Undertesting for Pediatric Appendicitis Tied to Delayed Diagnosis

By Lisa Rapaport

September 01, 2021

(Reuters Health) - Many children with a delayed diagnosis of appendicitis have less clinically apparent symptoms, and many of these patients for whom imaging would be indicated don't receive it, a new study suggests.

Researchers examined data on 748 patients treated in U.S. emergency departments between January 1, 2010, and December 31, 2019, who were under 21 years old and received a diagnosis of appendicitis. The analysis included 277 (37%) control cases when appendicitis was diagnosed at the first emergency department visit and 471 (63%) cases of delayed diagnosis, when patients went undiagnosed at the first visit but then got diagnosed at the second visit to the emergency department.

The Pediatric Appendicitis Risk Calculator (pARC) was used to assess individual features of appendicitis and the pretest likelihood of appendicitis. Patients with a delayed diagnosis had a pretest likelihood of appendicitis that was 39% to 52% lower than in children who received a diagnosis at their first emergency department visit, researchers report in JAMA Network Open.

Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable, researchers concluded.

"Most children with abdominal complaints don't have appendicitis," said lead study author Dr. Kenneth Michelson, of the division of emergency medicine at Boston Children's Hospital.

Children with appendicitis can have subtle symptoms, and tests for appendicitis are not perfect, Dr. Michelson said by email.

"It makes our job challenging," Dr. Michelson said. "Still, I was surprised that most cases with a delayed diagnosis have missed opportunities where we could have improved the diagnostic process."

The patients with delayed diagnosis were less likely to experience some typical appendicitis symptoms including pain with walking (adjusted odds ratio 0.16), maximal pain in the right lower quadrant (aOR, 0.12), and abdominal guarding (aOR, 0.33).

Patients who had a delayed appendicitis diagnosis were also more likely than those diagnosed at the first emergency department visit to have a complex chronic condition (aOR, 2.34).

Not all patients with indicated imaging had this done. Depending on how missing data on white blood cell count was accounted for, 104 (22%) to 289 (61.3%) of children with a delayed diagnosis had imaging done.

One limitation of the study is it only looked at pediatric hospitals, and results may not be generalizable to outcomes elsewhere. Researchers were also unable to account for potential sociodemographic factors that might contribute to delayed diagnoses.

Even so, the results underscore that clinicians need to use standardized evaluation and management approaches for patients with acute abdominal pain, said Dr. Anupam Kharbanda, author of an editorial accompanying the study and chief of critical care services at Children's Minnesota in Minneapolis.

This can be done via clinical scoring systems and care recommendations which are based on expert panels, Dr. Kharbanda said by email.

"By standardizing the care that is delivered, we can hopefully reduce delays," Dr. Kharbanda said. "We also need to take steps address the racial disparities in care delivery that exist."

SOURCE: https://bit.ly/3gP3DHv JAMA Network Open, online August 31, 2021.