Abstract
Objective
To evaluate whether mandatory imaging is an effective strategy in suspected appendicitis for reducing unnecessary surgery and costs.
Methods
In 2010, guidelines were implemented in The Netherlands recommending the mandatory use of preoperative imaging to confirm/refute clinically suspected appendicitis. This retrospective study included 1,556 consecutive patients with clinically suspected appendicitis in 2008–2009 (756 patients/group I) and 2011–2012 (800 patients/group II). Imaging use (none/US/CT and/or MRI) was recorded. Additional parameters were: complications, medical costs, surgical and histopathological findings. The primary study endpoint was the number of unnecessary surgeries before and after guideline implementation.
Results
After clinical examination by a surgeon, 509/756 patients in group I and 540/800 patients in group II were still suspected of having appendicitis. In group I, 58.5% received preoperative imaging (42% US/12.8% CT/3.7% both), compared with 98.7% after the guidelines (61.6% US/4.4% CT/ 32.6% both). The percentage of unnecessary surgeries before the guidelines was 22.9%. After implementation, it dropped significantly to 6.2% (p<0.001). The surgical complication rate dropped from 19.9% to 14.2%. The average cost-per-patient decreased by 594 € from 2,482 to 1,888 € (CL:−1081; −143).
Conclusion
Increased use of imaging in the diagnostic work-up of patients with clinically suspected appendicitis reduced the rate of negative appendectomies, surgical complications and costs.
Key Points
• The 2010 Dutch guidelines recommend mandatory imaging in the work-up of appendicitis.
• This led to a considerable increase in the use of preoperative imaging.
• Mandatory imaging led to reduction in unnecessary surgeries and surgical complications.
• Use of mandatory imaging seems to reduce health care costs.
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Abbreviations
- CT:
-
Computed Tomography
- IRB:
-
Institutional Review Board
- MRI:
-
Magnetic Resonance Imaging
- NPV:
-
Negative Predictive Value
- PPV:
-
Positive Predictive Value
- US:
-
Ultrasound
References
Raja AS, Wright C, Sodickson AD et al (2010) Negative appendectomy rate in the era of CT: an 18-year perspective. Radiology 256:460–465
Ditillo MF, Dziura JD, Rabinovici R (2006) Is it safe to delay appendectomy in adults with acute appendicitis? Ann Surg 244:656–660
Omari AH, Khammash MR, Qasaimeh GR, Shammari AK, Yaseen MK, Hammori SK (2014) Acute appendicitis in the elderly: risk factors for perforation. World J Emerg Surg 9:6
Andersson RE, Hugander A, Thulin AJ (1992) Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 158:37–41
Berry J Jr, Malt RA (1984) Appendicitis near its centenary. Ann Surg 200:567–575
Bakker OJ, Go PM, Puylaert JB, Kazemier G, Heij HA, Werkgroep richtlijn Diagnostiek en behandeling van acute a (2010) [Guideline on diagnosis and treatment of acute appendicitis: imaging prior to appendectomy is recommended]. Ned Tijdschr Geneeskd 154:A303
Nasiri S, Mohebbi F, Sodagari N, Hedayat A (2012) Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis. Int J Emerg Med 5:26
Naffaa LN, Ishak GE, Haddad MC (2005) The value of contrast-enhanced helical CT scan with rectal contrast enema in the diagnosis of acute appendicitis. Clin Imaging 29:255–258
Pooler BD, Lawrence EM, Pickhardt PJ (2012) MDCT for suspected appendicitis in the elderly: diagnostic performance and patient outcome. Emerg Radiol 19:27–33
Hakkart-van Roijen L TS, Bouwmans CA. (2010) Dutch manual for cost research. Handleiding voor kostenonderzoek, methoden en standard kostprijzen voor economische evaluaties in de gezondheidszorg. College voor zorgverzekeringen
Briggs AH, Wonderling DE, Mooney CZ (1997) Pulling cost-effectiveness analysis up by its bootstraps: a non-parametric approach to confidence interval estimation. Health Econ 6:327–340
Webster DP, Schneider CN, Cheche S, Daar AA, Miller G (1993) Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age. Am J Emerg Med 11:569–572
Wen SW, Naylor CD (1995) Diagnostic accuracy and short-term surgical outcomes in cases of suspected acute appendicitis. CMAJ 152:1617–1626
Bongard F, Landers DV, Lewis F (1985) Differential diagnosis of appendicitis and pelvic inflammatory disease. A prospective analysis. Am J Surg 150:90–96
Lau WY, Fan ST, Yiu TF, Chu KW, Wong SH (1984) Negative findings at appendectomy. Am J Surg 148:375–378
Ege G, Akman H, Sahin A, Bugra D, Kuzucu K (2002) Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol 75:721–725
Soyer P, Dohan A, Eveno C et al (2013) Pitfalls and mimickers at 64-section helical CT that cause negative appendectomy: an analysis from 1057 appendectomies. Clin Imaging 37:895–901
Seo H, Lee KH, Kim HJ et al (2009) Diagnosis of acute appendicitis with sliding slab ray-sum interpretation of low-dose unenhanced CT and standard-dose i.v. contrast-enhanced CT scans. AJR Am J Roentgenol 193:96–105
Pooler BD, Lawrence EM, Pickhardt PJ (2012) Alternative diagnoses to suspected appendicitis at CT. Radiology 265:733–742
Kong V, Aldous C, Handley J, Clarke D (2013) The cost effectiveness of early management of acute appendicitis underlies the importance of curative surgical services to a primary healthcare programme. Ann R Coll Surg Engl 95:280–284
Wojciechowicz KH, Hoffkamp HJ, van Hulst RA (2010) Conservative treatment of acute appendicitis: an overview. Int Marit Health 62:265–272
Kruis W, Morgenstern J, Schanz S (2013) Appendicitis/diverticulitis: diagnostics and conservative treatment. Dig Dis 31:69–75
Acknowledgments
The scientific guarantor of this publication is Prof. Dr. RGH Beets-Tan. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors has significant statistical expertise. Institutional Review Board (IRB) approval was not required because this is retrospective study, and in our country IRB approval is not required for this type of retrospective studys and patient consent was therefore waived. In our University Hospital all patients are informed that their anonymised data can be used for research purposes. No patient in this study raised an objection to the use of his/her anonymised data. Written informed consent was waived by the IRB. Methodology: retrospective, observational, performed at one institution.
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Lahaye, M.J., Lambregts, D.M.J., Mutsaers, E. et al. Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis. Eur Radiol 25, 1464–1470 (2015). https://doi.org/10.1007/s00330-014-3531-0
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DOI: https://doi.org/10.1007/s00330-014-3531-0