah School of Medicine, Salt Lake City, UT, USA.
authors.forename: Angela J
authors.initials: AJ
authors.lastname: van Atta
authors.forename: Henry J
authors.initials: HJ
authors.lastname: Baskin
authors.forename: Connie K
authors.initials: CK
authors.lastname: Maves
authors.forename: Michael D
authors.initials: MD
authors.lastname: Rollins
authors.forename: Robert G
authors.initials: RG
authors.lastname: Bolte
authors.forename: Michael B
authors.initials: MB
authors.lastname: Mundorff
authors.forename: Seth P
authors.initials: SP
authors.lastname: Andrews
authors.forename: David M
authors.initials: DM
authors.lastname: Dansie
mesh_terms: D001064:Appendicitis / Q000000981:diagnostic imaging* / Q000191:economics; D001065:Appendix / Q000000981:diagnostic imaging; D002648:Child; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006776:Hospitals, Pediatric; D006786:Hospitals, Urban; D006801:Humans; D017410:Practice Guidelines as Topic; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014463:Ultrasonography; D014481:United States