Using the Analytic Hierarchy Process for Prioritizing Imaging Tests in Diagnosis of Suspected Appendicitis

In clinical guideline or criteria development processes, such as those used in developing American College of Radiology Appropriateness Criteria (ACR AC), experts subjectively evaluate benefits and risks associated with imaging tests and make complex decisions about imaging recommendations. The analytic hierarchy process (AHP) decomposes complex decisions into structured smaller decisions, incorporates quantitative evidence and qualitative expert opinion, and promotes structured consensus building. AHP may supplement and/or improve the transparency of expert opinion contributions to developing guidelines or criteria.

To conduct an empirical test using health services research tools, we convened a mock ACR AC panel of emergency department radiology and nonradiology physicians to evaluate by multicriteria decision analysis, the relative appropriateness of imaging tests for diagnosing suspected appendicitis. Panel members selected benefit-risk criteria via an online survey and assessed contrast-enhanced computed tomography, magnetic resonance imaging, and ultrasound using an AHP-based software. Participants were asked whether the process was manageable, transparent, and improved shared understanding. Priority scores were converted to rankings and compared to the rank order of ACR AC ratings.

When compared to magnetic resonance and ultrasound imaging, participants agreed with the ACR AC that contrast-enhanced computed tomography is the most appropriate test. Contrary to the ACR AC ratings, study results suggest that magnetic resonance is preferable to ultrasound. When compared to nonradiologists, radiologists' priority scores reflect a stronger preference for computed tomography.

Study participants addressed decision-making challenges using a relatively efficient data collection mechanism, suggesting that AHP may benefit the ACR AC guideline development process in identifying the relative appropriateness of imaging tests. With additional development, AHP may improve transparency when expert opinion is used in clinical guideline or appropriateness criteria development.