Disparities in Ultrasound Use for Diagnosing Pediatric Appendicitis Across United States Emergency Departments

Introduction: An ultrasound (US)-first approach for evaluating appendicitis is recommended by the American College of Radiology. We sought to assess the access to and utilization of an US-first approach for children with acute appendicitis in United States Emergency Departments.

Methods: Utilizing the 2019 Nationwide Emergency Department Sample, we performed a retrospective cohort study of patients <18 y with a primary diagnosis of acute appendicitis based on International Classification of Disease 10th Edition Diagnosis codes. Our primary outcome was the presentation to a hospital that does not perform US for children with acute appendicitis. Our secondary outcome was the receipt of a US at US-capable hospital. We developed generalized linear models with inverse-probability weighting to determine the association between patient characteristics and outcomes.

Results: Of 49,703 total children, 24,102 (48%) received a US evaluation. The odds of presenting at a hospital with no US use were significantly higher for patients aged 11-17 compared to patients <6 y (adjusted odds ratio [aOR] [95% confidence interval (CI)]: 1.59, [1.19- 2.13], P = 0.002); lowest median household income quartile compared to highest (aOR [95% CI]: 2.50, [1.52-4.10], P < 0.001); rural locations compared to metropolitan (aOR [95% CI]: 8.36 [5.54-12.6], P < 0.001), and Hispanic compared to non-Hispanic White (aOR [95% CI]: 0.63 [0.45-0.90], P = 0.01). The odds of receiving a US at US-capable hospitals were significantly lower for patients >6 y, lowest median household income quartiles, and rural locations (P < 0.05).

Conclusions: Rural, older, and poorer children are more likely to present to hospitals that do not utilize US in the diagnosis of acute appendicitis and are less likely to undergo US at US-capable hospitals.