Cost-effectiveness of Imaging Protocols

for Suspected Appendicitis

Rebecca Jennings, MD,a,d He Guo, MSc, MPP,b Adam Goldin, MD, MPH,c Davene R. Wright, PhDa,d,e

Inaccurate diagnosis of appendicitis leads to increased costs and morbidity.

BACKGROUND: abstract
Ultrasound costs less than computed tomography (CT) or MRI but has lower sensitivity and
may not visualize the appendix.
METHODS: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).
RESULTS: Themost 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’ risk of appendicitis but not the proportion of visualized appendices.
CONCLUSIONS: Tailored approaches to imaging based on patients’ risk of appendicitis are the most
cost-effective. Imaging is not cost-effective in patients with a probability ,16% or .95%. For
moderate-risk patients, ultrasound without secondary signs of inflammation is sufficient even
without appendix visualization.

a
Departments of Pediatrics and cPediatric General and Thoracic Surgery, Unviersity of Washington, Seattle WHAT’S KNOWN ON THIS SUBJECT: Ultrasound-first
Children’s Hospital, Seattle, Washington; bSchool of Pharmacy, The Comparative Health Outcomes, Policy, and imaging protocols are used to evaluate suspected
Economics (CHOICE) Institute, University of Washington, Seattle, Washington; dSeattle Children’s Research Institute, appendicitis to decrease cost and radiation exposure
Seattle, Washington; and eDepartment of Population Medicine, Harvard Medical School and Harvard Pilgrim Health
from computed tomography use, but there is a paucity
Care Institute, Harvard University, Boston, Massachusetts
of data on the optimal ultrasound approach to achieve
Drs Jennings and Wright conceptualized and designed the study, drafted the initial manuscript, and cost-effectiveness.
reviewed and revised the manuscript; Ms Guo helped design the model, conducted the initial
analyses, and reviewed and revised the manuscript; Dr Goldin provided critical review of the WHAT THIS STUDY ADDS: For patients with low to
conceptualization and design of the study, helped interpret the data, and critically reviewed the medium risk of appendicitis, it is most cost-effective to
manuscript for important intellectual content; and all authors approved the final manuscript as perform an ultrasound first. If the appendix is not
submitted and agree to be accountable for all aspects of the work. visualized, providers can forego a follow-up computed
DOI: https://doi.org/10.1542/peds.2019-1352 tomography if the ultrasound has no secondary signs
of inflammation.
Accepted for publication Nov 18, 2019
Address correspondence to Rebecca Jennings, MD, Department of Pediatrics, Seattle Children’s To cite: Jennings R, Guo H, Goldin A, et al. Cost-
Hospital, 4800 Sand Point Way NE, M/S FA.2.115, Seattle, WA 98105. E-mail: rebecca.jennings@ effectiveness of Imaging Protocols for Suspected Appendicitis.
seattlechildrens.org Pediatrics. 2020;145(2):e20191352

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PEDIATRICS Volume 145, number 2, February 2020:e20191352 ARTICLE
Appendicitis is the most common
indication for pediatric emergency
surgery.1 Appendicitis with and
without peritonitis are the fifth and
12th most costly pediatric conditions
at general hospitals and cost $278
million and $156 million annually,
respectively.2 It is important to
diagnose pediatric patients with
appendicitis accurately because both
false-negative and false-positive
diagnoses are associated with
increased morbidity and costs.3,4
Diagnosing appendicitis relies heavily
on imaging and a provider’s
assessment of the risk of appendicitis
for a given patient.5 Ultrasound and
computed tomography (CT) are the
most common imaging modalities.6
Ultrasound costs less than CT and
does not use radiation, but it is less
accurate than CT for visualizing the
appendix and detecting
appendicitis.6,7 When providers fail to
visualize the appendix using
ultrasound, they employ additional
imaging (eg, CT) to clarify the
diagnosis, increasing imaging costs. In
pediatric emergency departments
(EDs), the appendix is only identified
in 25% to 73% of right-lower
quadrant (RLQ) ultrasounds.8 The
accuracy of ultrasounds that do not
visualize the appendix can be
increased by incorporating secondary
signs of inflammation.9 Some
hospitals use MRI for the evaluation
of suspected appendicitis as primary
or follow-up imaging as a way to
reduce patient exposure to
radiation.10,11 MRI is more sensitive
and specific than CT for suspected
appendicitis,12,13 but it is more costly.
A staged ultrasound approach, in
which ultrasound is an initial imaging
modality, can improve diagnostic
accuracy and decrease CT use.14–17 It
is unclear if a staged ultrasound
approach is cost-effective in settings
where the appendix is infrequently
visualized. Many imaging strategies
call for tailoring evaluation by
stratifying patient risk,18,19 such as
only performing imaging on medium-
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2 JENNINGS et al
risk patients, and not performing a CT
if there are no secondary signs of
inflammation in the RLQ seen on
ultrasound. The precise pretest
probability of (ie, likelihood of
having) appendicitis, for which
different approaches to the evaluation
of appendicitis are cost-effective, is
unknown.
The cost-effectiveness of various
imaging approaches can be evaluated
by using decision-analytic models,
which conduct virtual clinical trials,
simulating costs and health effects of
different screening approaches on the
same population of theoretical
patients. This method can compare
multiple diagnostic approaches,
particularly when inaccurate
diagnosis is rare but burdensome.
Previous decision-analytic models
assessed the cost-effectiveness of
various imaging protocols for
diagnosing pediatric appendicitis but
did not address ultrasounds that do
not visualize the appendix, did not
evaluate MRI, or did not stratify
patients by risk.7,20–22 We aimed to
identify the most cost-effective
imaging strategy for suspected
appendicitis using more robust
modeling assumptions than have
been previously employed. Our
secondary aims were to identify
health and facility characteristics that
impact cost-effectiveness.
METHODS
Decision-Analytic Model
We simulated a hypothetical cohort of
children presenting to an ED with
suspected appendicitis using
a decision-analytic Markov cohort
model created in TreeAge (TreeAge
Pro Healthcare; TreeAge Software Inc,
Williamstown, MA). We compared the
following imaging strategies (Fig 1):
CT only (strategy A); MRI only
(strategy B); or a staged approach
using ultrasound followed by CT or
MRI (1) after all ultrasounds that are
either negative or do not visualize the
appendix (strategies C and F), (2)
after all ultrasounds that do not
visualize the appendix (strategies D
and G), or (3) only after ultrasounds
that do not visualize the appendix if
the ultrasound has secondary signs of
inflammation in the RLQ (strategies E
and H). Lastly, we modeled discharge
and surgery for all patients without
any imaging (strategies I and J,
respectively) to evaluate the test and
test-treatment threshold of imaging.
Strategies represented existing
described protocols and the existing
literature.7,20,22
We estimated the costs of imaging
and surgical procedures, and the
costs and health effects attributable
to false-negative and positive
diagnoses, including increased risk of
perforation and negative
appendectomy, respectively. We
assumed patients who had imaging
tests that were falsely interpreted as
negative returned to the ED, at which
point they would be diagnosed with
appendicitis and have an increased
perforation risk. A simplified version
of 1 arm of the decision tree (strategy
E) is shown in Fig 2. The full decision
tree is provided (Supplemental Figs 4
and 5). The study was deemed
exempt by the Seattle Children’s
Hospital Institutional Review Board.
Model Input Data
We estimated input parameters
including imaging test characteristics
and health outcomes of children with
suspected acute appendicitis from
published studies (Table 1). We used
meta-analyses describing imaging test
characteristics when available.12,23
For ultrasound test characteristics,
we included published studies that
compared positive or negative
ultrasound results for pediatric
patients with suspected appendicitis
to positive or negative rates of
appendicitis at surgery or follow-up.
Test characteristics of ultrasounds
that visualize the appendix were
estimated from published studies that
excluded nonvisualized
appendices.8,9,16–18,24–27,30–33 Test

FIGURE 1
Schematic of imaging strategies included in model.
characteristics of the presence of
secondary signs of inflammation
in ultrasounds that do not visualize
the appendix were estimated
from studies that separately reported
the test characteristics when
the appendix is not visualized,
with and without secondary
signs,9,16,24,27,30-32 assuming that
patients with secondary signs
had appendicitis and those
without secondary signs did
not have appendicitis. We
used a weighted average
from these studies for
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PEDIATRICS Volume 145, number 2, February 2020
sensitivity and specificity point
estimates.
We estimated visualization rates for
patients with and without
appendicitis separately using
weighted averages from published
data.8,9,16,18,24–27,30–33 None
of the appendix visualization
studies differentiated between
ruptured and nonruptured
appendices.
Mortality from a negative
appendectomy was assumed to be
equal to mortality for pediatric
patients with uncomplicated
appendicitis.
Health-Related Quality of Life
Health-related quality of life
associated with perforated and
uncomplicated appendicitis was
estimated by using the Pediatric
Quality of Life Inventory (PedsQL),
which was administered to patients
hospitalized at our freestanding
children’s hospital from June 2009 to
April 2018. The PedsQL, a validated
standardized questionnaire, produces
scores on 4 subscales: physical,
emotional, social, and school
functioning. We used published
regression equations to estimate
utility values from the PedsQL
subscales.44 We identified patients
using International Classification of
Diseases, Ninth Revision, Clinical
Modification and International
Classification of Diseases, 10th
Revision, Clinical Modification codes of
540.9 and K35.80 or K35.89 for acute
appendicitis and 540.0 and K35.2 or
540.1 and K35.3 for perforated
appendicitis.21 We assumed the
utility value for negative
appendectomy would be the same as
for uncomplicated acute appendicitis.
We used published PedsQL data for
ED patients with minor injuries to
estimate the utility values for ED
patients presenting with abdominal
pain but no appendicitis, defined as
the “well state.”42,43
Costs
Inpatient costs for uncomplicated and
perforated appendicitis were
estimated by using the 2016 Kids’
Inpatient Database (KID), a national
database of hospital charge data. We
defined patients with uncomplicated
and perforated appendicitis using
International Classification of
Diseases, 10th Revision, Clinical
Modification codes of K35.80 or
K35.89 and K35.2 or K35.3,
respectively. We assumed that the
cost of negative appendectomies was
the same as that of uncomplicated
appendicitis. We also included
3
FIGURE 2
Simplified version of strategy E.

professional fees in total costs (not
included in KID cost data) by
including professional charges based
on assumed Current Procedural
Terminology (CPT) codes charged by
providers21 and average length of
stay in the KID for uncomplicated and
perforated appendicitis. We
estimated imaging and ED visits costs
using 2017 Medicare hospital fees40
and professional fees by CPT code.41
Total cost estimates are included in
Table 1, and the components are
shown in Supplemental Table 3. All
costs were adjusted to 2017 US
dollars by using the Personal Health
Care Expenditure deflator.45
Cost-effectiveness Analysis
A cost-effectiveness analysis was
conducted from the payer perspective
over a 1-year time horizon.46 Our
primary effectiveness measure was
the quality-adjusted life-year (QALY),
a composite measure of morbidity
and mortality.46 QALYs for each
strategy were calculated as the
number of years spent living a health
state (ie, appendicitis or appendicitis
with perforation) multiplied by the
utility value for that health state
(Table 1). Because appendicitis and
ED visits are temporary health states,
the patient was assumed to
experience decreased utility for
1 month then return to a state of
perfect health for the remaining
11 months of the year. We ranked
each of the 10 alternative screening
approaches according to increasing
cost. Approaches that were more
costly but less effective than an

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4 JENNINGS et al
TABLE 1 Model Inputs
Probability Factor Point Estimate Range
Proportion of patients with appendicitis8–10,14–16,24–29 0.326 0.145–0.614
Ultrasound with visualized appendix, sensitivity8,9,16–18,24–26,30–33 0.986 0.957–1.0
Ultrasound with visualized appendix, specificity8,9,16–18,24–26,30–33 0.936 0.654–1.0
Proportion ultrasound that do not visualize appendix among patients with appendicitis8,9,16,18,24–27,30–33 0.158 0.0172–0.394
Proportion ultrasound that do not visualize appendix among patients without appendicitis8,9,16,18,24–27,30–33 0.466 0.104–0.910
Secondary signs of inflammation on ultrasound without visualized appendix, sensitivity9,16,24,27,30–32,34 0.534 0.29–1.0
Secondary signs of inflammation ultrasound without visualized appendix, specificity9,16,24,27,30–32 0.9439 0.6–0.99
CT, sensitivity23 0.95 0.92–0.97
CT, specificity23 0.92 0.90–0.94
MRI, sensitivity12 0.965 0.943–0.978
MRI, specificity12 0.961 0.935–0.977
Proportion of patients with perforation at presentation358,15,29,30,33,36 0.286 0.174–0.405
Proportion of patients with perforation after delayed diagnosis3,37 0.774 0.774–0.81
Mortality, uncomplicated appendicitis36,38 0.0001 0.0001–0.0001
Mortality, perforated appendicitis36,38,39 0.000347 0.0002–0.0004
Cost of limited abdominal ultrasound, $40,41 228.61 171.46–285.77a
Cost of abdominal and pelvic CT with contrast, $40,41 805.55 604.44–1007.40a
Cost of abdominal and pelvic MRI without contrast, $40,41 1160.80 1284.41–2140.69a
Cost of hospitalization for appendicitis without rupture, $ 9460.90 4559.69–16 010.45
Cost of hospitalization for appendicitis with rupture, $ 15387.10 5792.20–32 310.18
Cost of ED visit without imaging, $ 665.83 499.37–832.38a
Disutility for appendicitis without ruptureb 0.0624 0.0146–0.1509
Disutility for appendicitis with ruptureb 0.0837 0.0149–0.2275
Disutility for ED visit42,43,b 0.017 0.009–0.026
a 75% to 125% of 2017 Medicare reimbursement.
b Disutility is defined as 1-utility.

alternative approach were considered Sensitivity Analyses RESULTS

dominated and excluded from further
calculations.46 The remaining
approaches were reranked according
to increasing costs. The least
expensive and least effective
screening approach was the baseline
for comparison. We then calculated
the net costs, the cost of the strategy
minus the cost of the next-
lowest–ranking strategy, and net
QALYs (the effectiveness of the
strategy minus the effectiveness
of the next-lowest–ranking strategy)
for each screening alternative.
Our cost-effectiveness outcome
was the incremental cost-
effectiveness ratio (ICER) for each
alternative, or net costs divided by
net QALYs.47
We conducted 1- and 2-way
sensitivity analyses to assess how
robust our results were to inputs.
Ranges are reported in Table 1. In our
2-way sensitivity analysis, we varied
the pretest probability of appendicitis
and proportion of ultrasounds that
visualize the appendix from 0% to
100%. The latter was varied at a fixed
ratio for patients with and without
appendicitis. We assessed thresholds
at which the most cost-effective
approach changes. This allowed us to
create a tailored imaging approach
based on a patient’s pretest
probability of appendicitis and
a hospital’s appendix
visualization rate.
Cost-effectiveness
Results are summarized in Table 2.
Strategy E is the least costly strategy,
with a cost of $4815 and 0.9969
QALYs. In this strategy, all patients
with suspected appendicitis undergo
an initial ultrasound. If the ultrasound
does not visualize the appendix but
has secondary signs of inflammation,
then the patient undergoes a CT. If
there are no secondary signs of
inflammation on ultrasound, then the
patient is discharged. All but 3
strategies were dominated, with
lower effectiveness and higher cost
than their next least expensive
comparators being observed (Table 2,
Supplemental Table 4). Strategies B

TABLE 2 Cost-effective Analysis

Strategy Cost, $ Incremental Effectiveness, Incremental ICER, $ per
Cost, $ QALYs Effectiveness QALY
Strategy E: staged ultrasound, CT if US does not visualize appendix but has 4815.03 0 0.99694 0 0
secondary signs of inflammation
Strategy H: staged ultrasound, MRI if ultrasound does not visualize appendix but 5070.69 255.66 0.996986 4.37 3 1025 5 846 752
has secondary signs of inflammation
Strategy B: MRI 5521.28 450.59 0.997015 2.90 3 1025 1.563107

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PEDIATRICS Volume 145, number 2, February 2020 5
(MRI only) and H (staged ultrasound
with MRI only if ultrasound does not
visualize the appendix but has
secondary signs of inflammation)
provide small QALY gains over
strategy E, but the ICER for each is
significantly higher than standard
willingness-to-pay thresholds of
$100 000 to $150 000 per QALY
gained.46
Sensitivity Analysis
The 1-way sensitivity analysis
demonstrated that ICERs were most
sensitive to the prevalence of
appendicitis, the cost of appendicitis
treatment, and the specificity of
ultrasounds with appendix
visualization (Supplemental Fig 6).
The other inputs had little impact on
ICERs, meaning that within the range
of the input that was simulated, the
ICER did not vary substantially.
A 2-way sensitivity analysis (Fig 3)
demonstrated little effect of the
proportion of visualized ultrasounds
FIGURE 3
a
Two-way sensitivity analysis. Probability of appendicitis can be estimated by using examination, ancillary tests, or scoring systems.
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6 JENNINGS et al
on optimal strategies even when
visualization is low. Strategy I
(discharge all) is the optimal strategy
when the pretest probability of
having appendicitis is ,∼16%.
Strategy E is optimal when the pretest
probability is between 16% and 67%.
With higher pretest probability
(67%–95%), strategy D is optimal
(all nonvisualized appendices on
ultrasound are followed by CT). When
the pretest probability is .95%, then
strategy J (surgery without imaging)
is optimal.
Because the absence of secondary
signs of inflammation in the RLQ
when the ultrasound does not
visualize the appendix has a lower
sensitivity than a negative ultrasound
result when the appendix is seen, it is
only cost-effective to forego a CT with
a nonvisualized ultrasound if there
are no secondary signs of RLQ
inflammation and the patient has
a lower risk of appendicitis. To
maximize cost-effectiveness, when
a patient has a higher risk of
appendicitis, all ultrasounds that do
not visualize the appendix should be
followed by CT. The sensitivity of an
ultrasound that visualizes the
appendix is high enough that a CT
after a negative ultrasound result is
only cost-effective when the
proportion of nonvisualized
ultrasounds is high. Furthermore, we
found that if the patient has a low
or high pretest probability of
appendicitis, it is cost-effective for
patients to forego imaging entirely.
DISCUSSION
In this study, we provide guidance to
clinicians regarding the most cost-
effective imaging strategies for
pediatric patients with suspected
appendicitis, with particular
consideration on risk stratifying
a patient’s pretest probability of
appendicitis and a hospital’s
proportion of ultrasounds that are
unable to visualize the appendix. The
most cost-effective strategy is highly
dependent on a patient’s risk
stratification. At a prevalence ,16%
and .95%, patients can forego
imaging entirely. For patients with
a risk of appendicitis between 16%
and 67%, it is cost-effective to
perform an initial ultrasound and
forego additional imaging if the
ultrasound does not visualize the
appendix but shows no secondary
signs of inflammation. When the
pretest probability of appendicitis is
.67%, it is cost-effective to follow-up
all nonvisualized ultrasounds with
a CT even without secondary signs of
inflammation on ultrasound.
We found that even when the
appendix is rarely visualized,
ultrasound as the initial imaging
modality for intermediate-risk
patients is cost-effective. This is
important because most quality-
improvement initiatives that
examined the ultrasound-first
approach have been conducted in
children’s hospitals, but most
pediatric patients are seen in general
EDs,48 where the proportion of
ultrasounds that visualize the
appendix may be lower. Our results
suggest all hospitals should adopt
risk stratification followed by
eventual ultrasound in patients
with intermediate probability of
appendicitis. It is important to note
that our results were sensitive to
changes in the specificity of
ultrasound with visualization of the
appendix; when ultrasound is not
read by a pediatric radiologist, it may
have a lower specificity, which would
impact the cost-effectiveness of
ultrasound-first approaches.
The optimal imaging strategy is
highly dependent on a patient’s
pretest probability of appendicitis;
therefore, imaging strategies should
be tailored on the basis of
a provider’s assessment of an
individual patient’s risk of
appendicitis. Providers can estimate
a patient’s appendicitis risk using
ancillary tests or scores such as the
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PEDIATRICS Volume 145, number 2, February 2020
Pediatric Appendicitis Risk
Calculator49 or Pediatric Appendicitis
Score.50 Our findings are consistent
with previous studies and European
guideline recommendations.18,19,51
The risk thresholds for imaging we
identified are similar to those derived
from risk prediction tools. The
Pediatric Appendicitis Risk Calculator
scoring tool identifies patients with
medium risk of appendicitis from
15% to 85%, similar to our model’s
recommendation of imaging at a risk
level of 16% to 95%.49 Furthermore,
our results align with previous
findings that patients with a low
likelihood of appendicitis can be
discharged with an ultrasound that
does not visualize the appendix
but has no secondary signs of
inflammation given the high negative
predictive value of an ultrasound
without secondary signs in low-risk
clinical settings.9,32 It is important to
note that many of these baseline
estimates of pretest probability are
from studies at children’s
hospitals.18,50 The advantage of using
our model to establish test thresholds
is that it can accurately estimate rare
outcomes, such as missed diagnosis
leading to increased perforation risk,
and identify precise pretest
probabilities at which different
imaging approaches are most
cost-effective.
Given the high cost of surgery and
hospitalization relative to imaging in
the ED, we found that it is only cost-
effective to forego imaging when
there is a high risk for appendicitis.
Our own personal experience is that
there is much variation in the
approaches that providers use with
high-risk patients. This exemplifies
why decision models using virtual
cohorts are helpful for informing
clinical practice.
Many hospitals have adopted quality-
improvement initiatives aimed at
reducing CT use for suspected
appendicitis to reduce exposure to
ionizing radiation. Given high
uncertainty about long-term effects of
radiation levels seen with a single
abdominal CT,52 we did not model
potential future cases of radiation-
induced cancer. Importantly, the CT-
only protocol was not cost-effective
even without considering radiation.
Therefore, an ultrasound-first
protocol would not only reduce
patients’ exposure to ionizing
radiation but also improve value.
Because the appendicitis treatment
and recovery period is brief, there
were only minor differences in
QALYs. It remains important to
consider the effect QALYs have on our
results because ICERs identify
dominant approaches (both more
effective and less costly). A cost-only
analysis would mask these dominant
scenarios. With a higher sensitivity
and specificity than CT, MRI-based
imaging strategies have minimally
higher QALY gains than do CT-based
strategies. Because of the higher cost
of MRI, the ICERs for MRI-based
strategies are significantly higher
than accepted willingness-to-pay
thresholds. New short-duration,
appendix-specific MRI protocols
could make MRI more cost-effective if
those protocols reduce costs
substantially.13
There has been recent interest in the
treatment of assumed uncomplicated
appendicitis with antibiotics without
surgery.53,54 Wu et al43 demonstrated
that this approach can be cost-
effective. Because this approach costs
less than operative management,54 it
may affect the cost-effectiveness of
diagnosis. Recent studies have
suggested some cases of
uncomplicated appendicitis may
resolve spontaneously,53 suggesting
there may be a risk of overtreating
mild appendicitis detected by
ultrasound or CT. Furthermore, some
patients with false-negative diagnosis
of appendicitis may have spontaneous
resolution of their mild appendicitis.
This analysis was subject to
limitations. We did not account for all
possible costs and consequences
7
related to imaging and outcomes.
Perforated appendicitis can lead to
abdominal strictures and scarring,
leading to obstruction and potential
future surgeries. Imaging can lead to
incidental findings with unclear
clinical significance, which may
necessitate further imaging and
invasive procedures. We did not
account for sedation when assessing
MRI costs and morbidity. Many input
parameter estimates are based on
studies performed at children’s
hospitals. As is common in decision-
analytic models, we made multiple
modeling assumptions. However,
sensitivity analyses provide
robustness checks on our
assumptions and results. Finally, we
could not extract imaging costs from
total hospital costs; therefore, costs
for patients with appendicitis include
2 imaging modalities. However,
imaging represents a fraction of total
treatment costs, and this change is
unlikely to affect our results.
CONCLUSIONS
Accurate diagnosis of appendicitis
can be challenging, with
consequences for both false-positive
and false-negative diagnoses. It is
important to minimize potential
negative consequences of imaging,
including radiation, incidental
findings, and costs. We demonstrate
that for patients with a risk of
appendicitis ,16% or .95%,
imaging is not cost-effective. For
patients at moderate risk .16%,
an ultrasound without secondary
signs of RLQ inflammation
can be sufficient even if the
appendix is not visualized and
even in settings where the
appendix is infrequently visualized.
For patients with higher risk
of appendicitis, providers
should tailor their imaging
approach for patients on the basis
of a patient’s pretest probability
of appendicitis.
ACKNOWLEDGMENTS
We thank Wren Haaland, MPH, of
Seattle Children’s Hospital, who
created early iterations of the
model and Matthew Dellinger, MD,
and Joel Tieder, MD, MPH, of
Seattle Children’s Hospital and
the University of Washington
School of Medicine, who reviewed
the article.
ABBREVIATIONS
CPT: Current Procedural
Terminology
CT: computed tomography
ED: emergency department
ICER: incremental cost-
effectiveness ratio
KID: Kids’ Inpatient Database
PedsQL: Pediatric Quality of Life
Inventory
QALY: quality-adjusted life-year
RLQ: right-lower quadrant

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the University of Washington and Seattle Children’s Hospital Quality Improvement Scholars Program.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3349.

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JENNINGS et al
 Cost-effectiveness of Imaging Protocols for Suspected Appendicitis
Rebecca Jennings, He Guo, Adam Goldin and Davene R. Wright
Pediatrics originally published online January 21, 2020;

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 Cost-effectiveness of Imaging Protocols for Suspected Appendicitis
Rebecca Jennings, He Guo, Adam Goldin and Davene R. Wright
Pediatrics originally published online January 21, 2020;

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