Missed Opportunity for Initial Diagnosis in Children With Complex Appendicitis

Shruthi Srinivas; Wendy Jo Svetanoff; Sidhant Kalsotra; Brenna Rachwal; Taha Akbar; Kristine L Griffin; Madeline Su; Brian Kenney; Kyle Van Arendonk; Gail E Besner

doi:10.1097/PEC.0000000000003326

Missed Opportunity for Initial Diagnosis in Children With Complex Appendicitis

Pediatr Emerg Care. 2024 Dec 30. doi: 10.1097/PEC.0000000000003326. Online ahead of print.

Authors

Shruthi Srinivas, Wendy Jo Svetanoff¹, Sidhant Kalsotra², Brenna Rachwal², Taha Akbar², Kristine L Griffin¹, Madeline Su³, Brian Kenney¹, Kyle Van Arendonk, Gail E Besner¹

Affiliations

¹ From the Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH.
² Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH.
³ The Ohio State University College of Medicine, Columbus, OH.

PMID: 39730146
DOI: 10.1097/PEC.0000000000003326

Abstract

Objectives: Delayed diagnosis of acute appendicitis in children may result in complex appendicitis with appendiceal perforation. Delayed diagnosis can result from missed opportunity for initial diagnosis (MOID) despite medical attention. Studies report MOID of less than 5% in pediatric emergency departments (EDs), but we hypothesized that many MOID occurs outside tertiary care facilities. Our goals were to determine the MOID rate in all presenting facilities in children with complex appendicitis and to identify associated risk factors.

Methods: Children (age ≤18) undergoing appendectomy for complex appendicitis between 2018 and 2022 at a single free-standing academic children's hospital were reviewed. Missed opportunity for initial diagnosis was defined as evaluation for related symptoms without a diagnosis of appendicitis within 7 days prior to appendectomy. Logistic regression and UpSet plots were used to identify associated risk factors.

Results: Of 856 children, 140 (16.4%) had MOID. Most MOID originated from nontertiary facilities [urgent care (38.6%), local EDs (26.4%), primary care (25.0%)] compared to our pediatric ED (11.4%). Compared to single-encounter diagnosis, MOID was associated with younger age (adjusted odds ratio per year [aOR] 0.93, 95% confidence interval [CI]: 0.88-0.97) and non-English/Spanish primary language (aOR 2.61, 95% CI: 1.18-5.76). Uninsured patients had lower MOID (aOR 0.22, 95% CI: 0.05-0.96). Missed opportunity for initial diagnosis was associated with more complications (33.6% vs 19.1%, P < 0.0001), prolonged length of stay (6 vs 4 days, P < 0.0001), and increased readmission (11.4% vs 6.6%, P = 0.044).

Conclusions: Missed opportunity for initial diagnosis of complex appendicitis occurs in nontertiary care facilities, is more common in younger children and non-English/Spanish speakers, and is associated with worse outcomes, highlighting the need for interpreters and algorithmic evaluation in nontertiary care facilities.