title: Computed Tomography Utilization for the Diagnosis of Acute Appendicitis in Children Decreases With a Diagnostic Algorithm.
abstract: OBJECTIVE
  The primary objective of this project was to decrease computed tomography (CT) utilization for the diagnosis of appendicitis in an academic children's hospital emergency department (ED) through a multidisciplinary quality improvement initiative.
  
  
  BACKGROUND
  Appendicitis is the most common abdominal diagnosis leading to the hospitalization of children in the United States. However, the diagnosis of appendicitis in children can be difficult and many centers rely heavily upon CT scans. Recent recommendations emphasize decreasing CT use among pediatric patients because of an increased lifetime risk of radiation-induced malignancies.
  
  
  METHODS
  A retrospective review was conducted of patients diagnosed with appendicitis in the ED at Children's Mercy Hospital from January 1, 2011 to February 28, 2014 to establish a baseline cohort. From August 1, 2014 to July 31, 2015, a newly designed diagnostic algorithm was used in the ED and patients were prospectively followed. Any patient discharged from the ED received a follow-up phone call. Patients treated for appendicitis before and after pathway implementation were compared. In addition, any patient evaluated for appendicitis after implementation of the algorithm was analyzed for adherence to the clinical pathway. Differences between the 2 groups were analyzed using ANOVA, Wilcoxon Rank Sum, χ, and Fisher Exact tests.
  
  
  RESULTS
  Of 840 patients seen after implementation of the diagnostic algorithm, 267 were diagnosed with appendicitis. After implementation of the algorithm, CT utilization decreased from 75.4% to 24.2% (P < 0.0001) in patients with appendicitis. CT utilization was 27.3% after implementation, regardless of the ultimate diagnosis or algorithm adherence. The diagnostic pathway had a sensitivity of 98.6% and specificity of 94.4%.
  
  
  CONCLUSIONS
  Implementation of a diagnostic algorithm for appendicitis in children significantly decreases CT utilization, whereas maintaining a high sensitivity and specificity.
authors.affiliation: *Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX †Division of Emergency Medicine and Urgent Care, Children's Mercy Hospital, Kansas City, MO ‡Department of Radiology, Children's Mercy Hospital, Kansas City, MO §Division of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, MO.
authors.forename: Sohail R
authors.initials: SR
authors.lastname: Shah
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Sinclair
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Theut
authors.forename: Kathy M
authors.initials: KM
authors.lastname: Johnson
authors.forename: George W
authors.initials: GW
authors.lastname: Holcomb
authors.forename: Shawn D
authors.initials: SD
authors.lastname: St Peter
mesh_terms: D000465:Algorithms; D001064:Appendicitis / Q000000981:diagnostic imaging*; D002648:Child; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D058996:Quality Improvement; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*