Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis

Kharbanda, Anupam B.; Vazquez‐Benitez, Gabriela; Ballard, Dustin; Vinson, David R.; Chettipally, Uli K.; Dehmer, Steven P.; Ekström, Heidi; Rauchwerger, Adina S.; McMichael, Brianna S.; Cotton, Dale M.; Kene, Mamata V.; Simon, Laura; Zhu, Jingyi; Warton, E. Margaret; O’Connor, Patrick J.; Kharbanda, Elyse O.

doi:10.1001/jamanetworkopen.2020.36344

Cited by 18 publications

(13 citation statements)

References 37 publications

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“…A recently published randomized trial to reduce imaging in children with abdominal pain across 17 EDs encountered similar provider reluctance to discharge patients home without imaging. 22 To address this concern, it is vital to remove the stigma associated with a patient returning to the ED with appendicitis who was previously seen and discharged home with return precautions. This is an acceptable outcome, as the diagnosis can be difficult to make when patients present soon after symptoms begin.…”

Section: Discussionmentioning

confidence: 99%

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

D'Cruz

Linden

Devin

et al. 2022

Pediatric Quality &Amp; Safety

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Introduction: Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

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Section: Discussionmentioning

confidence: 99%

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

D'Cruz

Linden

Devin

et al. 2022

Pediatric Quality &Amp; Safety

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“…A recent cluster randomized trial also demonstrated that an EHR integrated clinical decision support aid that utilized the pediatric appendicitis risk score led to a decrease in CT and ultrasound use among patients with low risk of appendicitis. 21…”

Section: Discussionmentioning

confidence: 99%

Impact of HEART Score Decision Aid on Coronary Computed Tomography Angiography Utilization and Diagnostic Yield in the Emergency Department

McMahon

Shrestha

Thode

et al. 2023

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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Objective: Emergency physicians are challenged to efficiently and reliably risk stratify patients presenting with chest pain (CP) to optimize diagnostic testing and avoid unnecessary hospital admissions. The objective of our study was to evaluate the impact of a HEART score-based decision aid (HSDA) integrated in the electronic health record on coronary computed tomography angiography (CCTA) utilization and diagnostic yield in adult emergency department (ED) CP patients with suspected acute coronary syndrome. Methods: We conducted a before and after study to determine whether implementation of a mandatory computerized HSDA would reduce CCTA utilization in ED CP patients and improve the diagnostic yield of obstructive coronary artery disease (CAD) (≥50%). We included all adult ED CP patients with suspected acute coronary syndrome during the first 6 months of 2018 (before) and 2020 (after) at a large academic center. CCTA utilization and obstructive CAD yield were compared in patients before and after implementing the HSDA using χ 2 tests. Secondarily, we assessed the association of HEART scores and CCTA results. Results: Of the 3095 CP patients during the before study period, 733 underwent CCTA. Of the 2692 CP patients during the after study period, 339 underwent CCTA. CCTA utilization before and after HSDA was 23.4% [95% confidence interval (95% CI), 22.2-25.2] and 12.6% (95% CI, 11.4-13.0), respectively; mean difference was 11.1% (95% CI, 0.9-13.0). Among 1072 patients undergoing CCTA, mean (SD) age and percent females before versus after HSDA were 54 (11) versus 56 (11) years and 50% versus 49%, respectively. We included 1014 patients (686 before and 328 after) for the yield analysis. Obstructive CAD was present in 15% (95% CI, 12.7-17.9) and 20.1% (95% CI, 16.1-24.7) before and after HSDA, respectively; mean difference was 4.9% (95% CI, 0.1-10.1). Conclusions: Implementation of a mandatory electronic health record HSDA aid reduced ED CCTA utilization by half and improved the diagnostic yield.

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“…A recent cluster randomized trial demonstrated that an electronic medical record-linked clinical decision support tool that utilized the pARC score led to a decrease in CT and US use among patients with a pARC <15% in one healthcare system, with no safety concerns or adverse events. 23 Previous studies have shown favorable outcomes when selective imaging is used in patients with an intermediate risk of appendicitis. [24][25][26][27] In a prospective, observational cohort study conducted by Saucier et al at an academic pediatric ED, 119 (60%) of enrolled patients were found to be intermediate risk for appendicitis (PAS 4-7).…”

Section: Discussionmentioning

confidence: 99%

“…This discrepancy is most likely due to our small sample size; however, the rates of appendicitis are similar in these low‐risk categories, demonstrating the reproducibility of the pARC score in identifying low‐risk patients. A recent cluster randomized trial demonstrated that an electronic medical record‐linked clinical decision support tool that utilized the pARC score led to a decrease in CT and US use among patients with a pARC <15% in one healthcare system, with no safety concerns or adverse events 23 …”

Section: Discussionmentioning

confidence: 99%

Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center

Becker

Bergmann

Vazquez‐Benitez

et al. 2022

Academic Emergency Medicine

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Objectives: Appendicitis is a common pediatric condition requiring surgery. The pediatric appendicitis risk calculator (pARC) was recently developed to guide clinical care.The objective of this study is to describe resource utilization and clinical outcomes among children with appendix ultrasound (US) scans risk stratified by pARC score.Methods: Prospective enrolled observational cohort single-center study of children aged 5-18, who had an US for suspected appendicitis. We estimated the rate of appendicitis, rate of equivocal US scans, and resource utilization by pARC score strata.Total adjusted charges were determined for low-risk pARC patients compared to discharged emergency department (ED) patients with abdominal pain and complete blood count (CBC) obtained without advanced abdominal imaging.Results: Over the 13-month study period, 407 children were enrolled. The overall rate of appendicitis was 33.4%, and 199 (49%) were male. The observed rate of appendicitis was 3.3% in those with a pARC score of <15% and 96.8% in those with a pARC score of ≥85%. Of enrolled patients, 152 (37.3%) had a pARC score <15%. Of those with a pARC score of <15%, the negative appendectomy rate was 28.6%, and the rate of equivocal US was 49.3%. The rate of CT scans and hospitalizations was 19% and 23%, respectively. Median total charges for patients with pARC <15% with usual care were $3756. Median total charges for patients presenting to the ED with abdominal pain who had a CBC but no advanced abdominal imaging performed was $2484, indicating a potential savings of $1272 per patient. Conclusions:There is a high rate of resource utilization among patients who are low appendicitis risk by pARC score. Outcome variation by pARC scores presents future opportunity to selectively reduce resource utilization in pediatric patients.

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Effect of Clinical Decision Support on Diagnostic Imaging for Pediatric Appendicitis

Cited by 18 publications

References 37 publications

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

Impact of HEART Score Decision Aid on Coronary Computed Tomography Angiography Utilization and Diagnostic Yield in the Emergency Department

Resource utilization and outcomes among children risk stratified by pediatric appendicitis risk calculator at a tertiary pediatric center

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