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Influence of the use of Decision Tools for Appendicitis and Diverticulitis on Diagnostic Certainty in the Emergency Department

SL Gans, JJS Kiewiet, B Mirck, SC Donkervoort, BC Vrouenraets, DJ Gouma and MA Boermeester

Rationale: Correctly identifying patients with acute appendicitis or diverticulitis is a diagnostic challenge. The majority of these patients are referred for additional imaging. Decision tools can be used to prevent over-utilization of imaging by selecting patients for diagnostic imaging. Several decision tools have been developed and validated, however their influence on the use of hospital resources and certainty of diagnosis has not yet been evaluated. The objective of current study was to assess the influence of the use of decision tools on clinical practice. Methods: Between 2009 and 2013 adult patients with acute abdominal pain (AAP) were included in a multicenter prospective cohort study (AAP study). Immediately after clinical evaluation surgical residents recorded their diagnosis and its certainty (VAS score). A decision tool had to be completed in case of suspected acute appendicitis or diverticulitis. Upon completion, residents were provided with the outcome and recorded their diagnosis and certainty once more. An expert panel assigned the final diagnosis after three months of follow up. Results: A total of 294 patients were enrolled in three hospitals. The clinical diagnosis was correct in 81 of the 143 patients (56.6%) suspected of appendicitis. A combined clinical diagnosis with decision tool use was registered in 132 patients suspected of appendicitis and correct in 72 patients (54.5%). The clinical diagnosis was correct in 11 of the 20 patients (55%) suspected of diverticulitis. The level of certainty of residents increased after completion of the decision tool for only 19.2% of patients with final diagnosis appendicitis and 13.6% patients without appendicitis. For diverticulitis these proportions were 36.4% and 37.5%, respectively. In only 18% of patients with diverticulitis the decision tool was reported to influence the utilization of imaging, and in none of the patients with an alternative final diagnosis. Conclusion: This multi-center prospective cohort study demonstrates that use of decision tools for acute appendicitis and diverticulitis has limited influence on the modest accuracy and certainty of a clinical diagnosis. Currently, decision tools are unlikely to influence utilization of hospital resources. The diverticulitis decision tool has some potential to influence daily practice.