Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess?

Rates of Concurrent Computed Tomography Imaging Following Ultrasound for Pediatric Patients With Appendicitis

INTRODUCTION

Imaging guidelines recommend an ultrasound (US)-first approach to evaluate appendicitis to minimize radiation. However, the association between US and computed tomography (CT) utilization remains unclear. We aimed to determine how increased US utilization correlated with the rate of CT evaluation of pediatric acute appendicitis.

METHODS

We conducted a retrospective cohort study using the 2019 Nationwide Emergency Department Sample. Eligible patients were aged less than 18 y with a diagnosis of appendicitis. Imaging was determined by Current Procedural Terminology codes. Concurrent imaging was defined as US and CT use during the same encounter. We calculated the hospital rate of concurrent imaging and categorized hospitals into tertiles: low (< 20%), medium (20%-40%), and high (> 40%). We developed generalized ordinal logistic regression models with inverse probability weighting to assess patient characteristics and hospital rates of concurrent imaging associations.

RESULTS

Our analysis included 485 hospitals and 23,976 patients. Thirty four percent were treated at hospitals in the lowest, 35% at the middle, and 31% at the highest tertile hospitals. We observed a negative correlation (-0.27, P < 0.001) between increasing US use and concurrent imaging use. The odds of presenting to a higher concurrent imaging rate hospital were significantly lower for Blacks (adjusted odds ratio [aOR] [95% confidence interval {CI}]: 0.6, [0.4-0.9]) and Hispanics (aOR [95% CI]: 0.7 [0.5-0.9]) in comparison to Whites. The odds of presenting to a higher concurrent imaging rate hospital were higher for patients in the second (aOR [95% CI]: 1.9 [1.2-3.2]) and lowest income quartile (aOR [95% CI]: 3.7 [1.1-13.1]) compared to the highest income quartile.

CONCLUSIONS

Increased US use correlated with decreased CT utilization for diagnosing appendicitis. White children and those in lower socioeconomic neighborhoods are more likely to visit hospitals with high concurrent imaging use.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BACKGROUND

Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

METHODS

Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

RESULTS

Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

CONCLUSION

Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

LEVEL OF EVIDENCE

Level V.