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Invited Commentary
August 31, 2021

Improving Appendicitis Care for All Patients

Author Affiliations
  • 1Department of Pediatric Emergency Medicine, Children’s Minnesota, Minneapolis
JAMA Netw Open. 2021;4(8):e2124523. doi:10.1001/jamanetworkopen.2021.24523

The new study by Michelson et al1 seeks to understand the clinical features associated with a delayed diagnosis of appendicitis as well as to delineate whether delays may have been preventable. Using 9 years of data from 5 centers participating in the Pediatric Health Information System (PHIS), Michelson et al1 identified 801 pediatric patients who had 2 emergency department (ED) visits within a 7-day period for which the diagnosis of appendicitis was made on the second ED visit. These delayed diagnoses were compared with controls, a group from a single center with a diagnosis of appendicitis during the index ED visit. Overall, cases and controls were similar in terms of age, sex, and clinical features for appendicitis, but differed in their race/ethnicity and insurance status. Of great concern, the authors determined that more than 75% of patients with delayed diagnoses likely or possibly should have been diagnosed with appendicitis on their first ED visit. After adjusting for available data, patients with a delayed diagnosis had longer duration of abdominal pain and lacked the typical features of appendicitis, such as maximal pain in the right lower quadrant.

The timely diagnosis of appendicitis is critical because delays in diagnosis are associated with risks for perforation and related complications. For this reason, appendiceal perforation rates have long been used as a measure of the quality of care delivered to patients with suspected appendicitis.2 Previous research has identified young age, female sex, African American race, non-English speaking, and government insurance as factors associated with higher rates of appendiceal perforation.3,4 Furthermore, a 2020 study by Goyal et al3 examining pediatric patients with suspected appendicitis reported that that non-Hispanic Black children were more likely to face delays in diagnosis and less likely to undergo imaging during their index ED visit.3 The findings of Michelson et al1 are consistent with these prior studies, highlighting that patients with a delayed diagnosis of appendicitis are treated differently than those with a timely diagnosis. The crucial question to consider as clinicians and researchers is: why does treatment differ across patient groups?

The study by Michelson et al1 provides some insight as to why the delays in diagnosing appendicitis may have occurred. First, the chief concerns among patients with delays in diagnosis included conditions associated with a lower or less urgent acuity index (eg, diarrhea, constipation, dysuria). Similarly, a 2020 study from a pediatric ED5 found that patients with nonspecific chief complaints had higher odds of having a missed diagnosis of appendicitis on their index ED visit. The methods by which patients are screened and triaged on presentation to the ED have also been shown to be variable and potentially biased. In a 2016 study, Zook et al6 examined the difference in triage classification by race for similar chief complaints at a single Children’s Hospital and found that Black, Hispanic, and Native American children were significantly more likely to receive low acuity triage scores than White children.6 Misclassification of patients at triage can lead to cognitive errors among clinicians secondary to anchoring bias. Clearly, more research is needed to understand the ED triage process, including the scoring systems used, implicit bias training for triage nurses, and methods to reduce variability and subjectivity that occur with the current approaches to accurately assessing risk.

Michelson et al1 also noted that patients with a delay in diagnosis had markedly lower rates of blood testing or imaging obtained during their index ED visit. The failure to consider appendicitis may have been secondary to clinician inexperience, the absence of a standard approach to patients with acute abdominal pain, or perhaps simply that patients presented early in their disease course. Nevertheless, Michelson et al1 reported that had the treating clinician followed the recommendations of an appendicitis scoring tool, such as the pediatric appendicitis risk calculator, many delayed diagnoses could have been prevented. Patients with delays in diagnosis may have presented with signs and symptoms less obvious for appendicitis, but red flags were present that should have triggered an evaluation. Despite the development and validation of several appendicitis scoring systems, they are used inconsistently. Furthermore, if a clinician is not considering the diagnosis of appendicitis secondary to a cognitive error, a clinical score will not be of value. Therefore, it is imperative to integrate appendicitis scoring tools and decision support into the electronic health record.7 The use of electronic clinical decision support tools that use clinical alerts to the clinician along with automated methods based on real-time analysis of the patient medical record could help to ensure that appendicitis scores are assigned with consistency and that treatment is standardized across facilities and clinician level of training.

To improve the diagnosis of appendicitis, EDs must engage in continual improvement in which key metrics are benchmarked, data are provided to clinicians, and missed diagnoses are reviewed. Standardization of care through the use of appendicitis scoring systems and automated decision support is integral to reducing variability in care for pediatric patients with suspected appendicitis.

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Article Information

Published: August 31, 2021. doi:10.1001/jamanetworkopen.2021.24523

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kharbanda AB. JAMA Network Open.

Corresponding Author: Anupam B. Kharbanda, MD, MSc, Department of Pediatric Emergency Medicine, Children’s Minnesota, 2545 Chicago Ave S, Minneapolis, MN 55415 (anupam.kharbanda@childrensmn.org).

Conflict of Interest Disclosures: None reported.

Michelson  KA, Reeves  SD, Grubenhoff  JA,  et al.  Clinical features and preventability of delayed diagnosis of pediatric appendicitis.   JAMA Netw Open. 2021;4(8):e2122248. doi:10.1001/jamanetworkopen.2021.22248Google Scholar
Ponsky  TA, Huang  ZJ, Kittle  K,  et al.  Hospital- and patient-level characteristics and the risk of appendiceal rupture and negative appendectomy in children.   JAMA. 2004;292(16):1977-1982. doi:10.1001/jama.292.16.1977 PubMedGoogle ScholarCrossref
Goyal  MK, Chamberlain  JM, Webb  M,  et al; Pediatric Emergency Care Applied Research Network (PECARN).  Racial and Ethnic Disparities in the Delayed Diagnosis of Appendicitis Among Children.   Acad Emerg Med. 2020. doi:10.1111/acem.14142PubMedGoogle Scholar
Levas  MN, Dayan  PS, Mittal  MK,  et al; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.  Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children.   J Pediatr. 2014;164(6):1286-91.e2. doi:10.1016/j.jpeds.2014.01.006PubMedGoogle ScholarCrossref
Drapkin  Z, Dunnick  J, Madsen  TE, Bryce  M, Schunk  JE.  Pediatric appendicitis: association of chief complaint with missed appendicitis.   Pediatr Emerg Care. 2020;36(4):e204-e207.PubMedGoogle Scholar
Zook  HG, Kharbanda  AB, Flood  A, Harmon  B, Puumala  SE, Payne  NR.  Racial differences in pediatric emergency department triage scores.   J Emerg Med. 2016;50(5):720-727. doi:10.1016/j.jemermed.2015.02.056 PubMedGoogle ScholarCrossref
Kharbanda  AB, Vazquez-Benitez  G, Ballard  DW,  et al; Clinical Research on Emergency Services and Treatments Network (CREST) and the Critical Care Research Center, HealthPartners Institute.  Effect of clinical decision support on diagnostic imaging for pediatric appendicitis: a cluster randomized trial.   JAMA Netw Open. 2021;4(2):e2036344. doi:10.1001/jamanetworkopen.2020.36344 PubMedGoogle Scholar
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