title: Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template.
abstract: OBJECTIVE
  Computed tomography (CT) for the diagnosis of appendicitis is associated with radiation exposure and increased cost. In an effort to reduce the diagnostic use of CT scans, we implemented a standardized ultrasound report template based on validated secondary signs of appendicitis.
  
  
  METHODS
  In September 2012, as part of a quality improvement project, we developed and introduced a four category standardized ultrasound report template for limited right lower quadrant abdominal ultrasounds. Outcomes for patients undergoing ultrasound or CT scan for appendicitis between 9/10/2012 and 12/31/2013 (Period 2, n=2033) were compared to the three months prior to implementation (Period 1, n=304).
  
  
  RESULTS
  In Period 1, 78 of 304 (25.7%) patients had appendicitis versus 385 of 2033 (18.9%) in Period 2 (p=0.006). Non-diagnostic exams decreased from 48% to 0.1% (p<0.001). Ultrasound sensitivity improved from 66.67% to 92.2% (p<0.001). Specificity did not significantly change (96.9% to 97.69%, p=0.46). CT utilization for appendicitis decreased from 44.3% in Period 1 to 14.5% at the end of Period 2 (p<0.001).
  
  
  CONCLUSIONS
  Implementation of a standardized ultrasound report template based on validated secondary signs of appendicitis nearly eliminated non-diagnostic exams, improved diagnostic accuracy, and resulted in a striking decrease in CT utilization.
authors.affiliation: Department of Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Jason W
authors.initials: JW
authors.lastname: Nielsen
authors.affiliation: Department of Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Boomer
authors.affiliation: Department of Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Kelli
authors.initials: K
authors.lastname: Kurtovic
authors.affiliation: Department of Radiology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Lee
authors.affiliation: University of Nebraska Medical Center, Omaha, NE, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kupzyk
authors.affiliation: The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Mallory
authors.affiliation: Department of Radiology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Brent
authors.initials: B
authors.lastname: Adler
authors.affiliation: Department of Radiology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: D Gregory
authors.initials: DG
authors.lastname: Bates
authors.affiliation: Department of Surgery, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA. Electronic address: brian.kenney@nationwidechildrens.org.
authors.forename: Brian
authors.initials: B
authors.lastname: Kenney
mesh_terms: D000465:Algorithms; D001064:Appendicitis / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D058996:Quality Improvement; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014463:Ultrasonography; D019564:Unnecessary Procedures; D055815:Young Adult
keywords: Acute appendicitis; Computed tomography; Secondary signs; Ultrasound