Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study

Abstract

Background. Pediatric abdominal pain accounts for more than 1 million emergency department (ED) visits annually, and appendicitis is the most common surgical emergency. Guidelines recommend ultrasound as the initial imaging study for diagnosing pediatric appendicitis. However, because of the variability in both the availability and interpretation of pediatric ultrasounds in general EDs, clinicians may potentially overuse computed tomography (CT). Shared decision making (SDM) and clinical decision support (CDS) tools may help avoid unnecessary CTs; however, it is not clear to what extent such tools are used. Our objective was to describe the current diagnostic approaches and challenges faced by physicians in general EDs when assessing potential pediatric appendicitis. Understanding the nuances specific to this context may help inform the creation of more universally applicable diagnostic guidelines and CDS tools. Methods. We conducted semi-structured interviews with physicians practicing in general EDs to assess the current approaches and challenges in diagnosing pediatric appendicitis. We sought input on the use of existing CDS tools such as the pediatric appendicitis risk calculator (pARC) and the role of SDM. We analyzed interview transcripts using a thematic approach. Results. We conducted 15 interviews and identified 5 themes: 1) the limited availability of ultrasound often precludes routine use, 2) physicians tend to rely on gestalt over CDS tools, 3) guidelines regarding the transfer of patients to pediatric centers are needed, 4) the pARC could be improved with the integration of general ED-specific recommendations, and 5) physicians described using SDM frequently, but conceptualization and execution varied. Conclusion. Physicians in general EDs identified challenges in the current approaches to diagnosing pediatric appendicitis. A diagnostic pathway that incorporates validated CDS and general ED-specific recommendations could optimize the process, enhance SDM, and potentially reduce unnecessary CTs.

Highlights

Diagnosing pediatric appendicitis is challenging, especially in general EDs where pediatric resources are often limited.

Physicians in general EDs reported that current imaging techniques and clinical decision support tools often fail to meet the needs of their setting.

Physicians often rely on their own experience and often incorporate family preferences (via shared decision making) into their diagnostic planning.

Physicians in general EDs reported that better guidelines and community-specific diagnostic algorithms and clinical decision support tools would improve patient care.

Keywords

shared decision making emergency medicine appendicitis

More than 1 million children in the United States visit emergency departments (EDs) annually for abdominal pain, and clinicians must identify those with appendicitis, the most common pediatric surgical emergency.^1–3 Evidence-based guidelines endorse a standardized approach to evaluating children with acute abdominal pain and recommend ultrasound as the initial imaging modality.^4,5 Ultrasound is preferred over computed tomography (CT) because it is less costly and avoids exposure to ionizing radiation, which can increase the risk of future malignancy.^6–8 However, ultrasound imaging is not universally available, the quality of the imaging is operator dependent, and expertise in obtaining and interpreting pediatric ultrasound images is limited. As such, nondiagnostic ultrasound results are common,^9,10 especially in general EDs, which lack dedicated pediatric staffing, resources, and expertise.

When ultrasound is either unavailable or inconclusive, ED clinicians face a dilemma regarding diagnostic next steps. For children at lower risk of appendicitis, obtaining a CT scan or “watchful waiting” (observation or discharge with close follow-up) are 2 reasonable options, each with its own associated costs, risks, and benefits. Depending on the proximity to a pediatric specialty center, some general ED clinicians may opt to transfer children at higher risk of appendicitis for cross-sectional imaging or surgical consultation. Clinicians may seek input from the patient or their parent/caregiver when making these decisions, either informally or through shared decision making (SDM).^11,12

Such decisions are challenging but even more so in general EDs, where pediatric resources are often quite limited. More than 85% of children requiring emergency care are evaluated in general EDs,¹³ so it is imperative to understand the diagnostic challenges unique to this setting and create interventions specific to this context. We designed an exploratory, qualitative study with the goal of identifying current approaches and challenges of diagnosing pediatric appendicitis in the general ED setting.

Methods

Study Design and Conceptual Frameworks

This qualitative descriptive study used semi-structured interviews to elicit physician perspectives on their diagnostic approach to suspected pediatric appendicitis, including the resources used and the role of SDM. Two conceptual frameworks informed the study design and semi-structured interview guide. The ED-Adapted National Academies of Science, Engineering, and Medicine (NASEM) Diagnostic Process Framework (Supplemental Figure 1) conceptualizes the patient’s diagnostic journey, from prehospital care, through the various components of the ED visit, to ultimate outcomes.¹⁴ The second framework is the Ottawa Decision Support Framework, which assesses and addresses clinicians’ and patients’ decisional support needs and facilitators for SDM.¹⁵

This study was approved by the University of Michigan Institutional Review Board and adheres to Consolidated Criteria for Reporting Qualitative Research (COREQ) standards.¹⁶

Interview Guide

A steering group consisting of experts in emergency medicine, pediatric appendicitis, SDM, health risk communication, emergency nursing, primary care, general surgery, pediatric surgery, and patient representatives convened to review the study goals and draft the initial interview guide. Interview questions focused on the clinicians’ typical diagnostic approach, use of clinical decision support (CDS) tools, perspectives on the role of SDM, and decisional support needs. We framed SDM-related questions with neutral language (without using the term “shared decision making”) to prompt authentic answers, rather than compel responses that conformed to perceived social norms.

In addition, we solicited physician familiarity with and feedback on a specific CDS tool, the pediatric appendicitis risk calculator (pARC), via an interactive demonstration of the tool at the conclusion of the interview. The pARC uses data from the patient’s history, exam, and white blood cell count to calculate their risk of appendicitis (Supplemental Table 1).¹⁷ It has been validated for use in the general ED setting and generally outperforms other pediatric appendicitis risk scores,^17–19 but the extent to which it is used by general ED clinicians is not known. In its current form, the pARC provides specific diagnostic recommendations based on the patient’s risk score for the pediatric ED setting (Supplemental Table 2). However, the optimal clinical actions have not yet been defined for general EDs.

We pilot tested the preliminary guide with 2 emergency medicine physicians and revised it based on their feedback prior to formal participant recruitment and data collection. The final interview guide is included as Appendix 1.

Participants and Sampling

We recruited physicians working in general EDs in the United States. Physicians board certified in emergency medicine, pediatrics, pediatric emergency medicine, or family medicine were eligible to participate. We recruited physicians via virtual flyers on private emergency medicine physician social media groups and snowball sampling. We used typical case sampling to represent the field’s average workforce in terms of sex, race, years of clinical experience, and practice location.²⁰ We aimed to recruit 15 participants, as evidence suggests most relevant codes are obtained within 12 in-depth interviews.²¹ The sample size was also informed by the information power framework based on the approach of qualitative description and the strength of interview dialogue.^21,22 Recruitment and data collection occurred from January to May 2024. Participants received $50 for their participation.

Data Collection and Analysis

We obtained informed consent from participants prior to the interview. We conducted and recorded all interviews via a communications platform and video conferencing service (Zoom Inc.). A professional transcription service transcribed all interviews verbatim and removed personal identifiers.

A team of 2 researchers (a pediatric emergency medicine physician and health services researcher and a master’s level researcher) with approximately 5 years of experience in qualitative research conducted the interviews and performed the analysis using a combined inductive and deductive approach.^23,24 First, we developed an a priori codebook based on conceptual frameworks and the interview guide.^14,15 Using the codebook, the 2 researchers independently coded 2 sets of interviews and then met to assess congruence, revise codes, and develop new codes. They then coded the remaining interviews independently and then reviewed all interviews again together, with discrepancies resolved through discussion to achieve consensus. Coding was performed using qualitative analysis software (MAXQDA 2022, Verbi Software). Themes were developed by assessing memos related to coded segments and using analytic features in MAXQDA such as the matrix code browser to identify patterns across interviews.²⁵

Results

We interviewed 15 physicians practicing in general EDs. Physicians were 60% male, 73% non-Hispanic White, and 80% board certified in emergency medicine. Participants were recruited from diverse practice settings, with equal representation of suburban, urban, and rural/critical access primary practice locations (Table 1, Supplemental Table 3). Interviews ranged from 33 to 69 min (mean = 53 min). The codebook was finalized after 8 interviews, and subsequent thematic analysis identified 5 major themes (Table 2).

Table 1

Participant Characteristics

N = 15	Number (%)
Sex
Male	9 (60)
Race/ethnicity
Asian	3 (20)
Hispanic	1 (7)
Non-Hispanic White	11 (73)
Non-Hispanic Black	0
Training
Emergency medicine	12 (80)
Pediatrics	2 (13)
Pediatric emergency medicine	1 (7)
Practice designation
Urban	5 (33)
Suburban	5 (33)
Rural or critical access	5 (33)
Geographic location
Midwest	8 (53)
East Coast	2 (13)
South	4 (27)
West Coast	1 (7)
Years in practice
<5	4 (27)
5–9	3 (20)
10–15	2 (13)
>15	6 (40)

Table 2

Key Themes and Illustrative Quotes

The limited availability and diagnostic utility of ultrasound often precludes routine use in general EDs	“I was ordering ultrasound for a while, and consensus is that our techs can’t find an appendix if it it’s labeled in 30-point hypoechoic font. We tried it . . . and we were always ending up getting the CT anyway, so it was just costing us time.” (MD #1)
	“In my experience, you order appendicitis ultrasound on a child, and at some point later, we’ll call it 2 hours, you get a report back that says, ‘it’s equivocal . . . .’ And you're like, well, I wasted 2 hours and I still don’t have any answers.” (MD #6)
	“I don’t know if that’s generational on the [ultrasound tech] training or it’s just site specific, but I know that at all of our community sites, our ultrasound techs, just, it’s just not visualized, you know, gas pattern overshadowing, etc., etc.” (MD #12)
Clinicians tend to rely on gestalt over clinical decision support tools or practice guidelines	“I think that clinical gestalt is what, at the end of the day, I’m going to use anyway. Even if I get a scoring tool and, the child will score a certain way, I think my experience and my initial gestalt is what I’m going to trust more than a tool.” (MD #14)
	“But I think without a good stepwise tool or approach, you’re kind of stuck using, you know, gut tools.” (MD #8)
	“If there is a clinical scoring system that I don’t know about, I’d love to learn more. But I guess I just go by my experience and my clinical decision making.” (MD #4)
Transfer decisions are complex, and better guidelines are needed to direct this process	“I’m in an ED that’s an hour from the big center. It’s 2 am, and I have a 10-year-old and I think they have appendicitis. They have a leukocytosis, their urine is normal . . . so I get a CT, and sure enough they have appendicitis. Then I call the surgeon and they say, ‘Yeah, send him here to the big hospital and we’ll take care of him.’ And then I get a nastygram later saying, ‘Why in the world did you order a CT?’ And I say, ‘Because I wanted to have a diagnosis before I called you.’ And they’re like, ‘Well, you should have just called us, and we would’ve said send them here.’” (MD #6)
	“When we call the referral centers to do a transfer to avoid a CT scan, it’s complicated. If it’s negative, then they are 4 hours downstate and there’s nothing wrong with them.” (MD #12)
	“I’m willing to work with the [transfer] system, but I just . . . I want it to make sense kind of a thing.” (MD #8)
The pARC tool could be improved with integration of general ED-specific recommendations for patients with intermediate risk	“I may start using that just as a gut check. When the tool helps me, I use it. When it’s not helpful, I'm not going to bring it up. But if it helps me to say, ‘Hey, this tool says it’s less than 3%, I think your risk is very low, let’s go home. If things get worse, please come back,’ that will only augment my discussion with the family.” (MD #6)
	“It’s like PERC, right? Like, high’s high and the low’s low, and what the hell do you do with intermediate? Well, it’s probably gonna tell you to get an ultrasound.” (MD #5)
	“I think that the disposition is what I’m looking for, right? I’m not satisfied with you just telling me its intermediate risk.” (MD #14)
Clinicians describe using SDM at various points in the diagnostic process, but their personal definitions of SDM vary	“There’s no point where I don’t have a shared decision making conversation. It’s always shared. And a lot of times they’ll say, ‘What would you do?’ And then I’ll tell them what I would do, but it’s always the decision they need to make.” (MD #3)
	“While we don’t always use the term shared decision making, I think that actually happens a lot more commonly in rural places because you don’t have the resources that are necessarily available at the bigger places, but you do have the assurance of follow up and kind of the different expectations.” (MD #11)
	“And I say, ‘I could go either way. There’s not a wrong answer, parents. Either we can do the next test, which is a CT scan, or we can say, Hey, maybe this is a stomach virus. But this is our decision point. We’re either going to do another test or I’m going to let you go home. If things get worse, come back, kind of a thing.'” (MD #6)

CT, computed tomography; ED, emergency department; pARC, pediatric appendicitis risk calculator; PERC, pulmonary embolism rule-out criteria; SDM, shared decision making.

Ultrasonography: Limited Availability and Utility

A key theme was that the limited availability and diagnostic utility of ultrasound often precludes routine use in many general EDs. Participant responses indicated that the availability of ultrasound technologists in general EDs is highly variable, ranging from 24-hour in-house coverage to call-in coverage, to no coverage. Even for sites with call-in coverage, however, ultrasound for suspected appendicitis was often an excluded indication. As one clinician described, “We have a special algorithm of when you can call the ultrasound tech in after hours and on the weekend. And suspicion for appendicitis is not one of those” (MD #14). Even when ultrasound coverage was available, many clinicians felt it was futile to order the test since it was often nondiagnostic. “Our ultrasound techs will not [do appendicitis] ultrasounds and, even if you get them to, they never visualize anything. Very rarely is the appendix seen” (MD #2).

Gestalt versus CDS

Our participants described reliance on clinical gestalt, referring to their intuition or gut feeling, over CDS tools or practice guidelines when assessing children with possible appendicitis. Most clinicians expressed familiarity with the Alvarado Score²⁶ and the Pediatric Appendicitis Score (PAS)²⁷ but noted that they did not find them particularly helpful. One clinician stated, “I haven’t found one that I find as compelling or as useful as some other clinical guides that I use” (MD #6). Only 1 clinician was familiar with the pARC tool. Nearly all participants acknowledged that they do not use CDS tools routinely. One clinician stated, “I’ve just gone with clinical gestalt for a few years now. I’m pushing mid to late career. So I’ve kind of stepped away from [scoring tools]” (MD #12). Another stated, “I’ll use a scoring system in my note to justify why I’m doing something,” (MD #7) but acknowledged they did this only if the score aligned with their clinical judgment. One participant voiced concern about using tools that were not designed for or tested in the relevant setting, stating, “I think most of those studies are done in EDs in bigger academic centers. So, it’s a little bit different when you’re in the middle of nowhere by yourself” (MD #14). Finally, most clinicians said that their department did not have or endorse a practice guideline for the evaluation of suspected pediatric appendicitis.

Better Guidance Is Needed for Transfer Decisions

Among the 15 clinicians interviewed, only 2 worked in clinical settings that could reliably perform appendectomies for all pediatric age groups. The remainder of the clinicians described transferring all or nearly all children with appendicitis for surgical management. Clinicians noted that transfer decisions are complex, and they felt that better guidance is needed to direct this process for both the accepting and referring facilities (Table 2). Specifically, clinicians wanted guidelines to identify which patients should be transferred to pediatric centers prior to undergoing cross-sectional imaging. Since many general EDs must transfer children with confirmed appendicitis to pediatric centers for definitive management, transferring before obtaining a CT is often a reasonable strategy. However, participants noted that accepting facilities vary in whether they are agreeable to this practice. One physician said, “I would say that 80% of the time I try to do that, they would indeed be agreeable, 20% they push back” (MD #11). Conversely, other physicians described that their accepting pediatric EDs strongly preferred imaging to be deferred until after transfer. “They don’t want us to image. I call first and say, ‘Hey, this is what I’m thinking . . . would you like me to get the CT?’ and they are like, ‘No, no, no, we’ll image here’” (MD #1).

For physicians practicing in rural locations, the decision to transfer before imaging was more complicated because of the often-significant distance to the nearest pediatric facility. One commented, “It’s a lot harder to pull a trigger to send somebody that may not have appendicitis when you’re sending them 2 hours away” (MD #2). Another rural physician described being reprimanded by the receiving facility for performing a CT before transfer and desiring better guidance in this scenario. But some physicians noted it would not be practical to transfer every case of pediatric abdominal pain. “You really don’t want me to send every kid that has belly pain up to you for an ultrasound, it’s just not feasible for your resources” (MD #8). Finally, one physician identified that incorporating a clinical score into transfer guidance might improve the process. “We’re pretty radiation heavy in the community. If we can change that in some way and I can start transferring kids based on a score to get an ultrasound that would be nice” (MD #1). Ultimately, participants desired formal transfer guidelines to help minimize the conflicting recommendations and simplify medical decision making.

The pARC and General ED-Specific Recommendations

Participants highlighted that the pARC could be improved with the integration of general ED-specific recommendations (Table 2). Only 1 clinician was aware of the pARC when asked about it during the interview, but most participants expressed enthusiasm when introduced to it during the interactive component. “There’s a lot of things I like here. And actually, it might help in circumstances where I can show it to the parents and be like, ‘Look, this is what this is saying. And I agree’” (MD #10). Most commented that pARC would be more useful if it was modified to include general ED-specific clinical recommendations, especially for the patients at intermediate risk of appendicitis based on their score. “We are asking this tool to do what we are already struggling to do . . . which is the gray area. It’s interesting to think about what would make it feel less gray. Somehow breaking it down into something more concrete would help us” (MD #14). Participants also noted that guidelines would be most valuable if they were less reliant on ultrasonography.

Clinicians Describe Using SDM Frequently, But Personal Conceptions Vary

A final theme was that most clinicians reported employing informal SDM at some point in the diagnostic process; however, we identified variations in their conceptualization of SDM (Table 2). SDM has traditionally been defined as a collaborative process in which clinicians and patients (or their caregivers) make health care decisions together, taking into account the risks and benefits of each option as well as the goals and preferences of the patient.¹¹ In our interviews, some clinicians equated SDM to informed consent or general involvement. One participant stated, “There’s no point where I don’t have a shared decision making conversation. It’s always shared” (MD #3). Another commented, “I try to make them feel very involved. I really try to make them understand what I’m thinking and doing” (MD #4). Another clinician said, “I use that term (SDM) to say, “is the family on board with this?” (MD #6). In contrast, other clinicians described a process that was more reflective of guided SDM, in which they offered choices but also nudged parents toward the decision that they (the clinician) perceived to be most appropriate.²⁸ One participant recalled talking to a parent and saying, “This could be appendicitis, but I really don’t want to have to do a CT scan. The other option is home and watchful waiting” (MD #12).

Nearly all clinicians described using some form of SDM to determine next steps for patients they felt to be at low to intermediate risk when ultrasound imaging was either unavailable or diagnostically equivocal. “If the index of suspicion is there, and the ultrasound comes back equivocal, usually, it’s shared decision making with parents about proceeding with CT” (MD #9). Many clinicians described having a typical script for this scenario: “So the framework I use in these situations goes something like, ‘Hey, there are two separate options here, and both have their merits. If I thought one was a slam dunk, I would tell you. But I want to talk about these options, give you some guidance, and then make a decision together, alright?’” (MD #13).

Discussion

This study describes current diagnostic practices and challenges that general ED physicians face when evaluating a child for suspected appendicitis. Participants identified several challenges specific to their practice settings: ultrasonography is usually not a viable diagnostic option, the lack of transfer guidelines to pediatric EDs complicates decision making, and current CDS tools lack applicability to their setting (often resulting in the use of gestalt over such tools). Our analysis also revealed that clinicians frequently use SDM in this scenario, but the conceptualization and execution of these conversations vary.

Insights from general ED physicians can help inform interventions designed to address these challenges and improve the diagnostic process in their specific setting. For example, most clinicians described that CDS tools are unhelpful in their current form. When introduced to the pARC, they found it to have compelling face validity but identified it could be improved with the addition of guidelines that would be more applicable to general EDs. Based on their comments, adapting the pARC to include recommendations for sites where ultrasound is either unavailable or when findings are nondiagnostic would make the tool more relevant for their setting. In addition, incorporating transfer guidelines based, in part, on a pARC score would simplify medical decision making, clarify clinical communication, potentially mitigate the need for CT, and enhance an evidence-based diagnostic pathway.

Several studies have described the implementation of a standardized diagnostic algorithm for pediatric appendicitis,^29–31 but an expert-endorsed, evidence-based pathway that would be suitable for most general EDs has not yet been devised. Clinicians in this study expressed a need for a “demonstrable, algorithmic process” to guide their evaluation and “to show parents it has been validated and is recommended by whatever national society” (MD #12). Previous work has demonstrated that incorporating risk scores into diagnostic algorithms in general ED settings seems to hold the most promise in standardizing the evaluation of pediatric appendicitis and reducing unnecessary cross-sectional imaging.^30,31 In addition, recent expert consensus recommends both the use of validated CDS tools and consideration of SDM in the diagnostic evaluation of children with abdominal pain and low to moderate risk of appendicitis.^32–34 Based on these principles, we can begin to conceptualize a theoretical diagnostic algorithm that incorporates these elements while also addressing the challenges raised by clinicians in our study.

Figure 1 illustrates a hypothetical pathway the begins with the patient’s pARC score and then provides a suggested diagnostic pathway based on the availability and diagnostic validity of ultrasound. The option to transfer patients who are higher risk for appendicitis is also included, and this could be further tailored based on a site’s proximity to a pediatric specialty center. For example, the farther the distance to the pediatric center, the higher the pARC score should be to prompt transfer before a definitive diagnosis (or confirmatory cross-sectional imaging). Finally, the algorithm also highlights key decision points at which SDM might be appropriate, with diagnostic and management options tailored to the specific ED’s capabilities. A diagnostic algorithm like this would need to be implemented and studied to understand its impact on clinical resource use, cost, and clinical outcomes.

Figure 1

Theoretical diagnostic algorithm incorporating the pediatric appendicitis risk calculator (pARC) score and opportunities for shared decision making (SDM; purple boxes) in the evaluation of a child with possible appendicitis who presents to a general emergency department.^17,18,35

Our data indicate that general ED clinicians are clearly open to engaging in SDM; however, their execution of SDM varies and may not always align with the principles of traditional SDM.³⁶ These findings suggest that clinicians may require more support in having these discussions. Formal SDM is often guided by a decision aid or clinical script; however, none currently exist specific to this clinical scenario. Tools to facilitate SDM have been developed for use in the emergency setting for many scenarios, including the management of febrile infants³⁷ and imaging decisions for children with minor head trauma.³⁸ Such tools have been successful in decreasing decisional conflict, enhancing patient/family engagement, and increasing physician trust.^38,39 A recent technical report on advance imaging for pediatric ED patients endorses the use of SDM for children at lower risk of appendicitis (based on CDS tools).⁴⁰ Creation of a well-designed SDM intervention for the evaluation of possible pediatric appendicitis in the general ED setting could help standardize SDM communication and improve the diagnostic process.

Ultimately, participants in our study wanted “a standardized approach” to diagnosing pediatric appendicitis. However, they also conceded that they currently rely more on gestalt than CDS tools or algorithms. This may be due, in part, to the fact that current tools do not meet the needs of general ED clinicians or match the resources of their practice setting. The findings from our study may help inform the creation of CDS tools or SDM interventions to improve medical decision making in general EDs. Nevertheless, we acknowledge that nudging clinicians to change behavior and use such tools, rather than relying on gestalt or personal practice patterns, will likely present an implementation challenge.^31,41

Limitations

Our study has several limitations. First, we recruited general ED physicians “to discuss how they work-up pediatric abdominal pain and communicate with families.” Participants were self-selecting and may reflect those who have a special interest in communication, which may positively bias perspectives on SDM. Second, the cohort did not include the perspectives of advanced practice providers (APPs) or residents, who may play a significant role in management decisions and patient communication. However, APPs and residents are supervised by attending physicians, and our goal was to study physician decision making. Third, our sample was less diverse than we intended, but it generally reflects the composition of the emergency medicine workforce at this time.^42–44

Conclusion

General ED physicians identified numerous challenges in the current approach to diagnosing pediatric appendicitis in the general ED context. A diagnostic pathway that incorporates validated clinical decision support (such as the pARC) and general ED-specific recommendations could standardize the diagnostic process, enhance SDM, and potentially reduce unnecessary CT scans.

Supplemental Material

sj-docx-1-mpp-10.1177_23814683261438831 – Supplemental material for Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study

Supplemental material, sj-docx-1-mpp-10.1177_23814683261438831 for Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study by Courtney W. Mangus, Sarah J. Parker, Brian J. Zikmund-Fisher, Anupam Kharbanda, Melissa Brooks, Helene M. Epstein, Timothy C. Guetterman, Emma Griffin, Aparna Joshi, Bryan Judge, Heather Orman-Lubell, Milisa Manojlovich, Brigid Rice, Gul R. Sachwani-Daswani, Suz Schrandt, Karen Elizabeth Speck, Prashant Mahajan and Elizabeth M. Schoenfeld in MDM Policy & Practice

Supplemental Material

sj-docx-2-mpp-10.1177_23814683261438831 – Supplemental material for Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study

Supplemental material, sj-docx-2-mpp-10.1177_23814683261438831 for Current Diagnostic Approaches and Challenges in the General Emergency Department Evaluation of Suspected Pediatric Appendicitis: A Qualitative Study by Courtney W. Mangus, Sarah J. Parker, Brian J. Zikmund-Fisher, Anupam Kharbanda, Melissa Brooks, Helene M. Epstein, Timothy C. Guetterman, Emma Griffin, Aparna Joshi, Bryan Judge, Heather Orman-Lubell, Milisa Manojlovich, Brigid Rice, Gul R. Sachwani-Daswani, Suz Schrandt, Karen Elizabeth Speck, Prashant Mahajan and Elizabeth M. Schoenfeld in MDM Policy & Practice

Footnotes

Acknowledgements

This work was presented at the Pediatric Academic Societies Conference in Honolulu, Hawaii, on April 28, 2025.

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Author Brian J. Zikmund-Fisher is a member of the Editorial Board of Medical Decision Making. The author did not take part in the peer review or decision-making process for this submission and has no further conflicts to declare. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this study was provided entirely by a grant (K08HS029523) from the Agency for Healthcare Research and Quality. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Ethical Considerations

This work was approved by the Institutional Review Board at the University of Michigan.

Consent to Participate

Written informed consent was obtained from all participants prior to participation.

Consent from Patients

Not applicable.

Consent for Publication

Not applicable.

Data Availability

Study data will be made available upon reasonable written request to the corresponding author.

ORCID iDs

Courtney W. Mangus

Brian J. Zikmund-Fisher

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