L. Schoel1, I. I. Maizlin1, T. Koppelmann1, M. Shroyer1, A. Douglas1, R. T. Russell1 1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA
Introduction: Appendicitis represents the most common surgical emergency in children, yet it can often be difficult to differentiate from other causes of acute abdominal pain. Diagnostic imaging modalities, such as computed tomography (CT) and ultrasonography (US), are often employed to assist with the diagnosis of acute appendicitis in children. The American College of Radiology recommends ultrasound as the first line imaging study for children with suspected appendicitis. Data from the American College of Surgeons NSQIP-Pediatric Appendectomy pilot identified our facility as a high outlier for CT utilization. We performed a quality improvement effort to reduce this utilization in favor of US-based diagnoses through creation of an appendicitis algorithm.
Methods: An evidence-based algorithm was created by a multidisciplinary team incorporating the Pediatric Appendicitis Score to direct surgical consultation and imaging recommendations for all patients presenting directly to our facility. We evaluated data from a two-year period, including one year preceding and one year following institution of the protocol, to assess changes in imaging strategies for pediatric appendicitis. Patients transferred from referring facilities with prior imaging were excluded. Standard statistical methods were utilized.
Results: A total of 227 patients (117 pre-/110 post-protocol initiation) were primarily evaluated in our Emergency Department and diagnosed with appendicitis during the period in question. There were no differences in gender, age, race, or BMI between the groups. There was a significant reduction in the utilization of CT following introduction of the protocol (Fig 1) and a concurrent increase in the utilization of US. Importantly, there were no differences in length of stay (p=0.27), post-operative complications (p=0.19), or negative appendectomy rates (p=0.40) between the two periods. Based on estimated imaging charges for US and CT, this reduction saves an estimated $109, 400 in health care costs for this population.
Conclusion: Based on NSQIP-Pediatric Appendectomy data, we initiated and experienced success in a quality improvement project to decrease the utilization of CT scans for diagnosis of pediatric appendicitis. This paradigm shift led to significant health care cost savings without negatively affecting post-operative outcomes. NSQIP data provide a useful framework on which to build collaborative quality improvement efforts.
