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Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis: A Cluster Randomized Trial
Anupam B Kharbanda1, Gabriela Vazquez-Benitez2, Dustin W Ballard3,4
1Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis.
Insights
The AppyCDS tool did not reduce overall diagnostic imaging for pediatric appendicitis. However, it showed potential for more appropriate imaging use in patients with low appendicitis risk scores.
Area of Science:
- Pediatric Surgery
- Health Informatics
- Emergency Medicine
Background:
- Appendicitis is a common pediatric surgical emergency.
- Increased reliance on imaging like CT and US for diagnosis.
- Need for improved efficiency and quality of care in pediatric appendicitis management.
Purpose of the Study:
- To evaluate the effectiveness of AppyCDS, an EHR-linked clinical decision support tool.
- Assessed impact on diagnostic imaging, healthcare costs, and patient safety outcomes.
- Focused on children with suspected appendicitis presenting to emergency departments.
Main Methods:
- A parallel, cluster randomized trial involving 17 EDs across three states.
- Patients aged 5-20 with abdominal pain were randomized to AppyCDS or usual care.
- AppyCDS used the pediatric appendicitis risk calculator (pARC) to guide care recommendations.
Main Results:
- No significant difference in overall CT, US, or any imaging use between groups.
- Exploratory analysis showed reduced imaging for low pARC scores (<15%) and CT for intermediate scores (16-50%).
- No significant differences in perforation, negative appendectomy, or missed appendicitis rates; costs were similar.
Conclusions:
- AppyCDS did not lead to overall reductions in diagnostic imaging for pediatric appendicitis.
- Exploratory findings suggest potential for optimizing imaging use in specific patient subgroups.
- Further research may refine CDS tools for more targeted application in appendicitis diagnosis.
Importance:
Appendicitis is the most common pediatric surgical emergency. Efforts to improve efficiency and quality of care have increased reliance on computed tomography (CT) and ultrasonography (US) in children with suspected appendicitis.
Objective:
To evaluate the effectiveness of an electronic health record-linked clinical decision support intervention, AppyCDS, on diagnostic imaging, health care costs, and safety outcomes for patients with suspected appendicitis.
Design, Setting, And Participants:
In this parallel, cluster randomized trial, 17 community-based general emergency departments (EDs) in California, Minnesota, and Wisconsin were randomized to the AppyCDS intervention group or usual care (UC) group. Patients were aged 5 to 20 years, presenting for an ED visit with right-sided or diffuse abdominal pain lasting 5 days or less. We excluded pregnant patients, those with a prior appendectomy, those with selected comorbidities, and those with traumatic injuries. The trial was conducted from October 2016 to July 2019.
Interventions:
AppyCDS prompted data entry at the point of care to estimate appendicitis risk using the pediatric appendicitis risk calculator (pARC). Based on pARC estimates, AppyCDS recommended next steps in care.
Main Outcomes And Measures:
Primary outcomes were CT, US, or any imaging (CT or US) during the index ED visit. Safety outcomes were perforations, negative appendectomies, and missed appendicitis. Costs were a secondary outcome. Ratio of ratios (RORs) for primary and safety outcomes and differences by group in cost were used to evaluate effectiveness of the clinical decision support tool.
Results:
We enrolled 3161 patients at intervention EDs and 2779 patients at UC EDs. The mean age of patients was 11.9 (4.6) years and 2614 (44.0%) were boys or young men. RORs for CT (0.94; 95% CI, 0.75-1.19), US (0.98; 95% CI, 0.84-1.14), and any imaging (0.96; 95% CI, 0.86-1.07) did not differ by study group. In an exploratory analysis conducted in 1 health system, AppyCDS was associated with a reduction in any imaging (ROR, 0.82; 95% CI, 0.73- 0.93) for patients with pARC score of 15% or less and a reduction in CT (ROR, 0.58; 95% CI, 0.45-0.74) for patients with a pARC score of 16% to 50%. Perforations, negative appendectomies, and cases of missed appendicitis by study phase did not differ significantly by study group. Costs did not differ overall by study group.
Conclusions And Relevance:
In this study, AppyCDS was not associated with overall reductions in diagnostic imaging; exploratory analysis revealed more appropriate use of imaging in patients with a low pARC score.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02633735.
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