Diagnostic stewardship optimizes detection of appendicitis

Abdominal pain is among the most common reasons children are taken to the emergency department.

A small proportion of them usually have appendicitis, and timely detection is essential.

To do so, clinicians often rely on imaging, such as ultrasound or CT scans.

Although delayed diagnosis of appendicitis in children can be life threatening, overtesting is wasteful and can even cause harm.

Now in a study, published in Academic Emergency Medicine, University of Michigan researchers found that emergency departments vary widely in how they balance the need to diagnose appendicitis with the potential harms of overtesting.

“Children with abdominal pain are a diagnostic conundrum. On the one hand those who have appendicitis need to be diagnosed in a timely manner, but on the other hand the most common diagnostic tool we use, a CT scan, exposes them to radiation,” said Alexander Janke, M.D., a clinical assistant professor of emergency medicine.

Although there are a range of tools that emergency clinicians can use, including ultrasounds, CT scans, blood tests and consultation with surgical specialists, their implementation varies among different emergency departments across Michigan.

The availability and quality of ultrasound, for example, isn’t guaranteed at every emergency department.

Similarly, pediatric surgical consultations may be easily obtained in some, but not other, emergency departments.

To better understand the balance between overtesting and delayed diagnosis, the researchers studied over 100,000 emergency department visits for children with abdominal pain aged 5-17 years.

“Children with abdominal pain are a diagnostic conundrum. On the one hand those who have appendicitis need to be diagnosed in a timely manner, but on the other hand the most common diagnostic tool we use, a CT scan, exposes them to radiation."

Alexander Janke, M.D.

The data were collected from 26 emergency departments within the Michigan Emergency Department Improvement Collaborative between May 2016 to February 2024.

MEDIC is a quality improvement network that supports over 50 Michigan hospitals and enhances the quality of emergency department care.

To this end, MEDIC maintains a data registry that tracks clinical practices across the state, providing insight into diagnostic imaging use.

The team used the registry to understand both the patterns of how abdominal pain is evaluated in children and whether these are related to delays in diagnosing appendicitis.

Among 120,112 cases of abdominal pain, only 0.1% had a delayed diagnosis of appendicitis and these were not associated with differences in imaging rates.

Researchers found that large pediatric centers achieve low rates of delayed diagnosis of appendicitis while also having the lowest rates of CT use.

“Unsurprisingly, pediatric centers were able to accurately diagnose appendicitis without heavy reliance on CT scans. This is likely due to their access to high-quality ultrasound capabilities, MRI protocols for pediatric appendicitis, and in-house pediatric surgical consultation,” said Courtney Mangus, M.D., clinical assistant professor of emergency medicine.

Although the study does not include real-time insights into how doctors made their decisions, the team hopes that it can be used as a foundation to drive diagnostic improvements.

They hypothesize that adherence to best practices and coordinating care across centers could improve the evaluation of children with abdominal pain.

“Different hospitals handle these cases in different ways. Diagnosis can be hard, and our work is a reminder to families that it is okay to ask questions and advocate for your child when you go to the emergency room,” Janke said. 

Additional authors: Kenneth Michelson, Keith Kocher, Kristian Seiler, Michelle Macy, Michele Nypaver, Prashant Mahajan and Rajan Arora.

Funding/disclosures: Blue Cross Blue Shield of Michigan and Blue Care Network as a part of the BCBSM Value Partnerships program.

Paper cited: “Exploring diagnostic stewardship in the emergency department evaluation of pediatric abdominal pain in a statewide quality collaborative,” Academic Emergency Medicine. DOI: 10.1111/acem.15075

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