Imaging providers shift from CT to ultrasound-dominant approach for pediatric appendicitis cases

Imaging providers have shifted away from CT and toward a more ultrasound-dominant approach to assessing appendicitis cases in pediatric patients over the last 15 years, researchers reported on Friday.

Educational campaigns to limit radiation dosage to children likely played a part in this shift. And the change has paid off in other ways, decreasing the rate of negative appendectomies, typically associated with longer lengths of stay and higher morbidity.

All told, per-patient CT utilization in these cases plummeted from 57% in 2004 all the way down to 19% by 2018. On the flipside, ultrasound took over the lion’s share, moving from 26% up to 63% in the same time span, researchers with Texas and Cincinnati children’s hospitals detailed in JACR.

“Our study is guided by a value-based healthcare framework that accounts for both imaging utilization trends and outcomes,” Shireen Hayatghaibi, with the Department of Radiology at the Houston-based pediatric provider, and colleagues wrote Aug. 28. “From this targeted, value-based healthcare approach, the change in imaging strategies has provided benefits,” they added later. “The switch to US as the dominant imaging strategy produced value, with outcomes slightly improving, offsetting costs associated with unnecessary surgery.”

The research team analyzed data for patients who received an appendectomy at one of 32 U.S. children’s hospital to reach their conclusions. Hayatghaibi et al. incorporated a total study population of 104,033 children ages 0-17, receiving care between 2004 and 2018. While CT use dipped considerably in these cases, radiography remained relatively flat, and MRI increased slightly (from 0.1% up to 2.2%). Meanwhile, the negative appendectomy dipped slightly, from 3.74% at the start down to 3.14%.

Researchers were surprised to find that magnetic resonance imaging accounted for such a tiny share of the pie, despite concerted efforts to promote its use.

“If the diagnostic imaging strategy for pediatric acute appendicitis is being driven, or substantially influenced by, a desire to reduce ionizing radiation exposure, MRI should have been more widely adopted,” Hayatghaibi noted. “The fact that it has not is likely multifactorial, with resource availability, lack of radiologist familiarity with interpretation, and lack of overall comfort with the examination possibly playing roles.”

Efforts from Imaging Wisely have likely propelled ultrasound’s rise, they added, along with coding changes out of the Centers for Medicare and Medicaid Services. The agency in 2011 mandated bundling of CT imaging of the abdomen and pelvis into one. Thus, computed tomography case estimates may have been inflated during the period between 2004-2010 prior to that shift, the research team noted.

Read more of the analysis in the Journal of the American College of Radiology here.