Effect of CT of the Appendix on Treatment of Patients and Use of Hospital Resources
ABSTRACT & COMMENTARY
Synopsis: A routine appendiceal CT performed in patients who present with suspected appendicitis improves patient care and reduces the use of hospital resources.
Source: Rao PM, et al. N Engl J Med 1998;338:141-146.
The aim of a recent study from rao et al was to evaluate the accuracy and cost-effectiveness of routine CT of the appendix in the management of patients with clinically suspected appendicitis. Appendiceal CT was performed on 100 consecutive patients in the emergency room who, on the basis of history, physical examination, and laboratory tests were to be hospitalized for observation of suspected appendicitis or for urgent appendectomy. Ultimate outcome was determined by surgical and pathological findings or by follow-up two months later. The usefulness of CT was evaluated in terms of its influence on treatment plan and cost. Of the 100 patients, 53 had appendicitis and 47 did not. Appendiceal CT was 98% accurate. CT findings altered management in 59 patients. In terms of cost, CT prevented unnecessary appendectomy in 13 patients and provided a cost savings of $47,281; it also saved 50 patient days of hospital admission, for a savings of $20,250. The overall savings were $447/patient. These authors conclude that a routine appendiceal CT performed in patients who present with suspected appendicitis improves patient care and reduces the use of hospital resources.
COMMENT BY EAMONN M.M. QUIGLEY, MD
Acute appendicitis is a common and clinically challenging problem. Traditionally, diagnosis has rested on a combination of historical and clinical findings, and because of the relatively frequent occurrence of atypical presentations, there has been a low threshold for surgical intervention for confirmation. Indeed, it has traditionally been a maxim of management in appendicitis that a good management strategy should involve a significant number of false-negative exploratory surgeries. It has been felt that this policy, given that these patients are usually young and fit, is to be preferred over reserving surgery for those with clinically "definite" appendicitis. It has been argued that the latter strategy will result in delayed diagnosis and even misdiagnosis, resulting in complications and their associated morbidity and mortality. The former, "trigger happy" surgical approach has, of course, recently been questioned in terms of cost efficacy given the escalating costs of surgery and hospitalization. Considerable interest has focused, therefore, on newer imaging techniques in the diagnosis of suspected appendicitis. Initially, following some positive reports, there was some enthusiasm for abdominal ultrasound, but further studies have questioned the accuracy and reliability of this modality. CT has also been advocated, and recent technical advances in computerized tomography have made this a realistic option in the assessment of appendicitis. The highest accuracy has been reported with helical or spiral CT performed after the installation of gastrografin into the colon. These results are impressive, and the detailed cost analysis suggests a significant savings for CT scanning. The application of this approach will, of course, depend on the availability of scanners and, perhaps more importantly, of an experienced radiologist who can read the scans at the time that they are done. This may not be feasible in all hospitals and will, therefore, significantly limit the application of this technique.