Reducing Radiation Exposure and Imaging Costs for Children With Appendicitis

Reducing Radiation Exposure and Imaging Costs for Children With Appendicitis 1024 575 Rachael Hardison
Black and white photo of boy sitting up on hospital bed

Appendicitis is one of the most common indications for abdominal surgery in children. Accurate, efficient diagnosis is critical for initiating timely treatment. Current imaging options for diagnosing appendicitis include ultrasound and computed tomography (CT). CT scans, while readily available and highly sensitive, require radiation exposure that can increase the risk of malignancy over the child’s lifespan.

The American College of Radiology guidelines recommend the use of ultrasound before CT scans in pediatric patients with signs of appendicitis. Ultrasound is cost efficient, non-invasive, and doesn’t involve radiation, but the results can be variable and operator-dependent.

To improve the quality of ultrasound diagnoses and cut down on radiation exposure from CT scans, surgeons at Nationwide Children’s Hospital spearheaded a project to develop a standardized ultrasound template and assess its utility and potential for cost savings. The study, published in the Journal of Surgical Research, found that using the template decreased the rate of CT scans and improved the accuracy of ultrasound diagnoses with a significant potential for imaging cost savings.

“Prior ultrasound reports did not provide sufficient concrete details to allow clinicians to utilize the information effectively in their clinical decision making,” says Andrew Nordin, MD, a Surgical Critical Care fellow and lead author on the study. “The goal in creating the ultrasound template was to eliminate this variability and provide a common set of findings and interpretations to better aid practitioners in identifying appendicitis; this, in turn, decreased our CT usage.”

The template classifies ultrasound findings into one of four categories by radiologists. Two categories are considered negative for appendicitis, and two are considered positive. The initial design and implementation of this ultrasound template was published in the Journal of Pediatric Surgery in 2015.

For the current study, the team led by Brian Kenney, MD, MPH, in the Department of Surgery at Nationwide Children’s conducted both a retrospective and prospective chart review. The researchers recorded imaging types and rates both before and after the introduction of the standardized ultrasound template in September 2012. Patients less than 18 years of age with suspected appendicitis were included in the review.

Use of the standardized ultrasound template decreased CT rates at Nationwide Children’s by 78.3 percent while rates of ultrasounds for suspected appendicitis increased by 22.6 percent. Standardizing ultrasound reports with the template also had a significant potential financial benefit – implementing the template led to an estimated cumulative imaging cost savings of over $100,000 for the time period examined.

The use of the ultrasound template is now standard for patients with suspected appendicitis at Nationwide Children’s. The authors hope that this will continue to reduce unnecessary radiation exposure in the pediatric population. They also suggest that incorporating an ultrasound template for appendicitis may provide similar benefits at other institutions.

“We have attained a significant and sustained reduction in our CT usage with the adoption of our standardized template,” says Dr. Nordin. “Applying the template may potentially minimize some of the user variability, but more importantly, it gives clinicians a common framework with which to interpret the results.”


Nordin AB, Sales S, Nielsen, et al. Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costsJournal of Surgical Research. 2018;221:77-83.

Nielson JW, Boomer L, Kurtovic K, et al. Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography templateJournal of Pediatric Surgery, 50 (2015), pp. 144-148.

Photo credit: Nationwide Children’s

About the author

Rachael is a PhD candidate in Biomedical Sciences at The Ohio State University and is completing her graduate studies at The Research Institute at Nationwide Children’s Hospital in the Center for Microbial Pathogenesis. She contributes to Pediatrics Nationwide and PediatricsOnline, an online newsletter for specialists.