1. Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Effect of Reduction in Use of Computed Tomography for Appendicitis Bachur RG, Levy JA, Callahan MJ, Rangel SJ, Monuteaux MC. Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis. JAMA Pediatr. Published online June 22, 2015. doi:10.1001/jamapediatrics.2015.0479.

2. Copyright restrictions may apply Background Advanced imaging is valuable in the diagnostic evaluation of possible appendicitis. Computed tomography (CT) performance is superior to ultrasonography (US). CT use dramatically increased during the first decade of the 21st century. With increased CT use, there has been a dramatic reduction in negative appendectomies without improvement in the rate of appendiceal perforation. There is concern over radiation risk from CT, especially with pediatric patients. US has become the primary imaging modality despite inferior performance (as compared with CT). Study Objectives To review trends in US and CT use among children with appendicitis from 2010 to 2013 at pediatric emergency departments (EDs) in the United States. To investigate simultaneous changes in the proportion of negative appendectomies, appendiceal perforation, and ED revisits. Introduction

3. Copyright restrictions may apply Study Design Pediatric Health Information Systems database review. Children presenting to 35 pediatric EDs in the United States. –January 1, 2010, through December 31, 2013. –Primary diagnosis of appendicitis or having an appendectomy. Main Outcomes Trends in diagnostic imaging. Associated trends in clinical outcomes related to appendicitis. –Negative appendectomy. –Appendiceal perforation. –3-day ED revisits (for missed diagnosis of appendicitis). Methods

4. Copyright restrictions may apply Methods Analytic Plan Test for trends of imaging use over time using a logistic regression model with imaging type as the dependent variable and year as the independent variable. Logistic regression models for 3 relevant outcomes as dependent variable and year of study as independent variable: –Negative appendectomy. –Perforated appendicitis. –3-day ED revisit. Validation substudy: sample of Pediatric Health Information Systems data reviewed at study institution to test assumptions. Limitations Administrative database without patient-level clinical data. –Accuracy of diagnosis. –Cannot account for imaging prior to presentation.

5. Copyright restrictions may apply Results 52 153 children with appendicitis. US use increased 46%. –From 24.0% in 2010 to 35.3% in 2013; absolute difference, 11.3%. –Adjusted test for linear trend, P =.02. CT use decreased 48%. –From 21.4% in 2010 to 11.6% in 2013; absolute difference, −9.8%. –Adjusted test for linear trend, P <.001. Outcomes –Proportion of negative appendectomies declined during the 4-year study period (from 4.7% in 2010 to 3.6% in 2013; adjusted test for linear trend, P =.002). –Proportion of appendiceal perforations and ED revisits did not change (adjusted tests for linear trend, P =.64 and P =.84, respectively).

6. Copyright restrictions may apply Results Use of Advanced Imaging Modality in the ED Over Time a

7. Copyright restrictions may apply Results Use of Advanced Imaging in the ED Over Time Among Pediatric Patients Diagnosed as Having Appendicitis

8. Copyright restrictions may apply Comment Between 2010 and 2013, use of US increased for abdominal imaging in children with appendicitis at major pediatric hospitals in the United States. During the same period, CT use for children with appendicitis declined substantially. Several important appendicitis-related quality measures have remained stable despite increased reliance on US. These results suggest improvements in either the diagnostic performance of US or other care processes in the management of children with suspected appendicitis.

9. Copyright restrictions may apply If you have questions, please contact the corresponding author: –Richard Bachur, MD, Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (richard.bachur@childrens.harvard.edu). Conflict of Interest Disclosures None reported. Contact Information