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Comparison of pediatric emergency physicians' and surgeons' evaluation and diagnosis of appendicitis
Anupam B Kharbanda1, Steven J Fishman, Richard G Bachur
1Division of Emergency Medicine, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA. ak493@columbia.edu
Insights
Pediatric emergency physicians and surgical residents show similar accuracy in predicting appendicitis, though physical exam findings vary. Their historical questioning is more consistent than their physical exam assessments.
Area of Science:
- Pediatric Emergency Medicine
- Surgical Resident Training
- Diagnostic Accuracy
Background:
- Appendicitis diagnosis in children relies on clinical assessment.
- Variability in diagnostic approaches can impact patient outcomes.
- Comparing diagnostic reliability between emergency physicians and surgical residents is crucial.
Purpose of the Study:
- To compare inter-examiner reliability between pediatric emergency physicians (EPs) and senior surgical residents.
- To evaluate the diagnostic accuracy of EPs and surgical residents in predicting appendicitis.
- To identify variations in eliciting historical and physical exam findings.
Main Methods:
- Prospective cohort study of children (3-18 years) with suspected appendicitis.
- Sequential examinations by a pediatric EP and a senior surgical resident.
- Comparison of inter-examiner reliability (kappa statistic) and predictive accuracy for appendicitis.
Main Results:
- Historical findings showed moderate to good agreement (kappa 0.33-0.82); physical exam findings showed poor to fair agreement (kappa 0.14-0.48).
- Both physician groups predicted similar median probabilities of appendicitis.
- Diagnostic accuracy was comparable for high (>90%) and low (<=10%) predicted probabilities of appendicitis.
Conclusions:
- Pediatric EPs and senior surgical residents demonstrate similar clinical prediction accuracy for appendicitis.
- Historical findings are elicited with greater similarity than physical exam findings.
- Findings support the development of standardized institutional management protocols for suspected appendicitis.
Objectives:
To compare the interexaminer reliability and ability to predict appendicitis between pediatric emergency physicians (EPs) and senior surgical residents.
Methods:
The authors conducted a prospective cohort study of children aged 3 to 18 years of age with signs and symptoms suspicious for appendicitis. Patients were initially examined by a pediatric EP attending and then by a consulting senior surgical resident. Physicians reported the presence or absence of specific historical and physical exam findings and predicted the likelihood the patient had appendicitis. Interexaminer reliability of historical and physical exam findings was compared (kappa statistic). Distributions and median probabilities of appendicitis were calculated for pediatric EP and surgeon predictions.
Results:
The authors evaluated 350 patients with acute abdominal pain. Historical questions revealed slight to very good agreement (kappa statistic range 0.33-0.82) between physician types, whereas physical examination findings exhibited poor to fair agreement (range 0.14-0.48). Physicians predicted similar median probabilities of appendicitis for patients who were ultimately diagnosed with appendicitis (75% vs. 70%; p = 0.73) and patients without appendicitis (25% vs. 30%; p = 0.59). For a subset of patients given a > or = 90% predicted probability of appendicitis, pediatric EPs and senior surgical residents had similar accuracy (80% vs. 79%; p = 0.92). Similarly, among patients with < or = 10% predicted probability, pediatric EPs were correct in 95% and senior surgical residents correct in 94% of patients (p = 0.63).
Conclusions:
Pediatric EPs and senior surgical residents elicit historical findings from patients with suspected appendicitis with a greater degree of similarity than physical examination findings, which exhibit a wide degree of variability. Pediatric EPs and senior surgical residents do not differ in their ability to clinically predict appendicitis. These findings may be helpful in developing institutional management protocols.
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