Peña B M, Taylor G A, Lund D P, Mandl K D
Department of Medicine, Division of Emergency Medicine, Children's Hospital, Harvard Medical School, Boston, MA 02215, USA.
Pediatrics. 1999 Sep;104(3 Pt 1):440-6. doi: 10.1542/peds.104.3.440.
Children evaluated in the emergency department for possible appendicitis are often admitted for observation, despite the widespread availability 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.
Retrospective chart review and decision analysis. Setting. Emergency department of a large, urban tertiary care pediatric teaching hospital.
All patients admitted from January 1996 to August 1997 for suspected appendicitis. METHOD OF ANALYSIS: Three modeled strategies were empirically applied to the retrospective cohort of patients admitted for observation. Outcomes and costs under the modeled strategies were compared with those under current practice. The three strategies were: 1) to obtain CT scans on all patients and 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 peripheral white blood cell count >10 000/mm(3) (10 x 10(9)/L) and admit all. The sensitivity and specificity of CT for diagnosing appendicitis were determined empirically from the data. A sensitivity analysis was performed.
The number of preoperative inpatient observation days, total hospital costs, and the rates of both missed appendicitis and negative laparotomies.
Of 609 patients hospitalized for possible appendicitis, 287 went directly to the operating room and 14 patients had known perforation and abscess. Three hundred eight children were observed and comprised the study cohort. Of the cohort, 112 (36.4%) underwent appendectomy and 26 (23.2%) of these had a normal appendix at pathology. Three patients were discharged from the hospital after observation and were subsequently readmitted with appendicitis (missed appendicitis). Among the 75 patients who had CT performed, the sensitivity and specificity of CT were both 97%. Under the current practice strategy, the cohort collectively accumulated 487 inpatient observation days and incurred a per patient cost of $5831. All three CT strategies would have reduced the total number of inpatient observation days, operations, 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 rate of missed appendicitis. The additional cost of preventing each case of missed appendicitis under this strategy compared with the strategy of obtaining CT scans and sending home those with negative findings was $150,304. Even at the lowest reported sensitivity and specificity of CT in the literature, the ordering of the three strategies remained constant and continued to reduce total cost per patient.
Compared with current practice, diagnostic strategies using CT could reduce costs and improve diagnosis, management, and outcomes for children with appendicitis.
尽管有准确的诊断检查手段，尤其是计算机断层扫描（CT）已广泛应用，但在急诊科接受评估的疑似阑尾炎患儿仍常被收住入院观察。我们试图制定有效且高效的策略，利用CT来诊断和管理疑似阑尾炎患儿。
回顾性病历审查和决策分析。地点：一家大型城市三级护理儿科教学医院的急诊科。
1996年1月至1997年8月因疑似阑尾炎入院的所有患者。分析方法：将三种模拟策略经验性地应用于回顾性观察入院患者队列。将模拟策略下的结果和成本与当前实际情况进行比较。这三种策略分别是：1）对所有患者进行CT扫描，对检查结果正常的患者予以出院；2）进行CT扫描并收住所有患者；3）对那些外周血白细胞计数>10000/mm³（10×10⁹/L）的患者选择性地进行CT扫描，并收住所有患者。根据数据经验性地确定CT诊断阑尾炎的敏感性和特异性。进行了敏感性分析。
术前住院观察天数、总住院费用以及漏诊阑尾炎和阴性剖腹探查的发生率。
609例因疑似阑尾炎住院的患者中，287例直接进入手术室，14例已知有穿孔和脓肿。308名儿童接受了观察，构成研究队列。在该队列中，112例（36.4%）接受了阑尾切除术，其中26例（23.2%）病理检查阑尾正常。3例患者观察后出院，随后因阑尾炎再次入院（漏诊阑尾炎）。在75例进行了CT检查的患者中，CT的敏感性和特异性均为97%。在当前实际策略下，该队列共累积487个住院观察日，每位患者的费用为5831美元。所有三种CT策略都将减少住院观察日总数、手术量、阴性剖腹探查次数以及每位患者的费用。对所有患者进行CT扫描然后收住入院的策略漏诊阑尾炎的发生率最低。与对检查结果阴性的患者进行CT扫描后送回家的策略相比，该策略预防每例漏诊阑尾炎的额外费用为150304美元。即使按照文献报道的CT最低敏感性和特异性，三种策略的排序仍保持不变，且继续降低每位患者的总成本。
与当前实际情况相比，使用CT的诊断策略可降低成本，并改善阑尾炎患儿的诊断、管理和治疗结果。
