Janke Alexander T, Michelson Kenneth A, Kocher Keith E, Seiler Kristian, Macy Michelle L, Nypaver Michele, Mahajan Prashant V, Arora Rajan, Mangus Courtney W
Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.
Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.
Acad Emerg Med. 2025 Mar;32(3):309-319. doi: 10.1111/acem.15075. Epub 2025 Jan 5.
Diagnostic stewardship is the effort to optimize diagnostic testing to reduce errors while avoiding overtesting and overtreatment. Abdominal pain and appendicitis in children are essential use cases. Delayed diagnosis of appendicitis can be dangerous and even life-threatening, but overtesting is harmful.
We conducted a retrospective cohort study of children aged 5-17 years presenting with abdominal pain to 26 EDs within the Michigan Emergency Department Improvement Collaborative (MEDIC) from May 1, 2016, to February 29, 2024. We defined two outcome measures summarized by ED. First, we describe the cross-sectional imaging:appendicitis visits ratio, defined as the count of ED visits resulting in any cross-sectional imaging (CT or MRI) divided by the count of ED visits with a diagnosis of appendicitis. Second, we describe the delayed diagnosis rate, defined by an ED visit for abdominal pain resulting in a discharge and subsequent return visit with a diagnosis of appendicitis within 7 days.
The sample included 120,112 pediatric visits for abdominal pain at 26 EDs; 4967 (4.1%) were diagnosed with appendicitis. The cross-sectional imaging:appendicitis visits ratio varied by site, from as low as 0.2 (95% confidence interval [CI] 0.1-0.2) at a pediatric site to as high as 7.9 (95% CI 4.8-16.4) at an urban ED. The proportion of pediatric ED visits for abdominal pain that resulted in an identified delayed diagnosis of appendicitis was 0.1% (141/120,112). All but four sites had fewer than 10 cases of delayed diagnosis across the study period.
In this retrospective cohort study of 120,000+ ED visits for pediatric abdominal pain, we found that the ratio of visits with cross-sectional imaging to diagnosed cases of appendicitis varied widely across EDs. Delayed diagnosis of appendicitis was uncommon. Adherence to best practices and improved imaging quality may hold promise to improve diagnostic stewardship for children with abdominal pain across EDs.
诊断管理旨在优化诊断测试，以减少错误，同时避免过度检查和过度治疗。儿童腹痛和阑尾炎是重要的应用案例。阑尾炎的延迟诊断可能很危险，甚至危及生命，但过度检查也有害。
我们对2016年5月1日至2024年2月29日期间在密歇根急诊科改进协作组织（MEDIC）内的26家急诊科就诊的5至17岁腹痛儿童进行了一项回顾性队列研究。我们定义了两个由急诊科汇总的结局指标。首先，我们描述横断面成像：阑尾炎就诊比例，定义为导致任何横断面成像（CT或MRI）的急诊科就诊次数除以诊断为阑尾炎的急诊科就诊次数。其次，我们描述延迟诊断率，定义为因腹痛进行的急诊科就诊导致出院，随后在7天内复诊诊断为阑尾炎。
该样本包括26家急诊科的120,112例儿童腹痛就诊病例；4967例（4.1%）被诊断为阑尾炎。横断面成像：阑尾炎就诊比例因地点而异，在一家儿科医院低至0.2（95%置信区间[CI]0.1-0.2），在一家城市急诊科高达7.9（95%CI 4.8-16.4）。因腹痛进行的儿科急诊科就诊中，最终确诊为阑尾炎且存在延迟诊断的比例为0.1%（141/120,112）。在整个研究期间，除了四个地点外，所有地点的延迟诊断病例均少于10例。
在这项对120,000多次儿科腹痛急诊科就诊的回顾性队列研究中，我们发现横断面成像就诊与确诊阑尾炎病例的比例在各急诊科之间差异很大。阑尾炎的延迟诊断并不常见。遵循最佳实践并提高成像质量可能有望改善各急诊科对腹痛儿童的诊断管理。
