Improving ultrasound quality to reduce computed tomography use in pediatric appendicitis: the Safe and Sound campaign

Abstract

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.

The clinical value of pathology tests and imaging study in the diagnosis of acute appendicitis

“…Although ultrasound has moderately high PPV, its sensitivity is generally poor, averaging approximately 65% across all subgroups: only slightly better than flipping a coin. This is likely due to its inherent limitations, as previously addressed 3 6 26…”

Editorial

“…Especially in resource-deficient countries like India, this would appear to be a safe and cost-effective staged diagnostic protocol. It is also important that ultrasonologists should be well trained to evaluate suspected acute appendicits, especially in small children, as improving US accuracy and quality has a big role in reducing CT use [14]. …”

Imaging in acute appendicitis: What, when, and why?

“…8,9,57,58 The role of USG as a screening modality is being re-introduced and reinforced by improving the quality of USG and its reporting. 57,59,60 Current trends show reduction in CT usage and resurgence in use of USG for diagnosis of AA, with encouraging results. Also, the possibility of low-dose CT scan protocols without compromising the diagnostic quality of imaging is being explored, with promising results in last 5 years.…”