European Radiology

, Volume 25, Issue 5, pp 1464–1470 | Cite as

Mandatory imaging cuts costs and reduces the rate of unnecessary surgeries in the diagnostic work-up of patients suspected of having appendicitis

  • M. J. Lahaye
  • D. M. J. Lambregts
  • E. Mutsaers
  • B. A. B. Essers
  • S. Breukink
  • V. C. Cappendijk
  • G. L. Beets
  • R. G. H. Beets-TanEmail author
Emergency Radiology



To evaluate whether mandatory imaging is an effective strategy in suspected appendicitis for reducing unnecessary surgery and costs.


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.


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).


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.


Imaging Diagnosis Appendicitis Health-care costs Operative surgical procedures 



Computed Tomography


Institutional Review Board


Magnetic Resonance Imaging


Negative Predictive Value


Positive Predictive Value





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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Copyright information

© European Society of Radiology 2015

Authors and Affiliations

  • M. J. Lahaye
    • 1
  • D. M. J. Lambregts
    • 1
  • E. Mutsaers
    • 1
  • B. A. B. Essers
    • 2
  • S. Breukink
    • 3
  • V. C. Cappendijk
    • 4
  • G. L. Beets
    • 3
  • R. G. H. Beets-Tan
    • 1
    Email author
  1. 1.Department of RadiologyMaastricht University Medical CentreMaastrichtThe Netherlands
  2. 2.Department of Epidemiology and Medical TechnologyMaastricht University Medical CentreMaastrichtThe Netherlands
  3. 3.Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
  4. 4.Department of RadiologyJeroen Bosch Hospital‘s HertogenboschThe Netherlands

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