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Missed Opportunity for Initial Diagnosis in Children With Complex Appendicitis
Shruthi Srinivas, Wendy Jo Svetanoff1, Sidhant Kalsotra2
1Department of Pediatric Surgery, Nationwide Children's Hospital.
Objectives:
Delayed diagnosis of acute appendicitis in children may result in complex appendicitis with appendiceal perforation. Delayed diagnosis can result from missed opportunity for initial diagnosis (MOID) despite medical attention. Studies report MOID of less than 5% in pediatric emergency departments (EDs), but we hypothesized that many MOID occurs outside tertiary care facilities. Our goals were to determine the MOID rate in all presenting facilities in children with complex appendicitis and to identify associated risk factors.
Methods:
Children (age ≤18) undergoing appendectomy for complex appendicitis between 2018 and 2022 at a single free-standing academic children's hospital were reviewed. Missed opportunity for initial diagnosis was defined as evaluation for related symptoms without a diagnosis of appendicitis within 7 days prior to appendectomy. Logistic regression and UpSet plots were used to identify associated risk factors.
Results:
Of 856 children, 140 (16.4%) had MOID. Most MOID originated from nontertiary facilities [urgent care (38.6%), local EDs (26.4%), primary care (25.0%)] compared to our pediatric ED (11.4%). Compared to single-encounter diagnosis, MOID was associated with younger age (adjusted odds ratio per year [aOR] 0.93, 95% confidence interval [CI]: 0.88-0.97) and non-English/Spanish primary language (aOR 2.61, 95% CI: 1.18-5.76). Uninsured patients had lower MOID (aOR 0.22, 95% CI: 0.05-0.96). Missed opportunity for initial diagnosis was associated with more complications (33.6% vs 19.1%, P < 0.0001), prolonged length of stay (6 vs 4 days, P < 0.0001), and increased readmission (11.4% vs 6.6%, P = 0.044).
Conclusions:
Missed opportunity for initial diagnosis of complex appendicitis occurs in nontertiary care facilities, is more common in younger children and non-English/Spanish speakers, and is associated with worse outcomes, highlighting the need for interpreters and algorithmic evaluation in nontertiary care facilities.
Insights
Delayed diagnosis of complex appendicitis in children, termed missed opportunity for initial diagnosis (MOID), frequently occurs outside hospitals. This leads to worse outcomes, especially in younger, non-English speaking children.
Area of Science:
- Pediatric Surgery
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Delayed diagnosis of acute appendicitis in children can lead to complex appendicitis and perforation.
- Missed opportunity for initial diagnosis (MOID) is a key factor in delayed diagnosis, often occurring outside specialized pediatric centers.
Purpose of the Study:
- To determine the rate of MOID in children with complex appendicitis across all initial presenting facilities.
- To identify risk factors associated with MOID in pediatric complex appendicitis.
Main Methods:
- Retrospective review of children (≤18 years) with complex appendicitis undergoing appendectomy (2018-2022).
- MOID defined as evaluation for related symptoms without appendicitis diagnosis within 7 days prior to surgery.
- Logistic regression and UpSet plots used to analyze risk factors.
Main Results:
- 16.4% of 856 children experienced MOID, predominantly from non-tertiary facilities (urgent care, local EDs, primary care).
- MOID was linked to younger age and non-English/Spanish primary language; uninsured patients had lower MOID.
- MOID correlated with increased complications, longer hospital stays, and higher readmission rates.
Conclusions:
- MOID is prevalent in non-tertiary settings for pediatric complex appendicitis.
- Younger children and non-English speakers are at higher risk for MOID.
- Improved diagnostic strategies, including interpreter services and algorithmic evaluation, are needed in non-tertiary facilities.
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