Validation of the Pediatric Appendicitis Risk Calculator (pARC) in a Community Emergency Department Setting

Abstract

Study objective: The pediatric Appendicitis Risk Calculator (pARC) is a validated clinical tool for assessing a child's probability of appendicitis. Our objective was to assess the performance of the pARC in community emergency departments (EDs) and to compare its performance with that of the Pediatric Appendicitis Score (PAS).

Methods: We conducted a prospective validation study from October 1, 2016, to April 30, 2018, in 11 community EDs serving general populations. Patients aged 5 to 20.9 years and with a chief complaint of abdominal pain and less than or equal to 5 days of right-sided or diffuse abdominal pain were eligible for study enrollment. Our primary outcome was the presence or absence of appendicitis within 7 days of the index visit. We reported performance characteristics and secondary outcomes by pARC risk strata and compared the receiver operator characteristic (ROC) curves of the PAS and pARC.

Results: We enrolled 2,089 patients with a mean age of 12.4 years, 46% of whom were male patients. Appendicitis was confirmed in 353 patients (16.9%), of whom 55 (15.6%) had perforated appendixes. Fifty-four percent of patients had very low (<5%) or low (5% to 14%) predicted risk, 43% had intermediate risk (15% to 84%), and 4% had high risk (≥85%). In the very-low- and low-risk groups, 1.4% and 3.0% of patients had appendicitis, respectively. The area under the ROC curve was 0.89 (95% confidence interval 0.87 to 0.92) for the pARC compared with 0.80 (95% confidence interval 0.77 to 0.82) for the PAS.

Conclusion: The pARC accurately assessed appendicitis risk for children aged 5 years and older in community EDs and the pARC outperformed the PAS.

Trial registration: ClinicalTrials.gov NCT02633735.

Figure 1.

Flow diagram pARC = pediatric Appendicitis Risk Calculator, RISTRA = A clinical decision support system RISk STRAtification tool embedded in the electronic health record, RLQ = right lower quadrant, WBC = white blood cell count

Figure 2.

Receiver operator curve for pARC and PAS pARC = pediatric Appendicitis Risk Calculator; PAS = Pediatric Appendicitis Score pARC area under the curve 0.89 (95% CI 0.87–0.92), PAS area under the curve 0.80 (95% CI 0.77–0.82)

Figure 3.

Calibration plot for pARC Blue plot is pARC Orange plot is pARC after calibration Hosmer-Lemeshow goodness of fit 11.81 (p=0.160) Calibration intercept and slope on the logit scale was −0.615 (SE 0.76, p<0.0001) and 1.10 (SE .057, p<0.0001)