title: Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis.
abstract: There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging.
  
  
  
  We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention).
  
  
  
  The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT.
  
  
  
  Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio holly.depinet@cchmc.org.
authors.forename: Holly
authors.initials: H
authors.lastname: Depinet
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Daniel
authors.initials: D
authors.lastname: von Allmen
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Alex
authors.initials: A
authors.lastname: Towbin
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Richard
authors.initials: R
authors.lastname: Hornung
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Mona
authors.initials: M
authors.lastname: Ho
authors.affiliation: Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
authors.forename: Evaline
authors.initials: E
authors.lastname: Alessandrini
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D001064:Appendicitis / Q000000981:diagnostic imaging*; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways / Q000592:standards*; D020000:Decision Support Systems, Clinical; D057286:Electronic Health Records; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D065186:Interrupted Time Series Analysis; D008297:Male; D009820:Ohio; D019095:Point-of-Care Systems; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014463:Ultrasonography / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*; D055815:Young Adult