title: Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign.
abstract: BACKGROUND
  Safety concerns about the use of radiation-based imaging such as computed tomography (CT) in children have resulted in national recommendations to use ultrasound (US) for the diagnosis of appendicitis when possible. We evaluated the trends in CT and US use in a statewide sample and the accuracy of these modalities.
  
  
  METHODS
  Patients less than or equal to 18 years undergoing appendectomy in Washington State from 2008 to 2013 were evaluated for preoperative US/CT use, as well as imaging/pathology concordance using data from the Surgical Care and Outcomes Assessment Program.
  
  
  RESULTS
  Among 3,353 children, 98.3% underwent preoperative imaging. There was a significant increase in the use of US first over the study period (P < .001). The use of CT at any time during the evaluation decreased. Despite this, in 2013, over 40% of the children still underwent CT imaging. Concordance between US imaging and pathology varied between 40% and 75% at hospitals performing greater than or equal to 10 appendectomies in 2013. Over one third (34.9%) of CT scans performed in the evaluation of children with appendicitis were performed after an indeterminate US.
  
  
  CONCLUSIONS
  Although the use of US as the first imaging modality to diagnose pediatric appendicitis has increased over the past 5 years, over 40% of children still undergo a CT scan during their preoperative evaluation. Causality for this persistence of CT use is unclear, but could include variability in US accuracy, lack of training, and lack of awareness of the risks of radiation-based imaging. Developing a campaign to focus on continued reduction in CT and increased use of high-quality US should be pursued.
authors.affiliation: Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98101, USA; Surgical Outcomes Research Center, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98101, USA; CHASE Alliance, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98101, USA. Electronic address: mkotagal@uw.edu.
authors.forename: Meera
authors.initials: M
authors.lastname: Kotagal
authors.affiliation: Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98101, USA; Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Morgan K
authors.initials: MK
authors.lastname: Richards
authors.affiliation: Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Teresa
authors.initials: T
authors.lastname: Chapman
authors.affiliation: Department of Radiology, Swedish Medical Center, Seattle, WA, USA.
authors.forename: Lisa
authors.initials: L
authors.lastname: Finch
authors.affiliation: Department of Emergency Medicine, Providence Centralia Hospital, Centralia, WA, USA.
authors.forename: Bessie
authors.initials: B
authors.lastname: McCann
authors.affiliation: Department of Radiology, Mary Bridge Children's Hospital, Tacoma, WA, USA.
authors.forename: Amaya
authors.initials: A
authors.lastname: Ormazabal
authors.affiliation: Department of Surgery, Madigan Army Medical Hospital, Tacoma, WA, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Rush
authors.affiliation: Department of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Adam B
authors.initials: AB
authors.lastname: Goldin
mesh_terms: D000293:Adolescent; D001062:Appendectomy; D001064:Appendicitis / Q000000981:diagnostic imaging* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003952:Diagnostic Imaging / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*; D014463:Ultrasonography
keywords: Appendicitis; Computed tomography; Radiology; Ultrasound