title: Variation in the Diagnosis and Management of Appendicitis at Canadian Pediatric Hospitals.
abstract: OBJECTIVE
  The objective was to characterize the variations in practice in the diagnosis and management of children admitted to hospitals from Canadian pediatric emergency departments (EDs) with suspected appendicitis, specifically the timing of surgical intervention, ED investigations, and management strategies.
  
  
  METHODS
  Twelve sites participated in this retrospective health record review. Children aged 3 to 17 years admitted to the hospital with suspected appendicitis were eligible. Site-specific demographics, investigations, and interventions performed were recorded and compared. Factors associated with after-hours surgery were determined using generalized estimating equations logistic regression.
  
  
  RESULTS
  Of the 619 children meeting eligibility criteria, surgical intervention was performed in 547 (88%). After-hours surgery occurred in 76 of the 547 children, with significant variation across sites (13.9%, 95% confidence interval = 7.1% to 21.6%, p < 0.001). The overall perforation rate was 17.4% (95 of 547), and the negative appendectomy rate was 6.8% (37 of 547), varying across sites (p = 0.004 and p = 0.036, respectively). Use of inflammatory markers (p < 0.001), blood cultures (p < 0.001), ultrasound (p = 0.001), and computed tomography (p = 0.001) also varied by site. ED administration of narcotic analgesia and antibiotics varied across sites (p < 0.001 and p = 0.001, respectively), as did the type of surgical approach (p < 0.001). After-hours triage had a significant inverse association with after-hours surgery (p = 0.014).
  
  
  CONCLUSIONS
  Across Canadian pediatric EDs, there exists significant variation in the diagnosis and management of children with suspected appendicitis. These results indicate that the best diagnostic and management strategies remain unclear and support the need for future prospective, multicenter studies to identify strategies associated with optimal patient outcomes.
authors.affiliation: Alberta Children's Hospital Research Institute and Department of Pediatrics, University of Calgary, Calgary, AB.
authors.forename: Graham C
authors.initials: GC
authors.lastname: Thompson
authors.affiliation: Hospital for Sick Children, University of Toronto, Toronto, ON.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Schuh
authors.affiliation: Centre Hospitalier Universitaire Ste-Justine, Universite de Montreal, Montreal, QC.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Gravel
authors.affiliation: Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON.
authors.forename: Sarah
authors.initials: S
authors.lastname: Reid
authors.affiliation: IWK Health Centre, Dalhousie University, Halifax, NS.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Fitzpatrick
authors.affiliation: Stollery Children's Hospital, University of Alberta, Edmonton, AB.
authors.forename: Troy
authors.initials: T
authors.lastname: Turner
authors.affiliation: Hospital for Sick Children, University of Toronto, Toronto, ON.
authors.forename: Maala
authors.initials: M
authors.lastname: Bhatt
authors.affiliation: Winnipeg Children's Hospital, University of Manitoba, Winnipeg, MB.
authors.forename: Darcy
authors.initials: D
authors.lastname: Beer
authors.affiliation: British Columbia Children's Hospital, University of British Columbia, Vancouver, BC.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Blair
authors.affiliation: Alberta Children's Hospital Research Institute and Department of Pediatrics, University of Calgary, Calgary, AB.
authors.forename: Robin
authors.initials: R
authors.lastname: Eccles
authors.affiliation: Children's Hospital London Health Sciences Centre, Western University, London, ON.
authors.forename: Sarah
authors.initials: S
authors.lastname: Jones
authors.affiliation: Children's Hospital London Health Sciences Centre, Western University, London, ON.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Kilgar
authors.affiliation: Alberta Children's Hospital Research Institute and Department of Pediatrics, University of Calgary, Calgary, AB.
authors.forename: Natalia
authors.initials: N
authors.lastname: Liston
authors.affiliation: Janeway Children's Health and Rehabilitation Centre, Memorial University, St. John's, NL.
authors.forename: John
authors.initials: J
authors.lastname: Martin
authors.affiliation: Alberta Children's Hospital Research Institute and Department of Pediatrics, University of Calgary, Calgary, AB.|Department of Community Health Sciences, University of Calgary, Calgary, AB.
authors.forename: Brent
authors.initials: B
authors.lastname: Hagel
authors.affiliation: Alberta Children's Hospital Research Institute and Department of Pediatrics, University of Calgary, Calgary, AB.|Department of Community Health Sciences, University of Calgary, Calgary, AB.
authors.forename: Alberto
authors.initials: A
authors.lastname: Nettel-Aguirre
mesh_terms: D000293:Adolescent; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001062:Appendectomy / Q000706:statistics & numerical data; D001064:Appendicitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000628:therapy*; D015415:Biomarkers; D002170:Canada; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005260:Female; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography
chemical_list: D000701:Analgesics, Opioid; D000900:Anti-Bacterial Agents; D015415:Biomarkers