{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T18:26:31Z","timestamp":1788805591802,"version":"build-2803163510"},"reference-count":54,"publisher":"American Academy of Pediatrics (AAP)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,2,1]]},"abstract":"<jats:sec>\n                  <jats:title\/>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>BACKGROUND:<\/jats:title>\n                  <jats:p>Inaccurate diagnosis of appendicitis leads to increased costs and morbidity. Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and may not visualize the appendix.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>METHODS:<\/jats:title>\n                  <jats:p>We conducted a cost-effectiveness analysis using a decision-analytic model of 10 imaging strategies for suspected appendicitis in a hypothetical cohort of patients: no imaging with discharge or surgery; CT only; MRI only; or staged approach with CT or MRI after 1) negative ultrasound result or ultrasound without appendix visualization, 2) ultrasound without appendix visualization, or 3) ultrasound without appendix visualization but with secondary signs of inflammation. Inputs were derived from published literature and secondary data (quality-of-life and cost data). Sensitivity analyses varied risk of appendicitis and proportion of visualized ultrasound. Outcomes were effectiveness (quality-adjusted life-years [QALYs]), total direct medical costs, and cost-effectiveness (cost per QALY gained).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>RESULTS:<\/jats:title>\n                  <jats:p>The most cost-effective strategy for patients at moderate risk for appendicitis is initial ultrasound, followed by CT if the appendix is not visualized but secondary signs are present (cost of $4815.03; effectiveness of 0.99694 QALYs). Other strategies were well above standard willingness-to-pay thresholds or were more costly and less effective. Cost-effectiveness was sensitive to patients\u2019 risk of appendicitis but not the proportion of visualized appendices.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>CONCLUSIONS:<\/jats:title>\n                  <jats:p>Tailored approaches to imaging based on patients\u2019 risk of appendicitis are the most cost-effective. Imaging is not cost-effective in patients with a probability &amp;lt;16% or &amp;gt;95%. For moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even without appendix visualization.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1542\/peds.2019-1352","type":"journal-article","created":{"date-parts":[[2020,1,21]],"date-time":"2020-01-21T13:27:00Z","timestamp":1579613220000},"source":"Crossref","is-referenced-by-count":40,"title":["Cost-effectiveness of Imaging Protocols for Suspected Appendicitis"],"prefix":"10.1542","volume":"145","author":[{"given":"Rebecca","family":"Jennings","sequence":"first","affiliation":[{"name":"Departments of Pediatrics and"},{"name":"Seattle Children's Research Institute, Seattle, Washington; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"He","family":"Guo","sequence":"additional","affiliation":[{"name":"School of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam","family":"Goldin","sequence":"additional","affiliation":[{"name":"Pediatric General and Thoracic Surgery, Unviersity of Washington, Seattle Children\u2019s Hospital, Seattle, Washington;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davene R.","family":"Wright","sequence":"additional","affiliation":[{"name":"Departments of Pediatrics and"},{"name":"Seattle Children's Research Institute, Seattle, Washington; and"},{"name":"Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Harvard University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2020,2,1]]},"reference":[{"issue":"4, pt 1","key":"2021120921394598600_B1","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1542\/peds.98.4.680","article-title":"Clinical outcomes of children with acute abdominal pain","volume":"98","author":"Scholer","year":"1996","journal-title":"Pediatrics"},{"issue":"11","key":"2021120921394598600_B2","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1002\/jhm.2624","article-title":"Epidemiology of pediatric hospitalizations at general hospitals and freestanding children\u2019s hospitals in the United States","volume":"11","author":"Leyenaar","year":"2016","journal-title":"J Hosp Med"},{"issue":"6","key":"2021120921394598600_B3","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1111\/acem.12144","article-title":"The implications of missed opportunities to diagnose appendicitis in children","volume":"20","author":"Naiditch","year":"2013","journal-title":"Acad Emerg Med"},{"issue":"11","key":"2021120921394598600_B4","doi-asserted-by":"crossref","first-page":"1244","DOI":"10.1111\/j.1553-2712.2000.tb00470.x","article-title":"False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery","volume":"7","author":"Graff","year":"2000","journal-title":"Acad Emerg Med"},{"issue":"3","key":"2021120921394598600_B5","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1097\/PEC.0000000000001049","article-title":"Current approach to the diagnosis and emergency department management of appendicitis in children","volume":"33","author":"Lipsett","year":"2017","journal-title":"Pediatr Emerg Care"},{"issue":"1","key":"2021120921394598600_B6","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1148\/radiol.2411050913","article-title":"US or CT for diagnosis of appendicitis in children and adults? A meta-analysis","volume":"241","author":"Doria","year":"2006","journal-title":"Radiology"},{"issue":"2","key":"2021120921394598600_B7","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1148\/radiol.2502080100","article-title":"Acute appendicitis in young children: cost-effectiveness of US versus CT in diagnosis\u2013a Markov decision analytic model","volume":"250","author":"Wan","year":"2009","journal-title":"Radiology"},{"issue":"7","key":"2021120921394598600_B8","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1111\/acem.12161","article-title":"Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort","volume":"20","author":"Mittal","year":"2013","journal-title":"Acad Emerg Med"},{"issue":"10","key":"2021120921394598600_B9","doi-asserted-by":"crossref","first-page":"1655","DOI":"10.1016\/j.jpedsurg.2016.03.005","article-title":"Secondary signs may improve the diagnostic accuracy of equivocal ultrasounds for suspected appendicitis in children","volume":"51","author":"Partain","year":"2016","journal-title":"J Pediatr Surg"},{"issue":"5","key":"2021120921394598600_B10","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1177\/000313481608200511","article-title":"An imaging diagnostic protocol in children with clinically suspected acute appendicitis","volume":"82","author":"Epifanio","year":"2016","journal-title":"Am Surg"},{"issue":"5","key":"2021120921394598600_B11","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1111\/acem.13180","article-title":"Magnetic resonance imaging versus ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis","volume":"24","author":"Imler","year":"2017","journal-title":"Acad Emerg Med"},{"issue":"6","key":"2021120921394598600_B12","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1007\/s00247-016-3557-3","article-title":"Magnetic resonance imaging in pediatric appendicitis: a systematic review","volume":"46","author":"Moore","year":"2016","journal-title":"Pediatr Radiol"},{"issue":"1","key":"2021120921394598600_B13","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1097\/PEC.0000000000001710","article-title":"Appendicitis: role of MRI","volume":"35","author":"Mittal","year":"2019","journal-title":"Pediatr Emerg Care"},{"issue":"11","key":"2021120921394598600_B14","doi-asserted-by":"crossref","first-page":"1258","DOI":"10.1111\/j.1553-2712.2009.00511.x","article-title":"An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in a pediatric emergency department with clinical assessment supported by a staged ultrasound and computed tomography pathway","volume":"16","author":"Ramarajan","year":"2009","journal-title":"Acad Emerg Med"},{"issue":"5","key":"2021120921394598600_B15","doi-asserted-by":"crossref","first-page":"e20151745","DOI":"10.1542\/peds.2015-1745","article-title":"Implementation of electronic clinical decision support for pediatric appendicitis","volume":"137","author":"Kharbanda","year":"2016","journal-title":"Pediatrics"},{"issue":"1","key":"2021120921394598600_B16","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1016\/j.jpedsurg.2014.10.033","article-title":"Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template","volume":"50","author":"Nielsen","year":"2015","journal-title":"J Pediatr Surg"},{"issue":"3","key":"2021120921394598600_B17","doi-asserted-by":"crossref","first-page":"e20154031","DOI":"10.1542\/peds.2015-4031","article-title":"Risk stratification to decrease unnecessary diagnostic imaging for acute appendicitis","volume":"138","author":"Depinet","year":"2016","journal-title":"Pediatrics"},{"issue":"6","key":"2021120921394598600_B18","doi-asserted-by":"crossref","first-page":"W707","DOI":"10.2214\/AJR.14.13212","article-title":"Value of focused appendicitis ultrasound and Alvarado score in predicting appendicitis in children: can we reduce the use of CT?","volume":"204","author":"Blitman","year":"2015","journal-title":"AJR Am J Roentgenol"},{"issue":"10","key":"2021120921394598600_B19","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1097\/PEC.0b013e3182a5c9b6","article-title":"Evaluation of a novel pediatric appendicitis pathway using high- and low-risk scoring systems","volume":"29","author":"Fleischman","year":"2013","journal-title":"Pediatr Emerg Care"},{"issue":"1","key":"2021120921394598600_B20","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1016\/j.jval.2015.10.007","article-title":"Cost-effectiveness of integrating a clinical decision rule and staged imaging protocol for diagnosis of appendicitis","volume":"19","author":"Gregory","year":"2016","journal-title":"Value Health"},{"issue":"4","key":"2021120921394598600_B21","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1016\/j.jamcollsurg.2014.12.019","article-title":"Cost-effectiveness of diagnostic approaches to suspected appendicitis in children","volume":"220","author":"Pershad","year":"2015","journal-title":"J Am Coll Surg"},{"issue":"6","key":"2021120921394598600_B22","doi-asserted-by":"crossref","first-page":"880","DOI":"10.1016\/j.jpedsurg.2004.02.036","article-title":"The optimal initial management of children with suspected appendicitis: a decision analysis","volume":"39","author":"Hagendorf","year":"2004","journal-title":"J Pediatr Surg"},{"issue":"2","key":"2021120921394598600_B23","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1007\/s00247-016-3727-3","article-title":"Ultrasound, computed tomography or magnetic resonance imaging - which is preferred for acute appendicitis in children? A Meta-analysis","volume":"47","author":"Zhang","year":"2017","journal-title":"Pediatr Radiol"},{"key":"2021120921394598600_B24","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1016\/j.jpeds.2016.11.062","article-title":"Clinical relevance of the nonvisualized appendix on ultrasonography of the abdomen in children","volume":"182","author":"Nah","year":"2017","journal-title":"J Pediatr"},{"issue":"4","key":"2021120921394598600_B25","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1111\/acem.12631","article-title":"Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use","volume":"22","author":"Schuh","year":"2015","journal-title":"Acad Emerg Med"},{"issue":"12","key":"2021120921394598600_B28","doi-asserted-by":"crossref","first-page":"1939","DOI":"10.1016\/j.jpedsurg.2016.09.009","article-title":"Benchmarking the value of ultrasound for acute appendicitis in children","volume":"51","author":"Cundy","year":"2016","journal-title":"J Pediatr Surg"},{"issue":"4","key":"2021120921394598600_B31","doi-asserted-by":"crossref","first-page":"849","DOI":"10.2214\/AJR.14.13026","article-title":"Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories","volume":"204","author":"Larson","year":"2015","journal-title":"AJR Am J Roentgenol"},{"issue":"1","key":"2021120921394598600_B48","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1148\/radiol.10100984","article-title":"Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA","volume":"259","author":"Krishnamoorthi","year":"2011","journal-title":"Radiology"},{"issue":"4","key":"2021120921394598600_B49","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1542\/peds.2013-2128","article-title":"Ultrasonography\/MRI versus CT for diagnosing appendicitis","volume":"133","author":"Aspelund","year":"2014","journal-title":"Pediatrics"},{"issue":"2","key":"2021120921394598600_B26","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1111\/acem.12873","article-title":"Accuracy of magnetic resonance imaging and ultrasound for appendicitis in diagnostic and nondiagnostic studies","volume":"23","author":"Kearl","year":"2016","journal-title":"Acad Emerg Med"},{"issue":"5","key":"2021120921394598600_B29","doi-asserted-by":"crossref","first-page":"538","DOI":"10.1111\/acem.12377","article-title":"Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound","volume":"21","author":"Ross","year":"2014","journal-title":"Acad Emerg Med"},{"issue":"2","key":"2021120921394598600_B30","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1007\/s00330-008-1176-6","article-title":"US examination of the appendix in children with suspected appendicitis: the additional value of secondary signs","volume":"19","author":"Wiersma","year":"2009","journal-title":"Eur Radiol"},{"issue":"7","key":"2021120921394598600_B32","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1007\/s00247-012-2358-6","article-title":"A critical evaluation of US for the diagnosis of pediatric acute appendicitis in a real-life setting: how can we improve the diagnostic value of sonography?","volume":"42","author":"Trout","year":"2012","journal-title":"Pediatr Radiol"},{"issue":"4","key":"2021120921394598600_B27","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1097\/PEC.0b013e318289e8d5","article-title":"Appendix not seen: the predictive value of secondary inflammatory sonographic signs","volume":"29","author":"Estey","year":"2013","journal-title":"Pediatr Emerg Care"},{"issue":"2","key":"2021120921394598600_B50","doi-asserted-by":"crossref","first-page":"723","DOI":"10.1016\/j.jss.2012.12.008","article-title":"Risk of perforation increases with delay in recognition and surgery for acute appendicitis","volume":"184","author":"Papandria","year":"2013","journal-title":"J Surg Res"},{"issue":"4","key":"2021120921394598600_B53","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1097\/00000658-200104000-00001","article-title":"Mortality after appendectomy in Sweden, 1987-1996","volume":"233","author":"Blomqvist","year":"2001","journal-title":"Ann Surg"},{"issue":"1","key":"2021120921394598600_B51","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1097\/00007611-198801000-00008","article-title":"Delayed diagnosis in pediatric appendicitis","volume":"81","author":"Golladay","year":"1988","journal-title":"South Med J"},{"issue":"3","key":"2021120921394598600_B52","doi-asserted-by":"crossref","first-page":"573","DOI":"10.1007\/s00268-011-1417-8","article-title":"Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006-2008","volume":"36","author":"Masoomi","year":"2012","journal-title":"World J Surg"},{"issue":"1","key":"2021120921394598600_B54","doi-asserted-by":"crossref","first-page":"e99","DOI":"10.1016\/j.jss.2011.05.001","article-title":"Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend","volume":"170","author":"Oyetunji","year":"2011","journal-title":"J Surg Res"},{"key":"2021120921394598600_B36","unstructured":"Centers for Medicare and Medicaid Services. Hospital outpatient PPS. Available at: www.cms.gov\/Medicare\/Medicare-Fee-For-Service-Payment\/HospitaloutpatientPPS\/index.html. Accessed October 18, 2018"},{"key":"2021120921394598600_B37","unstructured":"Centers for Medicare and Medicaid Services. CMS physician fee schedule. Available at: https:\/\/www.cms.gov\/apps\/physician-fee-schedule\/overview.aspx. Accessed October 18, 2018"},{"issue":"1","key":"2021120921394598600_B34","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1001\/archpediatrics.2011.694","article-title":"Health-related quality of life in pediatric minor injury: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory in the emergency department","volume":"166","author":"Stevens","year":"2012","journal-title":"Arch Pediatr Adolesc Med"},{"issue":"7","key":"2021120921394598600_B35","doi-asserted-by":"crossref","first-page":"1135","DOI":"10.1016\/j.jpedsurg.2016.10.009","article-title":"The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children","volume":"52","author":"Wu","year":"2017","journal-title":"J Pediatr Surg"},{"issue":"4","key":"2021120921394598600_B33","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1007\/s40273-017-0600-7","article-title":"Mapping the paediatric quality of life inventory (PedsQLTM) generic core scales onto the child health utility index-9 dimension (CHU-9D) score for economic evaluation in children","volume":"36","author":"Lambe","year":"2018","journal-title":"Pharmacoeconomics"},{"key":"2021120921394598600_B38","volume-title":"Cost-Effectiveness in Health and Medicine","author":"Basu","year":"2017","edition":"2nd ed"},{"key":"2021120921394598600_B39","volume-title":"Cost-Effectiveness in Health and Medicine","author":"Neumann","year":"2017","edition":"2nd ed"},{"issue":"9","key":"2021120921394598600_bib55","doi-asserted-by":"crossref","first-page":"iii","DOI":"10.3310\/hta15090","article-title":"An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health","volume":"15","author":"Carr","year":"2011","journal-title":"Health Technol Assess"},{"issue":"6","key":"2021120921394598600_B41","doi-asserted-by":"crossref","first-page":"1229","DOI":"10.1542\/peds.2006-3780","article-title":"Pediatric preparedness of US emergency departments: a 2003 survey","volume":"120","author":"Gausche-Hill","year":"2007","journal-title":"Pediatrics"},{"issue":"4","key":"2021120921394598600_B42","doi-asserted-by":"crossref","first-page":"e20172699","DOI":"10.1542\/peds.2017-2699","article-title":"Development and validation of a novel pediatric appendicitis risk calculator (pARC)","volume":"141","author":"Kharbanda","year":"2018","journal-title":"Pediatrics"},{"issue":"1","key":"2021120921394598600_B43","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2013-2208","article-title":"Prospective evaluation of a clinical pathway for suspected appendicitis","volume":"133","author":"Saucier","year":"2014","journal-title":"Pediatrics"},{"issue":"11","key":"2021120921394598600_B44","doi-asserted-by":"crossref","first-page":"4668","DOI":"10.1007\/s00464-016-5245-7","article-title":"Diagnosis and management of acute appendicitis. EAES consensus development conference 2015","volume":"30","author":"Gorter","year":"2016","journal-title":"Surg Endosc"},{"issue":"8","key":"2021120921394598600_B45","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1001\/jamapediatrics.2013.311","article-title":"The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk","volume":"167","author":"Miglioretti","year":"2013","journal-title":"JAMA Pediatr"},{"issue":"13","key":"2021120921394598600_B46","doi-asserted-by":"crossref","first-page":"1785","DOI":"10.1002\/bjs.10660","article-title":"Randomized clinical trial of antibiotic therapy for uncomplicated appendicitis","volume":"104","author":"Park","year":"2017","journal-title":"Br J Surg"},{"issue":"5","key":"2021120921394598600_B47","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1001\/jamapediatrics.2017.0057","article-title":"Comparison of antibiotic therapy and appendectomy for acute uncomplicated appendicitis in children: a meta-analysis","volume":"171","author":"Huang","year":"2017","journal-title":"JAMA Pediatr"}],"container-title":["Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2019-1352\/1078371\/peds_20191352.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/publications.aap.org\/pediatrics\/article-pdf\/doi\/10.1542\/peds.2019-1352\/1078371\/peds_20191352.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,12,10]],"date-time":"2021-12-10T06:20:31Z","timestamp":1639117231000},"score":1,"resource":{"primary":{"URL":"https:\/\/publications.aap.org\/pediatrics\/article\/145\/2\/e20191352\/81662\/Cost-effectiveness-of-Imaging-Protocols-for"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,2,1]]},"references-count":54,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2020,2,1]]},"published-print":{"date-parts":[[2020,2,1]]}},"URL":"https:\/\/doi.org\/10.1542\/peds.2019-1352","relation":{},"ISSN":["0031-4005","1098-4275"],"issn-type":[{"value":"0031-4005","type":"print"},{"value":"1098-4275","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,2,1]]},"article-number":"e20191352"}}