Cutting Through The Crap

Tuesday, July 5, 2011


Here's a small but pretty good example -- far from the whole reason, of course -- of why medical care costs so much:
Multidetector CT Should Be Standard of Care for Appendicitis
The symptoms of acute appendicitis are nonspecific, making preoperative diagnosis difficult from clinical findings alone. ... ...To reduce morbidity and mortality risks, it is desirable to have a low perforation rate at appendectomy, but this must be balanced against minimizing the rate of negative findings at appendectomy through appropriate patient selection.

Computed tomography (CT) has been used in an attempt to improve preoperative diagnosis of appendicitis, but there are few high-quality studies of its efficacy for this indication, particularly since the advent of multidetector CT (MDCT). Therefore, the objective of this study by Pickhardt and colleagues was to evaluate the diagnostic performance of MDCT in a large adult cohort with suspected acute appendicitis.

Study Synopsis and Perspective

MDCT is sensitive and specific and should be the standard of care for suspected appendicitis in adults, according to the results of an analysis of MDCT findings reported in the June 21 issue of the
Annals of Internal Medicine. (coloring mine.)

"Nonspecific." Funny how things change. Not too many years ago, it was said that appendicitis is a clinical diagnosis, a bedside diagnosis. You listen to the story, do a two-buck lab test, you examine the patient. Carefully. In the majority of cases, it's pretty clear. When it's not, that's when you do more tests. When I was sure, based on the preceding steps, that the patient had appendicitis, I was never wrong (or, at least, it was always something that needed an operation.) (Okay, it's been a long career. I suppose I've forgotten one or two. But no more than the CT scan was wrong. In fact, I operated a couple of times when I wasn't convinced, clinically, got a CT which was interpreted as showing appendicitis, and found nothing.)

But here's the point: I was willing to come to the ER and make the diagnosis. (I was also taught physical diagnosis.) In fact, it pissed me off when I was called after a CT scan had been done. (When I mentioned it, the ER docs invariably said all the other surgeons demanded that one be done before they were called.) As time went on, and CT scans were done more and more routinely, it became more and more uncomfortable for me when I told a patient that I didn't think we needed one. And now, given the legal climate, who in his or her right mind (right mind? A surgeon?) would be willing to forgo ordering a CT when there are articles out there like the above?

In my community a $500 million hospital just opened. (It's gorgeous, and cutting-edge, and I'd bet the cost was way above what they've announced.) There's a dedicated CT scanner in the ER. It can do a scan in around ten seconds. Originally, they took fifteen or twenty minutes.

Last time I checked, a CT scan of abdomen and pelvis cost around $1500 bucks, and it's been a while since I checked.

[Interesting factoid: the above-referenced article was published in a journal for primary docs. Clever, huh?]


rlbates said...

I so agree with you on this!

Kellie (General Surgeon) said...

I have had the same experience. It is rare that I see a patient before a CT is done. Not sure why clinical exam is going by the wayside, but it seems to be quickly becoming a lost art.

This is kind of like doing studies to see which is better, antibiotics or surgery for appendicitis. Surgery is certainly quicker and the most recent article I saw said it was better. No surprise there, at least for me. People with appendicitis have pain and even with antibiotics and pain medication, they have pain for a while.

Skeptical Scalpel said...

Agree. I have expressed similar sentiments on my own blog ( and In my personal series of 148 appendectomies in the last 2.5 years, I have operated without a preop CT scan only 11 times, mostly in young men with classic findings. CT for diagnosing appendicitis is here to stay and will not be replaced by ultrasound or MRI.

Anonymous said...

I am of the mind that CT scans have vastly benefited humanity precisely because the physical exam skills of the average doctor have waned over the last few decades since the author of this blog began his career. With ease of diagnosis, thanks to CT scans and other radio,ogy imaging technology, it is much easier to scan than palpate. Whether you, me or anyone else thinks that such a paradigm shift is good or bad is essentially irrelevant at this point in time. For, as was noted, CT scans are here to stay. Instead of looking at such scans as anathema, perhaps we in the medical community should continue to guide our colleagues to the proper and appropriate reasons for imaging our patients. As an interventional radiologist, that is exactly what we need more and exactly what I try to do in my daily interactions with my non-radiology colleagues. CT scans are de facto standard of care and rightly so. But that doesn't absolve us of the responsibility of appropriate imaging use. When there is an unequivocal case of appendicitis, operating without a scan seems reasonable, if the surgeon is confident. But I don't fault the surgeon or any other doctor who wishes to confirm the diagnosis and potentially prevent a false-positive diagnosis being discovered at surgery.

Change is good. But we must understand just what kind of change is occurring.

Paul Dorio said...

Sorry. My comment sent without my "moniker"

Please add my name and URL to the comments made by "the interventional radiologist."

Sid Schwab said...

I don't consider CT scans, or any imaging, "anathema." I consider them overused. But I don't expect it to change; rather, only to get worse and more expensive.

Anonymous said...

I don't get it..
not one mention of "W", Dick Chaney, Ronaldus Maximus, Michelle Bachman, or the "T" word...
you know, the one that rhymes with that "F" word that rhymes with "dagger". And why can't we just say the actual F Word instead of "the F word"
F words aren't N-words, they won't burn down your neighborhood, even the F words that are N-words.

and what lab test can you get for $2?? Man, your old.
and back in the bad old days when I had to work ERs for a living, one place actually had a matrix so you could see what each Surgeon wanted done before being called for various thangs..
Which was useful...
For making sure you pissed off each surgeon to the max, what were they gonna do? FIRE ME?!?!?!
Umm OK, one dude did succeed in getting me "not re-hired", I still had the last laugh, ball walking his Loops...


Paul Dorio said...

You're right, Sid, not "anathema." I should not try to use big words 'cause I might end up misplacing emphasis. Jk

And I think if we can promote the use of appropriateness criteria, then maybe Imaging will increase in usefulness, thereby continuing to enhance patient care, while costs will not increase at the same rate or to the same degree.

If we also eliminate self-referral, costs will also plummet, but that remains unproven and is a topic for another post.

Sid Schwab said...

Good comments, Paul. Thanks.