Practice guidelines decrease CT use in appendicitis evaluation

Implementation of a clinical practice guideline for evaluating appendicitis that focuses on early surgical consultation before obtaining advanced imaging markedly decreased reliance on computed tomography (CT) without loss of diagnostic accuracy, a study from a children’s hospital showed. A team of pediatric surgeons, pediatric emergency medicine physicians, and pediatric radiologists developed the clinical pathway to evaluate abdominal pain suggestive of appendicitis to emphasize clinical examination, early pediatric surgeon involvement, and selective use of ultrasound (US) as the initial advanced imaging modality.

To measure the effects of implementation of the guideline, investigators compared the percentage change in imaging use among 70 patients who had appendectomy in the year before implementation and 90 patients who underwent appendectomy after implementation, finding a 41% decrease in CT use among those in the postimplementation group. Among children in the preguideline group, 90% had CT scans, 6.9% had US, and 5.7% had no imaging. In the postguideline group, 48% underwent CT, 39.6% underwent US, and 15.6% had no imaging. The similar negative appendectomy rate was 5.7% in the preguideline group and 5.2% in the postguideline group (Russell WS, et al. Pediatr Emerg Care. 2013;29[5]:568-573).

COMMENTARY  Through the American Board of Internal Medicine Foundation Choosing Wisely campaign, physician specialty organizations have been given an opportunity to identify a list of 5 tests or procedures that may be overused by their member physicians. Participating organizations have distributed these lists to physicians and to patient groups in an effort to encourage thoughtful discussion. The American Academy of Pediatrics (AAP) has included in its list the use of CT scan in routine evaluation of abdominal pain (http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/). This doesn’t mean that the AAP suggests that this modality never has a role in evaluating this complaint. Rather, the AAP suggests that physicians and parents discuss the risks and benefits of the test while considering other alternatives (such as US or no testing at all). The multidisciplinary effort described in this article is exactly the type of result that founders of the Choosing Wisely campaign had hoped for in beginning this initiative. -Michael Burke, MD

DR BURKE, section editor for Journal Club, is chairman of the Department of Pediatrics at Saint Agnes Hospital, Baltimore, Maryland. He is a contributing editor for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.