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    • Appendectomy is recognized as a standard

    2018-11-06

    Appendectomy is recognized as a standard Diseases Related Group (DRG) payment system worldwide. Hospital managers prefer to format the clinical pathway for patients with appendicitis during hospitalization, attempt to shorten the length of stay, and discourage the use of a high-cost imaging diagnostic method such as CT. CT is one of the most common but expensive tests for patients with suspected appendicitis in the emergency service. Furthermore, total hospital expenditure for appendectomy decreases significantly by decreasing the length of stay as a policy in Taiwan. Health providers attempt to prevent excessive medical expenditure by avoiding unnecessary high-cost tests whenever possible because of the reimbursement policy of Taiwan\'s National Health Insurance. Preoperative use of ultrasound or CT for patients with suspected appendicitis has gradually increased, accompanied by a dramatic decrease in the negative appendectomy rate and statistically significant changes in the perforation rate over the last several years. However, clinical application of ultrasound or CT varied with the age and condition of patients in our emergency department. Therefore, we conducted a retrospective study for the evaluation of preoperative diagnosis through ultrasound or CT in patients with appendicitis and their medical expenditure based on the reimbursement system of Taiwan National Health Insurance in our hospital.
    Patients and methods A total of 1047 patients [555 (53.0%) males and 492 (47%) females] enrolled in this Flavopiridol hydrochloride retrograde study were operated after preoperative diagnosis using ultrasound or CT between 2008 and 2011 at our emergency department. The patients underwent preoperative diagnosis with or without the aid of CT or ultrasound. Patients were classified into the following groups: Group 1, CT and ultrasound; Group 2, CT only; Group 3, ultrasound only; and Group 4, neither CT nor ultrasound. Patient numbers of Groups 1, 2, 3, and 4 were 139, 180, 383, and 345, respectively (Table 1). The mean age of the patients was 41.4 ± 17.9 years, with a range of 6–87 years. The final diagnosis of appendicitis was based on an operative diagnosis of Ap (International Classification of Disease, ICD-9-CM codes 540, 540.0, 540.1, and 540.9). The severity of appendicitis was classified as appendicitis without peritonitis (Ap, ICD code 540.9), appendicitis with perforation and local abscess (Ap-perforation, ICD code 540.1), and appendicitis with peritonitis (Ap-peritonitis, ICD code 540.0) on the basis of operative and pathological findings. The pre-existing comorbidity of the patients was scored using the Charlson Comorbidity Index (CCI) scores of 0, 1, and ≥2. Clinical profiles of patients included age, sex, CCI, operative procedures (open or laparoscopic), and medical expenditure under the reimbursement system of Taiwan DRG (Tw-DRG). These patients\' variables, relationship with ultrasound or CT diagnosis, and medical expenditure were considered for analysis. Statistical analysis was performed with an unpaired Student t test after analysis of variance for more than two groups. A p value of <0.05 was considered significant.
    Results
    Discussion Either ultrasound or CT has widely been used for the diagnosis of suspected appendicitis in our emergency department. In pediatric patients, the sensitivity and specificity of ultrasound can approach those of CT, without the use of ionizing radiation. In a meta-analysis of 10,000 children who underwent ultrasound scans for the evaluation of possible appendicitis, sensitivity ranged from 50% to 100% and specificity from 88% to 99%. Our series revealed that CT was used in 23.6% of patients aged less than 20 years for the diagnosis of Ap. However, the sensitivity and specificity of CT were greater than those of ultrasound in older patients presenting with clinical signs of Ap. Ultrasound still remained the first choice in the emergency service. If CT could be avoided for emergency patients, then hospital expenditure and negative appendectomy rates might also decrease. In another study, the use of in-house CT was reported to decrease from 71.2% to 51.7% (p = 0.01) and the negative appendectomy rate was reported to increase (6.8% vs. 11%, p = 0.25), suggesting that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of Ap in children may safely reduce the use of CT scans and increase the use of ultrasound. Age was strongly associated with short-term mortality. The highest mortality rate was observed among children and older adults. Short-term mortality was mainly due to either delayed or incomplete imaging diagnosis. Therefore, the need to avoid harmful radiation and make an early diagnosis of Ap using CT varied according to the age group and clinical conditions.