Effect of computed tomography on patient management and costs in children with suspected appendicitis

Objective. Children evaluated in the emergency department for possible appe ndicitis are often admitted for observation, despite the widespread availab ility of accurate diagnostic studies, particularly computed tomography (CT) . We sought to establish effective and efficient strategies for using CT to diagnose and manage children with possible appendicitis. Design. Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric tea ching hospital. Patients. All patients admitted from January 1996 to August 1997 for suspected appendicitis. Method of Analysis. Three modeled strategies were empirically applied to th e retrospective cohort of patients admitted for observation. Outcomes and c osts under the modeled strategies were compared with those under current pr actice. The three strategies were: 1) to obtain CT scans on all patients an d discharge those with normal findings; 2) to obtain CT scans and admit all patients; 3) to selectively obtain CT scans on those patients with a perip heral white blood cell count >10 000/mm(3) (10 x 10(9)/L) and admit all. Th e sensitivity and specificity of CT for diagnosing appendicitis were determ ined empirically from the data. A sensitivity analysis was performed. Main Outcome Measures. The number of preoperative inpatient observation day s, total hospital costs, and the rates of both missed appendicitis and nega tive laparotomies. Results. Of 609 patients hospitalized for possible appendicitis, 287 went d irectly to the operating room and 14 patients had known perforation and abs cess. Three hundred eight children were observed and comprised the study co hort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of t hese had a normal appendix at pathology. Three patients were discharged fro m the hospital after observation and were subsequently readmitted with appe ndicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current pra ctice strategy, the cohort collectively accumulated 487 inpatient observati on days and incurred a per patient cost of $5831. All three CT strategies w ould have reduced the total number of inpatient observation days, operation s, negative laparotomies, as well as the per patient cost. The strategy of obtaining CT scans on all patients and then admitting them had the lowest r ate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtai ning CT scans and sending home those with negative findings was $150 304. E ven at the lowest reported sensitivity and specificity of CT in the literat ure, the ordering of the three strategies remained constant and continued t o reduce total cost per patient. Conclusion. Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for chil dren with appendicitis.