Introduction Safety concerns about the use of radiation-based imaging such as computed tomography (CT) in children have resulted in national recommendations to use ultrasound (US) for diagnosis of appendicitis when possible. We evaluated trends in CT and US use in a statewide sample and the accuracy of these modalities. Methods Patients ≤18 years old undergoing appendectomy in Washington State from 2008 to 2013 were evaluated for preoperative US/CT use as well as imaging/pathology concordance using data from the Surgical Care and Outcomes Assessment Program. Results Among 3353 children, 98.3% underwent preoperative imaging. There was a significant increase in the use of US first over the study period (p<.001). The use of CT at any time during the evaluation decreased. Despite this, in 2013 over 40% of children still underwent CT imaging. Concordance between US imaging and pathology varied between 40–75% at hospitals performing ≥10 appendectomies in 2013. Over one third (34.9%) of CT scans performed in evaluation of children with appendicitis were performed after an indeterminate US. Discussion While use of US as the first imaging modality to diagnose pediatric appendicitis has increased over the past five years, over 40% of children still undergo a CT scan during their preoperative evaluation. Causality for this persistence of CT use is unclear, but could include variability in ultrasound accuracy, lack of training, and lack of awareness of the risks of radiation-based imaging. Developing a campaign to focus on continued reduction in CT and increased use of high-quality ultrasound should be pursued.

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We develop a methodology for evaluating a decision strategy generated by a stochastic optimization model. The methodology is based on a pilot study in which we estimate the distribution of performance associated with the strategy, and define an appropriate stratified sampling plan. An algorithm we call filtered search allows us to implement this plan efficiently. We demonstrate the approach's advantages with a problem in asset / liability management for an insurance company.

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