The appendicitis algorithm five years later: Variability remains

Abstract

Background: Cost-effective care and minimizing computed tomography (CT) in children remain ideal. Our appendicitis work-up guideline decreased CT use when instituted in 2010. We reviewed 2015–2017 utilization to assess the need for modifications or education. Methods: A retrospective review identified all emergency department (ED) patients (0–18 years) evaluated for abdominal pain from 2015 to 2017. Associations with ED return, CT use, and guideline adherence were examined using multivariable logistic regressions. We obtained detailed cost of all services during the ED encounter; standardized cost was calculated in 2018 dollars. Results: 1,678 individuals were evaluated for abdominal pain; 43 underwent appendectomy. The guideline was applied to 8% all patients. For those undergoing appendectomy, there was no difference in guideline utilization rates between EM-trained and Pediatric EM-trained physicians (77.3% vs 81.0%). Guideline utilization was not associated with reduced CT use, with no difference by training (28.8% vs 36.4%). Ultrasound use, Pediatric Surgery consultation, antibiotics use, and ED time did not vary with guideline use or EM physician training type. Guideline adherence was associated with a lower likelihood of ED return (2 vs 4 patients, p = 0.015, OR = 0.004, 95% CI: 0.001 – 0.137). There was no difference in ED return by training (2/22 vs 4/21 patients). The mean total ED encounter cost difference by training was $158 (p = 0.101) Conclusion: Abdominal pain evaluation in pediatric patients remains variable. ED return for abdominal pain, potentially a proxy for diagnostic uncertainty, may be reduced with guideline adherence. Periodic education may improve compliance.