Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis
Holly Depinet1, Daniel von Allmen2, Alex Towbin2
1Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio holly.depinet@cchmc.org.
Insights
Standardized care pathways and electronic decision support tools reduced unnecessary computed tomography (CT) scans for appendicitis diagnosis in children. These interventions improved diagnostic workup without significantly impacting ultrasound use.
Area of Science:
- Pediatric emergency medicine
- Diagnostic imaging optimization
- Clinical decision support systems
Background:
- Increasing use of imaging for appendicitis diagnosis, despite identification of high/low-risk pediatric groups who may not benefit.
- Need for improved diagnostic workup to reduce unnecessary imaging in pediatric appendicitis.
Purpose of the Study:
- To evaluate the impact of a standardized care pathway and an electronic decision support tool on diagnostic imaging for appendicitis in children.
- To determine if these interventions could safely decrease the use of unnecessary imaging compared to historical controls.
Main Methods:
- Interrupted time series trial comparing diagnostic imaging (CT and ultrasound) proportions across three periods: historical controls, passive pathway diffusion, and active electronic decision support tool.
- Analysis focused on changes in imaging utilization within moderate- and high-risk pediatric appendicitis groups.
Main Results:
- Both passive and active interventions significantly reduced computed tomography (CT) use in moderate- and high-risk groups compared to historical controls.
- Ultrasound utilization increased across all risk groups after the interventions.
- Time series analysis indicated that secular trends did not explain the observed decrease in CT use.
Conclusions:
- Passive and active decision support tools effectively minimized unnecessary CT imaging for pediatric appendicitis.
- Further long-term studies are needed to fully understand the sustained effects of these interventions.
Background:
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.
Methods:
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).
Results:
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.
Conclusions:
Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
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