“It’s been a classic medical school question, does this person have appendicitis or not?” said Dr. Sean Gregory, USF College of Public Health assistant professor in the Department of Health Policy and Management.

Gregory recently had an article, “Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis”, published in the January 2016 issue of Value in Health.

Gregory and two researchers, Dr. Karen Kuntz, ScD, and Dr. Francois Sainfort, PhD, consulted with Dr. Anupa Kharbanda, MD, MSc, to evaluate the cost-effectiveness of a diagnostic protocol for appendicitis in children. The process uses a staged imaging protocol which involves having an ultrasound (US) and then if needed a computed tomography (CT) scan.

Appendicitis is a common pediatric emergency condition for children presenting to emergency departments (EDs).

“It’s a very hard diagnosis to make; it’s not straightforward. Appendicitis has very similar symptoms with those of other illnesses. Two problems can arise in diagnosis of appendicitis, the ED performs the surgery when it’s not actually necessary, or the child is not operated on when they actually should have the surgery,” Gregory said.

CT improves diagnostic accuracy, but exposes children to high doses of radiation, a risk factor for the development of cancers. A CT can also be incredibly expensive. US, though, is very inexpensive and has no radiation associated with it.

“You want the child to have a good diagnosis of their abdominal pain, but we don’t want to do something in the course of that diagnosis that is going to significantly increase their risk for cancer 30 years later,” Gregory said. “Our question to ourselves was could we mix these two innovations together to come up with a better and more cost-effective protocol?”

The study incorporated a validated clinical decision rule (CDR) developed by Kharbanda to enhance clinicians’ diagnostic ability and guide choices concerning when to use CT with the adaption of the staged US and CT imaging protocol.

The researchers created a hypothetical model and compared three different diagnosis methods:

• The usual care strategy, which represents a CT rate of 55%.
• The CDR/CT strategy, indicating CT only for patients classified as medium/high risk by the CDR.
• The integrated strategy, consisting of the CDR followed by US/CT staged imaging protocol, indicating US for patients scoring medium/high, followed by CT if US is negative or equivocal.

They found that using their method of the CDR and staged imaging protocol was the most cost-effective of the three methods.

“It was interesting to introduce this lower technology solution, ultrasound. Usually when you have lower technology and a lower price it’s because it doesn’t work as well, but this was a matter of matching the type of imaging to the acuity of the patient and that had a better result,” Gregory said.

Gregory and his team did face challenges while conducting their study.

“We questioned whether a surgeon who is going to operate on a child trusts the results of this new diagnostic protocol or at the end of the day are they going to want to do their own CT scan. That would basically change the results of the cost-effectiveness completely,” Gregory said.

The ability of the sonographer also would determine whether the protocol would be effective as well. The pre-teen and teenage girls are more difficult to diagnose with appendicitis because there might be other reasons that they are having abdominal cramping and girls have a more complex abdominal anatomy.

Even though their results found that cost-effectiveness performed equally well for boys and girls in the simulation, there was a question of whether or not the sonographer would be able to understand how to examine female abdominal anatomy versus male abdominal anatomy.

Another challenge was looking at the resources available at certain hospitals. Emergency rooms at children’s hospitals tend to have a lot of services that specialize in children and where the researchers believe this protocol would perform very well. In a community setting or a rural hospital, though, there might not be specialized pediatric expertise, so they questioned if these areas would be able to follow the protocol if they didn’t have specialized resources.

“These are challenges in a research perspective because they are very hard to quantify. The hope is that when folks put this into practice and actually measure the effectiveness, we’ll get more insights into those issues,” Gregory said.

Gregory would like for the results to find a way into the faculty practice here at USF and in the hospitals where the physicians practice. He is excited to see that his results are having an impact in about 10 children’s hospitals in the northeast United States.

“It’s great to be able to further the research by putting this protocol in practice and seeing if it indeed performs as we anticipated in the model,” Gregory said.

“We want to give the best health care that we can but we do need to be conscious of the cost, we don’t have unlimited resources,” Gregory said. “I do think that this study is a good way to really look at all the information and begin to recommend what will be most effective, especially when you want to incorporate long-term outcomes, including the increased risk for cancer later in life.”

Gregory, S., Kuntz, K., Sainfort, F., & Kharbanda, A. (2016). Cost-Effectiveness of Integrating a Clinical Decision Rule and Staged Imaging Protocol for Diagnosis of Appendicitis. Value in Health, 19(1), 28-35. doi:10.1016/j.jval.2015.10.007

Story by Caitlin Keough, USF College of Public Health