Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years
Open Access
- 2 April 2020
- journal article
- research article
- Published by Wiley in Academic Emergency Medicine
- Vol. 27 (9), 821-831
- https://doi.org/10.1111/acem.13931
Abstract
Objectives Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. Methods This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5 days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. Results Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic = 0.83, 95% confidence interval = 0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate = 1.1% in gestalt 1%–10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5 years since medical school graduation demonstrated improved gestalt performance over those with less experience (p = 0.007). All clinical characteristics tested, except pain <24 hours, were significantly associated with physician gestalt value (p < 0.05). Conclusion Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.This publication has 38 references indexed in Scilit:
- Utility of MRI After Inconclusive Ultrasound in Pediatric Patients With Suspected Appendicitis: Retrospective Review of 60 Consecutive PatientsAmerican Journal of Roentgenology, 2013
- Emergency Physicians’ Knowledge and Attitudes of Clinical Decision Support in the Electronic Health Record: A Survey‐based StudyAcademic Emergency Medicine, 2013
- An integrated EHR at Northern California Kaiser PermanenteApplied Clinical Informatics, 2012
- Clinician Judgment Versus a Decision Rule for Identifying Children at Risk of Traumatic Brain Injury on Computed Tomography After Blunt Head TraumaPediatric Emergency Care, 2009
- Knowledge Translation in International Emergency Medical CareAcademic Emergency Medicine, 2007
- Knowledge Translation in International Emergency Medical CareAcademic Emergency Medicine, 2007
- The San Francisco Syncope Rule vs physician judgment and decision makingThe American Journal of Emergency Medicine, 2005
- Performance Characteristics of Clinical Diagnosis, a Clinical Decision Rule, and a Rapid Influenza Test in the Detection of Influenza Infection in a Community Sample of AdultsAnnals of Emergency Medicine, 2005
- Does a Physicianʼs Ability to Accurately Assess the Likelihood of Pulmonary Embolism Increase with Training?Academic Medicine, 2000
- A practical score for the early diagnosis of acute appendicitisAnnals of Emergency Medicine, 1986